Thursday, August 10, 2017

Physicians’ efforts to save the ACA are a redemptive moment for the medical profession

While many people contributed to the defeat of the current efforts by Congress to repeal the Affordable Care Act (ACA), physicians had a big role in organizing opposition to repeal, individually and collectively through their professional societies—including through the American College of Physicians. It was a redemptive moment for American medicine, making up in part for its sad, sorry history of opposing health insurance for all.

It is sobering to review the medical profession’s century-long history of being unyielding opponents of universal coverage. To put a finer point on it, it was organized medicine—mainly the American Medical Association (AMA) and state medical societies—that opposed universal coverage or even partial steps toward it, since specialty societies for the most part were not involved in advocacy until the 1970s or later. Even when the specialties began to take on advocacy, they mostly addressed narrow issues that directly affected their own disciplines. This left the AMA and the state medical societies to speak for doctors on issues like access and coverage. 

In 1920, the AMA’s House of Delegates officially came out against what was called “compulsory health insurance” which “was viewed as a threat to professionalism itself, requiring acceptance of mandatory fee schedules, work reviews, organizations outside the doctor-patient relationship over which doctors have no control; and limits on patient choice of physician,” wrote Rosemary Stevens in her insightful book American Medicine and the Public Interest, originally published in 1971 and updated in 1998.  

The AMA’s opposition to universal coverage was so powerful that President Franklin Roosevelt did not include national health insurance with the recommendations that formed the basis of the Social Security Act of 1935 because “he feared, probably correctly, that because health insurance had such strong opposition from physicians [namely, the AMA] and others, if it were included in his program for economic security, he might lose the entire program,” wrote Robert M. Ball, in “Reflections on How Medicare Came About” in Medicare: Preparing for the Challenges of the 21st Century. Ball ran the Social Security program from 1962 to 1973, and he helped design Medicare for the Johnson administration.

When President Harry S. Truman advocated for national health insurance in 1948, “the AMA’s opposition approached hysteria,” Ball continued, noting that the AMA raised a “$3.5 million war chest—very big money for the time—with which it conducted a campaign of vituperation against the advocates of national health insurance.”

In the early 1960s, the AMA vehemently opposed the enactment of Medicare, even though Medicare as originally proposed by the Kennedy and Johnson administrations would have applied only to hospital services (coverage for physician services through the voluntary Medicare Part B program was added late in the process at the request of Congressman Wilbur Mills, the then-chairman of the Ways and Means Committee). “If physician services were left out entirely, we reasoned, the AMA’s opposition would have less standing,” Ball wrote. “By that time it was clear that the elderly had the most political appeal and potentially the most muscle.We wanted to get something going, and this seemed a plausible first step.” The AMA also opposed Medicaid, the sister program to provide coverage to some categories of poor women and children.

Although the AMA lost its fight against Medicare and Medicaid, both of which were signed into law by President Johnson on July 30, 1965, it continued to resist most efforts to expand the government’s role in health care through the 1970s and 80s. By the 1990s though, the AMA had tempered its views, and while it never got behind President Clinton’s failed Health Security Act, it also was no longer an unyielding opponent. The AMA even put its support behind programs to incrementally expand coverage, including the Children’s Health Insurance Program enacted in 1998.

This brings us to Obamacare. The AMA engaged constructively with President Obama and the congressional leadership on the Affordable Care Act, offering its qualified support for the bill leading up to its enactment in March, 2010. And, the AMA opposes the current efforts by President Trump and the GOP-controlled Congress to repeal and replace Obamacare with something that would cover fewer people and offer less protection for people with preexisting conditions. A sign of how much things have changed for the AMA is when its House of Delegates in June of this year resoundingly voted to oppose any legislative proposals to cap Medicaid—in other words, to keep it an open-ended entitlement program. This is not your grandfather’s AMA, for sure.

The AMA’s evolution to supporting some variations of universal coverage is welcome and necessary. Its speaking out against the current efforts to repeal the ACA should be applauded. Yet, it also must be acknowledged that many other physician organizations, representing even more doctors than the AMA can now claim as members, have made it their mission and their passion to advocate for universal coverage and against ACP repeal. 

I am particularly proud of the ACP’s leadership. The ACP first came out for universal coverage in the 1990s, gave qualified support to President Bill Clinton’s Health Security Act, and became a leading advocate during President Obama’s administration for what became the Affordable Care Act. But the current efforts by President Trump and the GOP-controlled Congress to repeal the ACA really tested ACP’s mettle. And the College passed the test, with flying colors.

