Wednesday, September 6, 2017

Doctors Defending Dreamers

Why should physicians care about President Trump’s decision to end the Deferred Action for Childhood Arrivals (DACA) program?

Because it brings “great harm” to health care, to medical education, and to the country, said the American College of Physicians in a statement issued moments after Attorney General Jeff Sessions announced the President’s decision.

Directly affected by the decision are Dreamers enrolled in U.S. medical schools.  “According to the Association of American Medical Colleges, in 2016, 108 students with DACA status applied to medical school, and 34 matriculants with DACA status entered medical school, bringing total medical school enrollment to approximately 70 students,” ACP noted in its statement. “Without the protections afforded to them by DACA, these students would be forced to discontinue their studies and may be deported. As these students train to become physicians, they will have the experience and background necessary to treat an increasingly racially and ethnically diverse patient population to fulfill the cultural, informational, and linguistic needs of their patients…”  Also affected are Dreamers “studying to be nurses, first-responders, scientists, and researchers, and approximately 1,000 foreign-born recruits who enlisted in the military under the protections offered by DACA could face deportation, according to the Washington Post.”  

Public health will also be adversely affected, according to ACP. “If the nearly 800,000 people who are currently benefiting from DACA have their protections removed, many will avoid seeking health care in order to reduce the risk of detection and deportation, and as noted above, those who seek to serve in the health care professions will be denied that opportunity.  Many will be forced to return to violent, war-torn and dangerous countries with poor health care services.”

That the President will delay full enforcement of his decision to end DACA “in no way mitigates the harm that will be done to the 800,000 law-abiding persons who have achieved permits under DACA to work or study in the United States without fear of deportation” said ACP. “They are now at risk of losing their jobs, being forced to drop out of school, and being deported in just a matter of months.” 

ACP called on President Trump to reverse his decision and continue protections for those with DACA-status—even though there is virtually no chance that he will.  More likely, Congress will need to act, by enacting legislation to block the deportation of Dreamers and to create a pathway for citizenship, as proposed by S. 128, the Bar Removal of Individuals who Dream and Grow our Economy (BRIDGE) Act, and S. 1615, the DREAM Act of 2017.

ACP’s decision to stand up for Dreamers reflects our long-standing commitment to creating a national immigration policy that recognizes the enormous contributions that immigrants make to the United States, and to health care in particular.  In 2011, ACP issued a policy paper that called “for a national immigration policy on health care that balances legitimate needs and concerns to control our borders and to equitably differentiate in publicly supported services for those who fully comply with immigration laws and those who do not, while recognizing that society has a public health interest in ensuring that all resident persons have access to health care.”  Further, ACP asserted in this paper that “Any policy intended to force the millions of persons who now reside unlawfully in the U.S. to return to their countries of origin through arrest, detention, and mass deportation could result in severe health care consequences for affected persons and their family members (including those who are lawful residents but who reside in a household with unlawful residents— such as U.S.-born children whose parents are not legal residents), creates a public health emergency, results in enormous costs to the health care system of treating such persons (including the costs associated with correctional health care during periods of detention), and is likely to lead to racial and ethnic profiling and discrimination.”

On January 30 of this year, ACP’s Board of Regents released a comprehensive statement on immigration policy, expanding on the 2011 paper, which “strongly opposes discrimination based on religion, race, gender or gender identity, or sexual orientation in decisions on who shall be legally admitted to the United States as a gross violation of human rights.”  Based on this policy, ACP has opposed President Trump’s executive orders to bar persons from several majority Muslim countries from entering the United States. 

ACP also said that “Priority should be given to supporting families in all policies relating to immigration and lawful admission to the United States to live, study, or work.”  Accordingly, “ACP opposes deportation of undocumented medical students, residents, fellows, practicing physicians, and others who came to the United States as children due to the actions of their parents (‘Dreamers’) and have or are eligible for Deferred Action for Childhood Arrivals (DACA) status. We urge the administration to preserve the DACA action taken by the previous administration until such time that Congress approves a permanent fix. The College also urges Congress to promptly enact legislation to establish a path to legal immigration status for these individuals to ensure that ‘Dreamers’ are permanently protected from deportation.”

For ACP, concern about immigration policy and its impact on health care clearly is nothing new.  What is new, regrettably, is that the current administration has chosen to embrace immigration policies that are discriminatory against persons based on their religion and country of origin, threaten to split up families that have members here both lawfully and unlawfully,  make it less likely that immigrants who lack legal residency will access needed health care services, and now, threaten with the deportation of Dreamers, who for all practical purposes, are as American as the rest of us, having lived almost their entire lives in the United States, and who stand to contribute so much to our country if the country has the wisdom to welcome them.   
This is why it is more important than ever that doctors defend Dreamers, and others who would be harmed by the current administration’s ill-advised immigration policies.

Today’s question: what do you think of ACP’s response to President Trump’s decision to discontinue DACA?

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?