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A Physician on Capitol Hill: An Outsider on the Inside

  • Manuel E. Jimenez
    Correspondence
    Address correspondence to Manuel E. Jimenez, MD, 423 Guardian Dr, 13th Fl Blockley Hall, Philadelphia, Pennsylvania 19104.
    Affiliations
    Robert Wood Johnson Foundation Clinical Scholars Program and the Leonard Davis Institute of Health Economics at the University of Pennsylvania and the Division of Child Development, Rehabilitation, and Metabolic Disease in the Department of Pediatrics, The Children’s Hospital of Philadelphia
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      It was early evening on December 23, 2009, when I raced across an underground tunnel in the US Capitol complex. It was dimly lit and quiet. Most staffers on Capitol Hill had already left for the holidays; only a few of the senator’s advisors remained. They, like I, had stayed to watch history unfold. I returned to the office and joined the others as they watched the TV announcer report what I had just witnessed on the Senate floor.
      After several intense months of debate and endless work, I had sat only feet away in the gallery as the senator cast the second of 3 historic votes. Now we waited for her to return, eager for her to share her experience. Procedural rules delayed the third vote until the next morning, but at this point, no one doubted the outcome: the US Senate would pass their version of the health care reform legislation. Just months earlier, I had been a resident at a large children’s hospital; now on the eve of this historic event, I was part of a US senator’s staff. How did I get here?
      Three years earlier, during my first months as an intern, I had sat across the table from the frustrated young mother of a child with a cognitive disability. In Spanish, she told me about her most recent individualized education program meeting. Overall, she had been satisfied, but she still wondered whether the school district would administer specialized testing to her child. She asked me to call the school board and clarify their plans. As I learned then and throughout my residency, pediatricians frequently encounter such scenarios. That day we resolved the issue easily, but I remember it for 2 reasons. First, the experience illustrated that a complex, multidisciplinary system would determine this child’s future, not health care alone. Second, I was reminded that we, as pediatricians, can help parents advocate for their children. Children with special health care needs always reminded me about these truths, especially my nephew, who was born with a chromosomal abnormality and brain malformation. One night, soon after his birth, as I sat with my sister, brother-in-law, and nephew in their kitchen, we questioned why 2 of his many doctors recommended medications with opposing mechanisms. My nephew, who could not sit independently, playfully batted at the silverware on the table. He vocalized and chuckled when my sister moved it beyond his reach. He was seated forward with a straight posture, and I realized that his new specialized chair made it possible. My sister had argued with the insurance company for months to get it, and her advocacy had made it happen. These experiences, both with my family and my patients, made me think about the big picture and how I could influence it as a pediatrician.
      At the end of residency, I became a congressional fellow through the Joseph P. Kennedy Jr. Foundation Public Policy Fellowship. The foundation placed professionals interested in developmental disabilities on Capitol Hill for 1 year. The timing was perfect: the health reform debate had just begun.
      One morning, anticipating my fellowship on the Hill, I visited a friend at a cafeteria at the Capitol. The place was crowded with people in dark suits, engrossed in conversation. Legal pads and coffee were everywhere. When I found my friend at a small table, I was surprised at how well he blended in. Outside, we had watched movies and played basketball, but inside the Longworth House Office Building, he was a seasoned Capitol Hill staffer. As my fellowship approached, I sought his advice. When I asked him to describe a typical day at work, he chuckled. My innocent question was like asking a resident to describe their average day. He said, “Most of the time you’ll feel like you’re drinking from a fire hose; the rest of the time you’ll probably feel like you’re drowning.” Shortly after arriving on Capitol Hill, his description came to life.
      I had found placement in the office of Senator Jeanne Shaheen, a first-term senator from New Hampshire. I remember our first meeting. Everything I had read and heard was true. My palms were a little sweaty and my voice cracked when I introduced myself, but her kind eyes and warm voice put me at ease when she smiled and said, “Hi, Manny, I’m Jeanne.” There wasn’t time to linger; the weekly staff meeting was about to begin. I gathered with the rest of the staff around a large table in the conference room. The senator sat at the head and opened with a story about a constituent she met over the weekend. Like many, his family was suffering because the economic downturn had decimated their farm. The story was a reminder of our purpose in Washington. I looked around. Many staffers had followed the senator from New Hampshire, a testament to her character and their loyalty. She asked for legislative updates and different staffers updated her on issues ranging from education to defense. Her questions were focused. Later in my fellowship, the senator would direct questions at me. Like a resident presenting on rounds, I had to be prepared with accurate and complete information, whether it was on the details of legislation or the health reform debate in general. The senator made sure that everyone participated; she even asked interns, by name, what they were hearing from constituents on the phones. An alarm rang; she was due for a vote on the Senate floor. The meeting ended.
