The ACP Advocate Blog

by Bob Doherty

Wednesday, August 26, 2015

Why physicians must speak out against mass deportation of undocumented immigrants

Mass deportation, as proposed by Donald Trump, and echoed to varying degrees by other politicians, would have a catastrophic effect on the health of the approximately 12 million undocumented residents of the United States.  Physicians accordingly have an ethical responsibility to speak out, individually and collectively, for the health of these people, and against mass deportation.

That the medical profession is obliged to advocate for the health of all persons, without regard to their legal residency status, is well-established.  ACP’s Ethics Manual, Sixth Edition, affirms that “All physicians must fulfill the profession's collective responsibility to advocate for the health, human rights, and well-being of the public.”  “Health and human rights are interrelated,” it continues. “When human rights are promoted, health is promoted. Violation of human rights has harmful consequences for the individual and the community. Physicians have an important role to play in promoting health and human rights and addressing social inequities. This includes caring for vulnerable populations, such as the uninsured and victims of violence or human rights abuses. Physicians have an opportunity and duty to advocate for the needs of individual patients as well as society.”

It is indisputable that people who are undocumented, and at risk of deportation, are especially vulnerable to adverse and inequitable health consequences:

- “Worries about their legal status and preoccupation with disclosure and deportation can heighten the risk for emotional distress and impaired quality of health.”
- “Restricted mobility; marginalization/isolation; stigma/blame and guilt/shame; vulnerability/ exploitability; fear and fear-based behaviors; and stress and depression are specific to undocumented immigrants and have health and mental health implications.”
- The psychosocial impact of deportation include “the trauma of sudden and imposed family separation” . . . “drug use and less interaction with medical or treatment services (including HIV testing, medical care, and substance abuse treatment” . . .adverse “changes in family structure and stability. ”
- “The aftermath of deportation impacts entire communities as it instills fear of family separation and distrust of anyone assumed to be associated with the government, including local police, school personnel, health professionals and social service professionals.”

Such adverse health impacts would be exponentially higher if the United States were to attempt to remove by force every person who is in the country unlawfully.

Recognizing this danger, the American College of Physicians asserted in a 2011 position paper on immigrant access to health care 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.”

Instead of mass deportation, ACP advocated “for a national immigration policy on health care that balances the needs of the country to control its borders, provides access to health care equitably and appropriately, and protects the public’s health.”

In the same paper, the College also cautioned that a policy of mass deportation could compromise the patient-physician relationship, if it required that physicians report on the legal status of their patients:

 “Any law that might require physicians to share confidential information, such as citizenship status to the authorities, that was gained through the patient–physician relationship conflicts with the ethical and professional duties of physicians. National immigration policy should respect the boundaries of this relationship and the ethical obligations of physicians and not require physicians to reveal confidential information. Therefore, federal policies should not intrude upon a physician’s obligation to treat patients, regardless of legal status, and physicians should not be required to report on the immigration status of patients.”

Finally, ACP advocated that:

“U.S.-born children of parents who lack legal residency should have the same access to health coverage and government-subsidized health care as any other U.S. citizen” noting that “as outlined by the 14th Amendment to the U.S. Constitution, all persons born or naturalized in the U.S. and subject to the jurisdiction thereof are citizens of the U.S. and of the state wherein they reside. This means that a child born in the U.S. to immigrant parents automatically becomes a citizen . . . U.S.-born children should not be at a disadvantage from receiving the benefits of U.S. citizenship because of their parents’ immigrant status and fear of deportation.”

ACP clearly was prescient in anticipating the current debate over mass deportation and the citizenship of U.S. born children of undocumented persons, addressing the issue solely from the standpoint of advocating for the individual and collective health of the all persons, without regard to legal residency status.  But given that the direction of the debate has taken a decidedly wrong turn in the four years since ACP released its recommendations, it is high time for physicians, and their professional associations, to raise their voices now, individually and collectively, against mass deportation of undocumented persons, for the constitutionally-guaranteed right of their U.S. born children to have the same access to health coverage and government-subsidized health care as any other U.S. citizen,  and against any policy would require that physicians report on the on the immigration status of their patients or otherwise compromise their ethical obligation to provide care for all.

