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Sen. John Barrasso (R-Wyo.) was not a politician born and bred.
“Wyoming’s doctor” spent much longer donning the sterile masks and scrubs of an orthopedic surgeon, tending to trauma patients flown in by helicopter at the Casper hospital where he practiced for more than two decades and in communities where he preached healthy behaviors to the cattle ranchers of the rural West.
The outsider’s perspective, central to President Donald Trump’s mantra of “draining the swamp,” is fast becoming part of the establishment. More and more health-care professionals have been joining the ranks of lawmakers in recent years, trading in stethoscopes for political power.
Just 25 of more than 2,000 congressional representatives were doctors from 1960 to 2004, according to one study published in the Journal of the American Medical Association. In 2004, that figure was eight, and today it stands at 14, not including Rep. Tom Price (R-Ga.), who is an orthopedic surgeon. He is poised to head the Department of Health and Human Services, which hasn’t been led by a doctor since 1989.
As another pivotal debate about the health-care system’s future looms, these doctors are poised to chart a new path for a divided industry.
Other lawmakers are ready to listen and at least partially defer to them, Dr. Ashish Jha, director of the Harvard Global Health Institute, said.
Health care made up 17.8 percent of the U.S. gross domestic product in fiscal 2016, according to the Centers for Medicare & Medicaid Services.
“As health care has become a larger and larger part of our economy, you’ve seen more and more interest among political leaders in regulating and shaping health care,” Jha told Bloomberg BNA. “A lot of doctors… who for decades have had a lot of autonomy have felt it’s kind of time to push back and get involved.”
The medical community has been split in recent months amid the largely GOP vision of Price and his fellow Republican physicians, a push toward an Affordable Care Act repeal, Medicaid financing reforms and drug pricing proposals.
With doctors on both sides of the aisle wanting change, and so much at stake in health-care politics, the next five to 10 years will only continue to bring doctors out of their offices, Jha said.
“At the bedside or in the operating room, you have those difficult conversations; what I say often up here is you have a lot of well-intentioned 25- to 35-year-olds that are very educated writing good policy, but that policy doesn’t always translate into practice,” Rep. Ami Bera (D-Calif.) said.
That can lead to laws that don’t quite work or are limited, said Bera, who practiced in internal medicine before directing a hospital system and leading Sacramento County as a chief medical officer. The county at the time contained around 200,000 uninsured people, which jump-started his interest in changing health-care systems to maneuver “limited resources” for all. Later, he worked in admissions for graduate medical education, shaping his views on workforce issues.
“You’ll find a lot of doctors talking about health care in the language of patients and see a lot of staff on health-care committees talking about it in the language of policy,” Bera told Bloomberg BNA. “You have to have both, but you can’t have really good policy unless you understand how it’s going to impact patients.”
The desire to become politically active comes in ebbs and flows, analysts said, with the last one in the 1990s and early 2000s when concerns over payment cuts under the Medicare sustainable growth rate formula ushered in a wave of doctors to Congress, Shawn Martin, senior vice president for advocacy at the American Academy of Family Physicians, said. Many owned their own small private practices.
Rep. Michael Burgess (R-Texas) rode that wave, the son and grandson of medical providers and a 25-year-practicing obstetrician. He notes in his official biography the fight to buck the sustainable growth rate was a goal of his since his 2003 election, one that finally came to fruition last year as more than 90 percent of representatives voted to change the formula for physicians’ Medicare reimbursement.
That record of single-minded health focus, and Burgess’s standing as the most senior doctor in Congress, could be a force to be reckoned with in the 115th Congress, as he takes control of the Energy and Commerce health subcommittee.
Persistent yet soft-spoken with a Texas drawl, his attentions have been pulled toward ridding the country of Obamacare. And more than 50 votes later—now with the support of a Republican-led House and White House—he hasn’t backed down.
In the opening months of 2017, Burgess has already pitched two health-care bills that aim to bring more maternity-care providers to shortage areas and expand health savings accounts, Bloomberg Government records show, while steering fiery, impassioned hearings about curbing spending in the $550 billion Medicaid program.
“As a physician, I have had the privilege of actually providing health care for hundreds of Medicaid patients,” he told the health subcommittee Feb. 1. “I have looked in their eyes, I have listened to their concerns, I have held their hands, and I know many of their stories.”
He added his new role as chairman, which saw his opening act advance bills limiting Medicaid benefits for lottery winners and lump-sum recipients, gave him the chance to help these patients.
“As we embark on this new Congress together, while I know we will have real differences, I hope we can agree on our shared goal: to improve the Medicaid program to provide access to high-quality care for those who truly need it,” he said.
Though Barrasso has joined Burgess in the corridors and talking points of Washington’s decision making, he also derides its influence.
Barrasso said he cultivated a frustration with the status quo while treating patients in the plains of the Cowboy State.
He noticed that despite the federal government’s increasing role as a health-care payer, Medicare reimbursements for his patients always lagged behind private insurance—even for preventive services like mammograms. And government hadn’t kept pace with new technology, he told Bloomberg BNA.
Instead, patients are the ones who really hold the keys to improving health, said Barrasso—who campaigned at health fairs in his state for years. These messages focused on prevention, combating obesity and wellness screenings for blood pressure.
“We as a country have just fallen behind,” he said. “It’s about empowering individuals to care for themselves, to help keep down the cost of care.”
Since he landed in the nation’s capital in 2007, Barrasso played witness to one of the largest overhauls in the past 50 years of health care: Obamacare, which he has also consistently and vehemently opposed.
He believes doctors should be in the conversations crafting policy, but policy makers shouldn’t be by a patient’s bedside in a doctor’s office.