ACP helped organize and lead a coalition of six front-line physician membership organizations—the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, American Congress of Obstetricians and Gynecologists, American Osteopathic Association, and American Psychiatric Association—to advocate for preserving coverage and opposing efforts to repeal and replace the ACA with alternatives that would leave millions more without health insurance. Collectively, the coalition represents over 560,000 physician and medical student members, the vast majority of front-line physicians in the United States. The six allied groups above have conducted 5 separate fly-ins (2-2-17, 3-7-17, 5-11-17, 6-28-17, 7-12-17) involving the leadership of those six front-line physician organizations, the most recent one was July 12. Meetings were held with targeted representatives and senators. 100 letters were hand delivered on June 28 to all Senate offices, signed by the group of six, containing state-specific data on the harmful impact of the Senate’s Better Care Reconciliation Act in each state.  

ACP, on its own, sent at least 36 action alerts to our grassroots network across the country, which includes targeted alerts to key House members and senators; conducted a “write to Congress” letter-writing campaign for all of our 50 chapter governors during our March Board of Governors meeting; launched 7 separate full-scale action campaigns for our 50 chapters that also involved targeted campaigns for 8-10 states with Republican senators who had expressed concerns about the repeal bills; sent 15 ACP National letters to Congress; sent 14 coalition letters to Congress; had 3 TV appearances on MSNBC, on “the Last Word” and with Kate Snow; sent 28 ACP and/or joint releases/statements on repeal efforts;  conducted local TV interviews that reached 16.2 million people with 549 airings of the content; and organized a social media campaign (including through my @BobDohertyACP twitter account) to organize opposition to repeal. And this is only a partial list of our efforts! You can learn more about ACP’s activities on our website

Our efforts, and those of so many others, paid off in the wee hours of July 28 when Senator John McCain joined Senators Susan Collins and Lisa Murkowski to cast their votes against Majority Leader McConnell’s last ditch effort to get repeal through the Senate.

That ACP, our sister coalition partners, today’s AMA, Doctors for America, the National Physicians Alliance, and many other organizations representing physicians, have done so much now to save coverage and access for millions cannot completely make up for a century of doctors failing their patients by opposing Medicare, Medicaid, and universal coverage. It doesn’t change the fact that there is a strong minority of physicians today who continue to believe, like the AMA in 1920, that universal coverage is “a threat to professionalism itself, requiring acceptance of mandatory fee schedules, work reviews, organizations outside the doctor-patient relationship over which doctors have no control; and limits on patient choice of physician”—one of whom, Dr. Tom Price, is now Secretary of the Department of Health and Human Services;  every current Republican physician who serves in Congress today holds similar views. It doesn’t change the fact that many other physician membership organizations were missing-in-action in opposing the current efforts to repeal coverage for millions, including most of the surgical specialty societies and many of the state medical societies. So yes, too many physicians today still hold views that led their predecessors to oppose every reasonable effort by the government to extend coverage to everyone.

But a much larger majority of physicians today have taken a stand for coverage, for their patients, and against efforts to take it away from them. Nothing can change history, when that was not the case, but it is redemptive to see the medical profession today do the right thing by their patients.

Today’s question: What do you think of the medical profession’s century-long history of opposing universal coverage, and the efforts by many physicians today to stand up for coverage and against ACA repeal?

Friday, June 23, 2017

Heartless and Harmful

President Trump told a group of Republican Senators that the House-based American Health Care Act is “mean”—and on this he surely called it right! How else would one describe a bill that would take health insurance away from 23 million people, allow states to waive rules requiring insurers to cover people with preexisting conditions at no extra charge, and raise premiums and deductibles to the oldest and sickest patients.  He reportedly urged the Senate to come up with a bill that has more “heart.”

Well, if that was his pitch, the draft bill released yesterday by Majority Leader Mitch McConnell is anything but.  It’s heartless and harmful to the most vulnerable in America: women, children, the disabled, the elderly, the sick and the poor; to people suffering from opioid addiction; and especially to the more than 70 million Americans who rely on Medicaid for coverage and access to health care.  Yet the President tweeted this morning in favor of the bill.  Go figure. 

In fact, in many respects, the Senate bill, introduced under the Orwellian name “The Better Care Reconciliation Act” (BCRA) of 2017, is meaner and has even less heart than the House bill. It cuts Medicaid by more than the House bill.  It allows states to waive almost all of the protections mandated by the ACA, including coverage for essential benefits (like chemotherapy and treatment for opioid use disorders) and the requirement that insurers spend at least 80 percent of their premiums on patient care services rather than administration and CEO compensation (and it even lifts the $500,000 cap on the amount that an insurer can deduct from taxes for CEO compensation!).  You can read about all of the things that are heartless and harmful in the bill in a letter ACP sent yesterday expressing our strongest possible opposition to it. 