Today’s question:  Will you take up the call to speak out against mass deportation and for policies to ensure access to healthcare for all U.S. residents, regardless of legal residency status?

Monday, August 17, 2015

Escaping the echo chamber

Humans have a tendency to seek confirmation of our own beliefs, choosing to surround ourselves with like-minded people and information sources—a phenomenon that social scientists call the “echo chamber” effect.

For instance, if I asked my neighbors in my upscale Washington DC community about their views on a range of issues, they almost uniformly would tilt liberal: support for Obamacare (although some would have a preference for single payer), pro-gun control, belief in global warming and support for policies to mitigate it, and pro-gay marriage. If my neighbors only get their news and opinions from sources like the New York Times and MSNBC’s Rachel Maddow, they likely would conclude that their liberal views are held by most Americans, except for a “misguided” minority of people who have been “duped” into holding unscientific, illogical and contrary conservative views.

On the other hand, if people who live in “red state” communities were to ask their neighbors about their views on a range of issues, they almost uniformly would tilt conservative: opposition to Obamacare, anti-gun control, disbelief in global warming and opposition to policies to mitigate it, concern about gay marriage. If they only get their news and opinions from sources like the Wall Street Journal and Fox News’ Sean Hannity, they likely would conclude that their conservative views are held by most Americans, except for a misguided minority of people who have been “duped” into holding unreligious, illogical and contrary liberal views.

This is nothing new:  long before Fox News and MSNBC, Americans turned to highly partisan sources for news that reinforced their own views.  The University of Wisconsin’s Center for Journalism Ethics observes that in the 19th century, “‘The power of the press,’ one journalist candidly explained, ‘consists not in its logic or eloquence, but in its ability to manufacture facts, or to give coloring to facts that have occurred.’ Party newspapers gave one-sided versions of the news.  Papers in opposition to Andrew Jackson in 1828 attacked him for marrying a woman before her divorce had been finalized.  He was the violator of marital virtue, a seducer.  Jackson, one paper declared, ‘tore from a husband the wife of his bosom.’  Pro-Jackson newspapers insisted on the general’s innocence, and accused his critics of violating his privacy.  There was no objective, middle ground.”  (Donald Trump might have felt right at home!). Yet the extent of the echo chamber effect has ebbed and flowed.   By the early 20th century “most newspapers ceased to be party organs.”

Today, we seem to be in an era where the echo chamber effect is back in full force.   The Pew Research Center reports that “Republicans and Democrats are more divided along ideological lines – and partisan antipathy is deeper and more extensive – than at any point in the last two decades. These trends manifest themselves in myriad ways, both in politics and in everyday life. And a new survey of 10,000 adults nationwide finds that these divisions are greatest among those who are the most engaged and active in the political process.”  “’Ideological silos’” are now common on both the left and right” Pew continues:

“People with down-the-line ideological positions – especially conservatives – are more likely than others to say that most of their close friends share their political views. Liberals and conservatives disagree over where they want to live, the kind of people they want to live around and even whom they would welcome into their families.”  63% of “consistently conservative” people say that “most of my friends share my political views”; 44% of “mostly conservative” people say the same.  Twenty-five percent of “mostly liberal” people, and 49% of “consistently liberal” people, report that most of their friends share their political beliefs.

Such ideological silos, reinforced by our own respective echo chambers, have contributed to an antipathy to the kinds of political compromises that are necessary for government to work, breeding self-reinforcing cynicism and anger about our political system and our politics.

(On a more positive note, Pew finds that “the majority [of Americans) do not have uniformly conservative or liberal views. Most do not see either party as a threat to the nation. And more believe their representatives in government should meet halfway to resolve contentious disputes rather than hold out for more of what they want.  Yet many of those in the center remain on the edges of the political playing field, relatively distant and disengaged, while the most ideologically oriented and politically rancorous Americans make their voices heard through greater participation in every stage of the political process.”)