“We could help more people with the same amount of money if Washington would get out of the way and let people in Wyoming make the decisions,” Barrasso said.
Many in his home state are angry, he said, because of how the ACA had caused people to shop around—not stick to doctors and plans they had built trust with and that met their needs but didn’t mandate essential benefits. In turn, their premiums and deductibles have gone up, he added.
“During the debate of the health-care law, President [Barack] Obama kept talking about coverage; doctors know coverage doesn’t matter if you can’t get care,” he said. “We need to have enough people taking care of patients.”
“If you’ve been a doctor, you’ve been there in the middle of the night with somebody delivering a baby, someone dying involved in significant trauma,” he said. “You see people at their best and see people at their worst.”
And, he added, doctors in Congress can share those stories with voters and career politicians.
That could be a unifying measure as Republicans scramble to determine a path forward on repealing the ACA (possibly in a piecemeal fashion) and what to replace it with, with the timing growing more murky by the day.
Barrasso did not discuss specifics of when or how a repeal might take shape.
One Louisiana lawmaker, Republican Sen. Bill Cassidy, is aggressively pitching his vision with a newly introduced bill dubbed the Patient Freedom Act of 2017 proposing health savings accounts, insurance reforms and retaining popular provisions like protecting those with pre-existing conditions.
Cassidy told Bloomberg BNA his 30 years serving Louisiana’s uninsured, low-income patients in the Baton Rouge area taught him that these patients can be trusted to make their own health-care decisions.
“I learned where some on the left would say lower-income patients don’t have the ability to make sophisticated decisions about allocating those resources—those are my patients,” he said. “They absolutely do.”
That means listening to their desires, rather than one-size-fits-all mandates, other Republicans argue.
Further, Cassidy said, an expansion of Medicaid is really an expansion of a system that underpays providers, meaning he often saw Medicaid patients alongside the uninsured. They weren’t able to get into specialists’ offices.
The vast majority of doctors in Congress are Republicans. That has traditionally been the case; in the JAMA study, they skewed GOP at a rate of 60 percent compared to 45.1 percent of all other lawmakers.
Democrats have shown signs of growing their ranks in recent years, with the 2012 election of Reps. Bera and Raul Ruiz (D-Calif.). Before the 113th Congress was just one serving in the House—Rep. Jim McDermott (D-Wash.), who left office this year.
The difference, as Bera sees it, is it “seems like many of them take the business approach to health care, the old school practicing doctor… who’s running the group practice. I look at it from the patient delivery side of health care.
“It’s a different side: How do I make money as a doctor and more how do I deliver better, more efficient care as a doctor?”
Cassidy countered that doctors in large institutions are salaried and “are somewhat disconnected from the need to balance the books.”
“When you’re in private practice, you’re the canary,” he said. “When you’re insulated you are not as aware, not as concerned about lack of sustainability in a program such as Medicaid.”
Bera said he gets along well with his GOP counterparts and wants to work with them on ensuring coverage in any replacement, as well as affordable and accessible care. That means tackling not just health insurance but also the underlying, expensive cost structure, which he believes should have come first in reform.
“That’s the harder one politically,” he said.
The son of migrant farmworkers in the dusty deserts of the Eastern Coachella Valley, Rep. Ruiz (D-Calif.) came to health care on a different path than many of the GOP physicians. After embarking on an education that took him to Harvard, he returned back to his medically underserved community to practice emergency room medicine.
He recalls emergency room visits, “firsthand experience of seeing the face of failed policies"—especially for the uninsured, middle-class, veterans and seniors who can’t afford premiums or have long wait times—and rejects the right’s rhetoric, which ACA supporters say could strip around 20 million people of health insurance.
And with a seat on the Energy and Commerce Committee, he’ll have more of a chance to defend his side of the aisle—which has dubbed GOP promises a plan to “Make America Sick Again.”
“That face will only get more bleak and gloomy if Republicans repeal the ACA,” Ruiz said.
Ruiz added that doctors on both sides of the aisle have taken a Hippocratic oath to “do no harm.” He intends to honor that in Congress.
The partisan nature of the health-care debate echoes the division at play in the larger medical community.
After the conservative Price was nominated—and endorsed by the American Medical Association—a #notmyAMA Twitter hashtag emerged, and more than 5,000 health-care practitioners signed a petition opposing the former orthopedic surgeon.
And in recent weeks, organizations representing primary-care providers like Martin’s have been meeting with Republican congressional leaders to protect care for patients.
Amid this environment, the time is ripe for more to get involved politically, Martin said.
“There are a lot of physicians out there that are concerned on both sides of the political spectrum with the consolidation, the placement of the practice of medicine in the spectrum of health-care delivery, how physicians are treated as compared to say hospitals, pharmaceutical companies, device companies,” Martin told Bloomberg BNA.
And experts seem to agree there are signs more Democratic lawmakers with health-care backgrounds will join the fold, given the ACA debate. Bera said he’s seeing more thinking about running.
“This is not a trend that’s going to slow down any time soon,” Jha said.
But that doesn’t mean there can’t be common ground.
“I find the incredibly deep split frustrating because there are two competing interests [among doctors in Congress],” Jha said. “Most of us who are physicians feel like we want both.”
He understands the desire for universal coverage and worries over the repercussions of losing insurance. And he also understands Republican fears about “how much government intrusion there is into medicine,” potentially hindering independence for patient care.
Jha proposes there should be a way for doctors on both sides of the aisle to unite and create a working policy.
“I can’t understand how the two things are at odds with each other,” Jha told Bloomberg BNA.
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Sen. Cassidy's health-care bill is at http://src.bna.com/l66.
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