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Covering state lawmakers, bills, and policy emerging from Jefferson City.

American Medical Association President - and Rural Missouri Physician - On Healthcare Reform

Dr. David Barbe
Scott Harvey

Six months ago, 97 of Missouri’s 114 counties only had one insurance participant in the Affordable Care Act exchanges. Today, 24 counties have no provider at all. As insurers across the country have dropped out of the exchanges established under the ACA, or Obamacare, it’s underscored the need to stabilize the market.

More insurance companies bring patient options and potentially reduced costs. Getting them into the market requires the right incentive.  

“The way to do that is by restoring what are called cost sharing subsidies to the insurance companies,” says Dr. David Barbe, president of the American Medical Association (AMA). “That helps reduce some of their risk so they’re willing to get back into the market.”

It’s one measure supported by the AMA. But overall, the organization could not get behind the Senate’s Better Care Reconciliation Act, which failed to win approval last month.

Barbe, who was sworn in as president of the American Medical Association in June, is a practicing doctor at Mercy Clinic Family Medicine in Mountain Grove, Missouri. He tells KSMU the AMA could not support a bill that covered far fewer people – in this case tens of millions less when compared to Obamacare. He adds that bills in both the House and Senate would also limit affordability by reducing subsidies for low income individuals to purchase insurance on the exchanges.

“Third big test for the AMA is what does it do for the safety net programs like Medicaid? Both [chamber bills] proposed substantial cuts to Medicaid funding compared to the current trajectory – current levels.”

Barbe says he’s “cautiously optimistic” that failure to pass healthcare reform in the Senate “will drive now a bi-partisan conversation.”

He says Obamacare did a lot of good things, including expanding access and Medicaid rolls. But affordability remains an issue. Barbe adds that money spent on healthcare must be done wisely.

“To structure payments to physicians and hospitals in a way that incentives high value care. And the same way for patients; we need to look for ways to engage patients to be better consumers on their own behalf.”

Prescription Drug Monitoring Program

Another provision of the Senate’s now sidelined bill was more funding to combat the opioid epidemic. In Missouri, state lawmakers have failed to pass a prescription drug monitoring program (PDMP). Until last month, it was the only state that didn’t have one. But on July 17, Gov. Eric Greitens established a PDMP by executive order. State governmental entities, including Springfield and Greene County, have also established their own programs.

Barbe says a lot goes into creating a successful PDMP.  That includes real time monitoring capabilities and for the program to be incorporated into a doctor’s normal workflow.

“The more difficult it is for the doctor to access that information the less likely he or she is to access it and therefore it doesn’t help.”

The PDMP established by Greitens allows for the collection of who is writing opioid prescriptions and dispensing the drugs. However, only the Missouri Department of Health and Senior Services can access the data.

Barbe thinks Missouri “can do better than an executive order” and says the state legislature should continue to pursue a program.

“There are excellent models in many other states around the country. They have been shown to reduce the amount of prescribing significantly. And when there’s fewer narcotics being prescribed, there are fewer overdoses and fewer deaths from that. There are fewer admissions to rehab facilities, which means there are fewer people getting addicted to narcotics.”

Boosting Doctor Moral

Looking ahead, Barbe says the AMA intends to focus time on improving the practice environment of physicians, citing high “burn-out rate.”

“It is higher now than it has ever been and it is continuing to rise,” says Barbe.

It means physicians are less engaged in the process and therefore not providing the best care possible, he says. It can even lead to early retirement at a time when health agencies are short on physicians.  

“So the AMA is working really hard to address those things that are producing that effect in physicians. Much of which is the burden of what we believe is unnecessary paperwork. It’s the burden of the electronic health record that doesn’t work for the physician or the patient in many cases. It’s the burden of preauthorization paperwork from insurance companies.”

In rural America, where much fewer physicians practice, Barbe acknowledges several challenges. He says it’s been more difficult in Missouri and other states that didn’t expand Medicaid.

“Because some of the other subsidies that were available to hospitals prior to the Affordable Care Act were eliminated with the idea that everyone will have coverage or access to coverage through Medicaid expansion or the exchanges.”

Barbe estimates Missouri has lost close to $10 billion in additional funding both due to non-expansion of Medicaid and loss of DSH payments. Under the Disproportionate Share Hospital program facilities can receive partial compensation from the federal government for treating Medicaid or uninsured patients.

Low Hanging Fruit

Other healthcare issues in this country are far less complicated to treat or legislate. Barbe says the AMA is focusing on raising awareness about controlling high blood pressure and diabetes.

“There are 80 million people in this country with high blood pressure. 30 million of those say ‘I have a regular source of medical care, I know who my doctor is,’ but yet their blood pressure is still not controlled…those people are at much higher risk for the complications of uncontrolled high blood pressure such as premature heart attacks and strokes.”

The same is true for diabetes, says Barbe. He says there are 84 million people with pre-diabetes.

“The shocking statistic - if that’s not shocking enough - is that 90 percent of those people do not know they have prediabetes and that they are risk for progressing onto diabetes and all of the sometimes fairly serious complications that come with that.”

The AMA has been pushing awareness and promoting partnerships with national organizations like the American Diabetic Association, the CDC (Center for Disease Control) and the Ad Council. A new website,, allows people to take a quick test to learn of potential risk factors. He says at last count over 400,000 people have visited to take the test.

The American Medical Association is the largest association of physicians in the U.S., representing about a quarter of a million doctors. Barbe is the AMA's 172nd president. Aside from his responsibilities on a national scale, his role with Mercy includes oversight of about 75 clinics and 200 physicians and advanced practitioners. Barbe grew up in Mountain Grove, and graduated from its high school. His undergraduate and medical degrees were obtained from the University of Missouri. After receiving family medicine training in Kansas, Barbe moved back to Mountain Grove to open his practice in 1983. He merged his independent practice with Mercy 15 years later.

Follow Scott Harvey on Twitter: @scottksmu

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