So what will it take to turn around the polarization that is dividing the country between uncompromising ideologues, paralyzing the political process, and poisoning our politics?

Well, the obvious answer is to seek out people who don’t think like ourselves, and diversify our sources of news and opinion to seek a range of opinions.  This, of course, is easier said than done, when many Americans say they want to be surrounded only by people who think the same way, when the news media and social media feeds on and fans such divisions.  Yet each of us can make the choice, on our own, to take a step outside of our own echo chambers, and encourage others to do the same.

In my own case, in my role as a spokesperson for the politically-diverse 143,000 members of the American College of Physicians, I make it a point to step outside the Washington DC echo chamber and travel to ACP chapters throughout the country, red state, blue state, and everything in between, to converse with physicians who represent the full spectrum of political persuasions.  This fall, for instance, I will be traveling to chapter meetings in Omaha, Nebraska; Wichita, Kansas; and Osage Beach, Missouri, all red state chapters; and Monterey, California and Seattle, Washington, blue state chapters.  I know from experience I will get an earful from internists whose political views span the spectrum from right to left (just like the comments I get on my blog posts)!

Nicholas DiFonzo, a psychologist who has studied the echo chamber effect, found that “when Republicans and Democrats were put in separate groups and each group was asked to discuss a derogatory rumor about the other party (e.g., ‘Republicans are uneducated;’ ‘Democrats give less to charity’) beliefs in these rumors polarized in predictable directions. When the discussion groups were mixed, this did not happen.”

Advocacy organizations that want to step outside their echo chambers must therefore ensure that the decision groups where policies are discussed and debated are inclusive of people who hold different policy and political perspectives.

To illustrate, ACP’s Health and Public Policy Committee (HPPC), the committee that developed recent policy papers on firearms, the Affordable Care Act, vaccine exemptions, LGBT persons’ access to care, and other controversial issues, currently has a membership of 13 physicians and one medical student.  HPPC’s members hail from Pennsylvania, New York (upstate), Texas, Wyoming, Kentucky, Washington (state), Minnesota, Tennessee, Arizona, Nebraska, and Wisconsin, a true mix of red, blue and swing states.  From what I know of their views as expressed by their comments at committee meetings, HPPC’s membership is just about evenly divided between conservative- and liberal-leaning physicians, Republicans and Democrats. HPPC’s members include physicians who own guns for hunting and personal protection and physicians who would never consider owning a gun.  It includes internists who live in small rural towns and internists who live in big cities; academic physicians and private practice doctors; young medical students through more senior physicians; physicians who own their own practices and physicians who are employed by large systems, men and women, the whole wonderful diversity found in ACP’s 143,000 members!  In addition, HPPC conducts an evidence-based review of the research literature before recommending policies to the Board of Regents, ensuring that ACP’s policies are not based just on the personal opinions of its members, but the evidence of what is effective in improving healthcare.

I believe that ACP’s approach to policymaking is a model that can and should be embraced by other physician advocacy organizations.  Before adopting policy, make an effort to visit physicians around the country to find out their concerns.  Make sure that the physicians who are elected or appointed to the governing bodies that develop your organization’s policies have a good mix of political perspectives, types of practice, age, gender, race, ethnicity, career stage, and age.  Put their opinions to the test by reviewing the evidence from research studies, some of which may uphold their initial views, others may cause them to reconsider them. Seek broader input from your membership and outside parties, continue to debate the issues, as informed by the evidence and the diverse views provided, and then reach a consensus. Once your organization adopts its policy recommendations, continue to welcome dissenting views.

Call it the anti-echo chamber approach to developing policy!

Today’s question: what will you do to step outside your echo chamber?

Thursday, July 30, 2015

Medicare and physicians, 50 years together: it’s complicated

Fifty years ago today, President Lyndon Baines Johnson signed Medicare (and Medicaid) into law.   Medicare’s relationship with physicians since then can best be described as a complicated one.