Yet Majority Leader McConnell plans to bring it to a vote next week, before Congress adjourns for an Independence Day recess, even though the bill was developed in secret, with no hearings, no committee “mark-ups,” and with no effort to consider the views of ACP and others who actually know something about how a lack of insurance affects patient care.  We won’t know the Congressional Budget Office’s assessment of what the bill would cost, and how many would lose coverage, until just hours before the bill will be voted on.
And make no mistake about it: the bill will pass the Senate unless three Republican Senators have the moral courage to say no to it, and if the Senate passes it, the House almost assuredly will do the same.  Game over.
But we can still win this fight, but only if enough of you, the constituents who your Senators are supposed to represent, speak out now about the harm it will do to patients. Today, ACP issued an all-hands-on-deck legislative alert to our Advocates for Internal Medicine, and linked to it in today’s ACP Advocate newsletter sent to all ACP members.  It has simple instructions and a sample script to use in making your calls.  We especially need calls to the following Senators: Susan Collins (ME), Lisa Murkowski (AK), Rob Portman (OH), Dean Heller (NV), Dan Sullivan (AK), Jeff Flake (AZ), Cory Gardner (CO), Bob Corker (TN), Bill Cassidy (LA), and Shelley Moore Capito (WV).

Next Wednesday, which may very well be the day before the bill will be voted on in the Senate, ACP’s President will fly to Washington to join with his counterparts with the American Academy of Family Physicians, American Academy of Pediatrics, American Congress of Obstetrics and Gynecology, American Psychiatric Association, and American Osteopathic Association to deliver personalized letter to all 100 U.S. Senators urging a NO vote on the bill, on behalf of the 560,000 physician and medical student members collectively represented by our organizations, and their millions of patients.  (Read the coalition’s statement on the Senate bill issued yesterday).
We are doing everything in our power to stop the Senate’s heartless and harmful bill from becoming law.  Please help us, and more importantly your patients, by calling your Senators now, 202-261-4530.

Today’s question: what have you done to stop the Senate bill?

Tuesday, May 16, 2017

Now, it’s the “Undeserving Sick” who don’t deserve health care

It’s been a long-held truism among conservatives that many of those who live in poverty in the United States are undeserving of help, because, well, it’s their own fault.  If they lived more virtuous lifestyles, studied and worked harder, and of course got a good paying job, they wouldn’t be poor. And if they don’t do these things, the thinking goes, then there is no obligation for “virtuous” taxpayers (well-off people with good jobs) to help support them through publicly funded poverty and income-transfer programs. 

(Never mind that people can be poor because there aren’t good schools where they live, or that well-paying factory and other semi-skilled jobs are a thing of the past, or that there isn’t accessible and affordable transportation to where the jobs are located, or that we’ve had decades of income stagnation, or that minimum wages have not kept pace with costs, or that their housing is substandard and their drinking water unsafe, or that labor unions are no longer around to negotiate for better wages and benefits, or that their parents and their parents before them were poor, so they likely will be as well—it’s all their fault, tough luck.   Or that the so-called virtuous and well-off people with good jobs and incomes have benefited from decades of income transfers from the poor to the rich, from living in good and safe communities with good schools and good jobs, from having nice cars to get them around  from their very nice houses to their very nice offices, even if it means sitting in traffic for 45 minutes, or that their parents were well-off people who gave them every advantage to get ahead—it’s all because of their virtue and hard-work, no luck involved). 

As offensive and factually wrong the “undeserving poor” narrative is, there is a variation of it that is now coming to the fore in the health care debate that may be even more offensive and wrong-headed, if that’s even possible, which is that people are sick because of their own bad choices and shouldn’t expect to get taxpayer-funded health care.  This undeserving sick narrative was used by President Trump’s budget director, Mick Mulvaney, to defend the American Health Care Act (AHCA) against late night TV host Jimmy Kimmel’s charge that the AHCA would deny care to children, like his own newborn, born with a congenital heart defect:

“The phrase ‘Jimmy Kimmel test’ was coined by Sen. Bill Cassidy, R-La., after Kimmel delivered a monologue last week in which he shared difficult circumstances about his son's birth and pleaded for politicians to keep Obamacare's guarantee for coverage of people with pre-existing illnesses. Cassidy said he would vote for a healthcare bill only if it met that test, and Mulvaney was asked by a member of the audience at the Light Forum at Stanford University in Palo Alto, Calif., if he agreed with that standard.

"‘I do think it should meet that test,’ Mulvaney said. ‘We have plenty of money to deal with that. We have plenty of money to provide that safety net so that if you get cancer you don't end up broke…that is not the question. The question is, who is responsible for your ordinary healthcare? You or somebody else?’

