How long did you wait for your last appointment? How far did you drive to get there?
Those two questions are where Medicare payment policy stops being an abstraction argued over in Washington and becomes something a patient feels on a Tuesday afternoon. When a practice closes, it is a patient who loses the doctor who knows her history. When a specialist stops taking new Medicare patients, it is a patient who waits months for an opening, or drives two hours to keep one. The formula that decides what Medicare pays a physician can look like a budget line. It is not a budget line in an exam room that no longer exists.
That is why Patients Rising supports the Patients First Act (H.R. 9693), and why we led a letter from the patient community to House and Senate leadership urging Congress to pass it this year. This post explains what the bill does, why we think it matters for patients specifically, and what we're asking you to do about it.
Adjusted for practice-cost inflation, Medicare physician payment has dropped 33 percent over the past 25 years, according to the American Medical Association. That is not a one-year dip. It is a quarter-century of erosion, driven in part by budget-neutrality rules that have not been updated in more than thirty years and by a steady drumbeat of annual cuts that Congress has had to scramble to soften, year after year, without ever fixing the underlying machinery.
I made this argument in a letter to the editor the Wall Street Journal published on September 3, responding to the Journal's editorial on a JAMA Surgery study finding that Medicare beneficiaries wait longer than privately insured patients for cancer treatment. Medicare reimbursement hasn't kept up with the market, which leaves commercial insurers effectively subsidizing Medicare and Medicaid, and chronic underpayment works the way any arbitrary price control works: it leads to rationing, in this case by quietly giving priority to patients with private plans. Practices close or sell to larger institutions. Physicians retire early. The ones who stay stop accepting new patients with certain Medicare plans. As I put it in the Journal, without reimbursement that mirrors reality, patients will learn the hard way that Medicare for All means healthcare for no one, and the people at the back of that line are the seniors and people with disabilities the program exists to serve.
The consequences are not hypothetical.
The Association of American Medical Colleges projects a national shortfall of up to 86,000 physicians by 2036. Independent and private practices, the kind that anchor care in small towns and rural counties, are disappearing fastest, and many of those communities are already federally designated Health Professional Shortage Areas. For the patients we hear from, that means the appointment is further away, the wait is longer, and the doctor who finally sees you doesn't know your name.
The Patients First Act was introduced by Reps. John Joyce of Pennsylvania, Kim Schrier of Washington, and Greg Murphy of North Carolina, three physicians from both parties, and what distinguishes it from the annual patch is that it goes at the structural causes. Four provisions carry the weight.
First, it gives physicians a permanent annual payment update tied to the Medicare Economic Index, which is the measure of what it costs to run a practice. Medicare's own Trustees warned in 2024 that without a change in how updates work, access to Medicare-participating physicians would "become a significant issue in the long term." Linking payment to practice-cost inflation is the plainest possible answer to that warning.
Second, it fixes budget neutrality. Under current law, whenever Medicare adds or revalues a service, it must cut payment across the board to offset the projected cost, using government estimates of how often that service will be used. Those estimates are frequently too high, and the law never requires anyone to go back and correct them. Physicians absorb cuts for utilization that never happened. The bill requires Medicare to compare its estimates against actual use and reconcile the difference, and it raises the dollar threshold that triggers these cuts in the first place.
Third, it replaces the Merit-based Incentive Payment System with something clinicians can actually use. MIPS has become a reporting burden that punishes small practices without much evidence that it improves outcomes. The bill's replacement, the Patient Outcome Improvement National Tabulation System, lets medical professionals help set the quality measures, builds in incentives for small and independent practices rather than penalties aimed at them, and credits the savings physicians generate by keeping patients out of the hospital.
Fourth, it makes value-based care reachable. The bill freezes the Qualifying Participant threshold for alternative payment models at 50 percent for several years and directs a hard look at what is keeping more physicians, particularly in smaller practices, from participating. If value-based care is the future, the on-ramp shouldn't be built for health systems alone.
A fair question: isn't physician payment the doctors' issue? Patients Rising judges every policy by one standard, which is whether it lowers what patients pay and makes care more predictable and accessible. Physician payment passes that test for a reason that is easy to miss. The alternative to paying independent physicians fairly is not cheaper care. It is care delivered in the most expensive setting available, by a hospital system that bought the practice, at facility rates, with facility fees, often farther from home. Patients pay for underpayment twice: once in access, and again at the counter.
We also believe the patient voice belongs in this conversation because patients are the ones who feel the decisions first. The physician organizations that have long carried this issue know the policy cold. What they cannot supply is the account of the parent driving across two counties for a pediatric specialist, or the retiree who found out her internist of twenty years sold the practice and the new owner isn't taking Medicare. That is what we bring, and it is why we convened the patient community's letter rather than simply signing someone else's.
Patients Rising has circulated a sign-on letter to Speaker Johnson, Leader Jeffries, Leader Thune, and Leader Schumer supporting H.R. 9693 and asking leadership to advance it this year. Patient and caregiver organizations from across the country joined it, representing communities in rare disease, oncology, autoimmune and inflammatory conditions, neurological disease, and chronic pain. We will update this post with the final letter and the full list of signers once it is delivered.
The letter is one step. The bill still has to move, and bills move when members hear from the people back home. If you take one action after reading this, make it a call or a short note to your representative's office asking where they stand on the Patients First Act, H.R. 9693, and telling them, in a sentence or two, what it has been like for you to get in to see a doctor. Those sentences are what a staffer remembers.
Congress has spent twenty-five years treating the symptoms of a broken payment formula one year at a time. The Patients First Act is a chance to treat the cause. We intend to keep pressing until it does.
Read the full text of H.R. 9693 on congress.gov. Read Terry's letter to the editor in the Wall Street Journal.