      Most days, I arrived at the office before 8. Coming off the train, I walked by protestors with prominent signs and megaphones. A little further, reporters gathered near the Supreme Court and reported on the big story of the day. The marble edifices seemed like a perfect backdrop for their reporting as they stood around the radiant white dome of the Capitol.
      By the time I arrived at my desk, I had already scanned the Capitol Hill press and major newspapers for articles related to health reform. Every day I was bombarded with information. Doctors, nurses, lawyers, patients, and industry professionals all came in with ideas to fix the health care system. Their ideas usually conflicted, and they often blamed each other for what they thought was wrong. I consumed information from the media—print, online, or television—and constantly sought credible policy briefs. Renowned experts were just a phone call away. Staffers on the Hill were bright and energetic. They were quick to make small talk but would cut to the chase. Their Blackberries, never more than an arm’s length away, were constantly buzzing.
      Meetings filled a significant portion of my day. In addition to meetings with other staffers, I spent a lot of time with constituents and advocacy groups, including physicians. These physicians took time to meet with policy makers, share their experiences, and advocate for their patients. Many of their stories triggered my own memories, such as when my hospital implemented its electronic medical record or when my patients waited months to see a specialist. Occasionally, physicians only wanted to discuss reimbursement issues. A few treated Senate staff condescendingly, as if their education and experience elevated them on the rungs of humanity. Thankfully, the positive experiences far outnumbered the negative ones. In fact, I worked with a few physicians throughout the year. For example, one physician led a team who identified frequent users of health care services and improved their care by maximizing coordination and outreach. This program improved quality and reduced costs. As a result, Senator Shaheen introduced a bill modeled on it. The experience reminded me that good work in the community can inspire federal policy.
      Although my clinical experience was useful in policy analysis, it was not always sufficient. Rather than talking about CBCs and BMPs in the hospital, I now had to understand that Rule 14 meant that a bill could proceed directly to debate. It also meant that when Rule 14 was used to bring legislation regarding the Medicare sustainable growth rate (SGR) formula to the Senate floor, I had to consider the economics behind the formula and its impact on other aspects of the budget. Congress introduced the SGR in the late 1990s as a mechanism to control health care costs. However, it is widely considered to be flawed, and physician groups want it repealed. At the time, repeal would cost the government over $200 billion, which would either have to be offset or would contribute further to the deficit. This dilemma fuels an ongoing debate.
      My year on Capitol Hill was filled with ups and downs. Reminiscent of my days in the ICU, I could not let myself get too comfortable. The health legislation itself was frequently on and off life support. Emergencies came and went. Triage was an essential skill. I would hurry up to wait, only to be caught off guard. There were tea parties, blizzards, midnight votes, and special elections. A legendary leader passed away, and others struggled to fill his shoes. At times, it seemed to be all for nothing, but on March 22, 2010, the health care reform legislation was passed. It would be signed into law shortly thereafter.
      Physicians’ response to previous iterations of health reform has ranged from opposition in the 1910s and 1950s to ambivalence in the 1990s. This time, the American Medical Association (AMA) endorsed the legislation with a not-so-subtle reminder to fix the SGR formula. Many state and specialty medical societies denounced the AMA’s endorsement. As a special interest group, it seems we doctors cannot get our act together. Yet I struggle to see our profession as an ordinary special interest group. We have a reason beyond our own interests to influence policymaking. It is, of course, our patients, who trust us with the most vulnerable moments in their lives.
      I completed my fellowship on Capitol Hill months ago. Now I write grants and research protocols instead of memos. I brief parents rather than a US senator. I am back experiencing the granular details of policy outcomes, like whether my patients get adequate services through their individualized education program or whether they are able to access behavioral services through their insurance. Recently, after a draining day, I walked to the train station with a friend who is also a physician. Like many conversations between physicians, policy matters crept in. We talked about some of our tough patients and the adversity they face. We talked about the news headlines, especially the budgetary crisis. We wondered how the resulting policy will impact our patients and our future on the front lines. About halfway through our train ride, my friend said, “The problem with Washington is that no one listens.” I paused a moment and replied, “They definitely can’t if we don’t speak up.”

      Acknowledgment

      Dr Jimenez is supported through the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania. The author would like to thank the Joseph P. Kennedy Jr. Foundation, the Children’s National Medical Center in Washington, DC, Senator Shaheen and her staff for their support, and Dr Jason Karlawish and Dr Anjali Jain for their feedback during the development of this essay.