He said the debate centered on whether others should pay the burden of paying for someone's healthcare.  "That doesn't mean we should take care of the person who sits at home, eats poorly and gets diabetes. Is that the same thing as Jimmy Kimmel's kid? I don't think that it is.’" [Emphasis added in italics].

Then there is Alabama Republican Rep. Mo Brooks, who justified segregating people with preexisting conditions into underfunded “high risk” pools (where they would likely be faced with staggeringly high premiums, deductible and coverage limits) because, well, it’s the not the responsibility of virtuous people to pay for the health care of people with preexisting conditions who brought it on themselves:

“‘My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool,’ said Brooks. ‘That helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. And right now those are the people—who’ve done things the right way—that are seeing their costs skyrocketing.’”

“I cannot adequately describe how much this enraged me” was physician Aaron Carroll’s poignant response to the “blame-the sick-for-being sick” meme, in an essay I'm sick. It's not my fault. And I shouldn't have to pay more for my health insurance he wrote for   Dr. Carroll recounts his own personal experience with ulcerative colitis, a chronic condition he acquired through no fault of his own, and raises important questions about the whole idea of blaming people for being sick:

There is certainly a case to be made that people have some responsibility for their health. But the lines aren’t clear at all. It’s easy to point at smokers and say they’re doing something harmful and are raising costs for all of us. That’s why we can charge smokers more under the ACA. After that…it gets dicey.

Do you start regulating what people eat? What they drink? If you eat dessert and I don’t, why should I have to pay for your health care? Should we charge people more if they drive cars, which is the number one killer of children? I like to ski. That has risks. So does rock climbing. Or playing contact sports. Should we make them stop, or charge them more? What about people who scuba dive?

Should we start charging more or less to people who have different organs, whether that be male and female reproductive organs or a spectrum of other differences in between?

Maybe the Congress member misspoke and my interpretation of his words is off. But maybe not. Maybe he does believe what he said, that people who did things the right way are the ones who are healthy. If that’s the case, then I have a few questions for him.

What did the baby born prematurely, the one with congenital heart disease, or the toddler with sickle cell disease, or the child with autism, or the little girl with leukemia, or the boy with asthma, or the adolescent with juvenile arthritis, or the young woman with lupus, or the young man with testicular cancer, or the new mother with breast cancer, or the new father with inflammatory bowel disease, or the woman with familial heart disease, or the man with early onset Parkinson’s disease, or the retiring woman with Alzheimer’s disease, or the elderly man with lymphoma — what did they do wrong?

Did they lead bad lives?

Take your time answering. I’ll wait.”

I share Dr. Carroll’s outrage, but would take it a step further.  Most of the examples he cites above are people who are born with a disease, or acquire one through their lifetimes that aren’t necessarily associated with any choices they made, like breast cancer or Alzheimer’s.  Or voluntary choices, like playing a contact sport or skiing.  While I agree with him that they should not be charged more for their health care as a result, I am as concerned about people who are sick with conditions that are associated with things they may or may not have done to stay healthy, like having a poor diet that leads to diabetes, or abusing drugs or alcohol (although I am sure that Dr. Carroll too shares this broader concern).

For one thing, the idea that these are “lifestyle choices”, freely made, is not correct; rather, the evidence suggests that they are due to a confluence of hereditary and environmental factors, trauma, poor education, income inequality and poverty, and other social determinants of health, especially for the poor.  As ACP argues in a new position paper, Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs,  “Substance use disorders have been regarded as a moral failing for centuries, a mindset that has helped establish a harmful and persistent stigma affecting how the medical community confronts addiction. We now know more about the nature of addiction and how it affects brain function, which has led to broader acceptance of the concept that substance use disorder is a disease, like diabetes, that can be treated.”  Many people in poorer communities live in “food deserts” where access to healthful diets is simply not available. 

Of course, many well-off people also engage in activities that may contribute to poor health—they may smoke, drive too fast, drink too much, abuse other prescription and illicit drugs, not exercise regularly,  and favor fast food over healthful diets.  The difference is that they can usually afford good health care insurance and access to the best physicians and hospitals when things go south.  Not so with the poor.

So the narrative that the undeserving sick don’t merit our help is really cut from the same cloth as the undeserving poor narrative: that some people, because they are sick and they are poor (which often go hand-in-hand), don’t deserve compassion, and certainly don’t merit financial help from those who are better off, money- or health-wise.  

Growing up, I was taught that “There but for the grace of God go I.”   We should approach health care policy in the same spirit, with the understanding that any one of us could  be poor or sick or both.  We don’t have the  right to selectively judge who “deserves” health care, and to suggest otherwise is an outrage.

Today's question: what is your reaction to the undeserving sick narrative?