First, recall that Medicare became law notwithstanding the American Medical Association’s fierce opposition to it. Three years prior to its enactment, AMA President Ed Annis warned that "We doctors fear that the American public is in danger of being blitzed, brainwashed, and bandwagoned" by the Kennedy administration’s proposal to provide compulsory health insurance to the elderly.  The AMA continued to fight tooth-and-nail against Medicare, even after the Johnson administration took up the cause following President Kennedy’s assassination.   After Medicare was enacted, however, the AMA came to the table to negotiate with the administration on its implementation. The ACP, for its part, did not participate in the debate over Medicare’s enactment, but once it became law, the College “began to realize that it could no longer limit its mission to education, professional standards, and fellowship: it had to became an advocate in policy and political arenas” as Dr. Lynne Kirk and I recount in the chapter "The American College of Physicians and Public Policy" in the recently-published Serving Our Patients and Profession: A Centennial History of the American College of Physicians, 1915-2015 (available for purchase in the ACP Catalog).

Second, despite the AMA’s forebodings, physicians and their patients have flourished under Medicare.  Before Medicare, seniors were often uninsured and many lived in poverty.  “While 48 percent of the elderly lacked health coverage in 1962, today just 2 percent do. And while the 15-year increase in life expectancy at age 65 achieved between 1965 and 1984 cannot be wholly attributed to Medicare, without its coverage many elderly Americans would simply not have had access to the medical advances that also have contributed to rising longevity” observes the Commonwealth Fund.  “In the early 1960s, the choices for uninsured elderly patients needing hospital service were to spend their savings, rely on funding from their children, seek welfare (and the social stigma this carried), hope for charity from the hospitals or avoid care altogether” wrote Rosemary Stevens, a sociologist at the University of Pennsylvania, quoted in the Politifact discussion of 'Were the early 1960s a golden age for health care?'  Before Medicare, much of the care that physicians provided to seniors was on a charitable or uncompensated care basis.  After Medicare, demand for medical care grew, pumping hundreds of billions of dollars into care provide by physicians.  It should be no surprise to anyone, then, that physicians saw huge gains in payments and their incomes: between 1967 and 1993 physician payments from Medicare grew at an average annual rate of 13.7 percent.  And despite price controls and spending caps, like the recently repealed Medicare SGR formula, Medicare per capita payments to physicians have continued to increase to the present day, although payments and incomes for primary care physicians have lagged behind other specialists.  In addition, U.S.-trained physicians who entered practice after 1965 have benefited from Medicare paying for their post-graduate education.

Yet my sense is that many physicians today look at Medicare with a complicated set of emotions: appreciation for all of the good it has done for their patients, acknowledgement that physicians themselves have greatly benefited from the infusion of public dollars, yet concern that Medicare has begat greater government intervention in the patient-physician relationship, as evidenced by a never-ending cascade of rules,  mandates, and performance measures imposed on harried doctors and their patients.

 Looking forward, most physicians are probably aware that Medicare will become an even bigger part of their daily lives, with more than 10,000 baby-boomers becoming Medicare-eligible each day for the next 20 years, yet they likely view this development with uncertainty and some trepidation.  Can the country afford it?  Who will pay for it?  Will greater government spending lead to even greater government controls, regulations and paperwork?  Will payments be fair and adequate?  Will Medicare really begin to do something meaningful to reduce the disparities in payments between primary care and other physician specialties?  Will pay-for-performance really improve patient care, or just be another hassle with unintended adverse consequences for patients?

These are all good questions, with no clear answers.  But on the most important question-- have physicians and their patients benefited over the past half century from Medicare?--the answer has to be an unequivocal yes.  The challenge going forward is to continue to sustain, support and fund the Medicare in a fiscally-responsible way, for the next 50 years and longer, while empowering physicians to improve care to patients without tying their hands with more unnecessary and counterproductive mandates.

Today’s question: How would you characterize the past, present and future relationship between Medicare with physicians on the program’s 50th birthday?

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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