Thursday, November 30, 2017

Warning: Congress’ tax reform bill is bad for your health

If legislation harmful to health was required to carry a Surgeon’s General warning like tobacco, the tax bill being voted on today by the Senate would surely qualify.  It will harm health care for many millions of Americans, leading to more uninsured persons and higher premiums.  It also will lead to automatic scheduled cuts to Medicare and many other programs that are vital to health care.  Yet despite all of this, the Senate is poised to vote later today on the Tax Cuts and Jobs Act, and right now, it looks more likely than not it will pass the chamber by a party-line, Republican only majority vote (all Democrats are expected to vote against it).

Here are 2 things you need to know about the bill and how it will hurt patients and their doctors:

1.  By repealing the Affordable Care Act (ACA) requirement that people purchase a qualified health insurance plan or pay a penalty to the government, people who buy coverage in the individual insurance market will see double-digit premium increases, many insurers will bolt from the markets resulting in less competition and choice, and 13 million people will become uninsured. The individual insurance requirement is needed because without it, many people will wait until they get sick to enroll in coverage, knowing that the ACA prohibits insurers from charging sick people more.  With more sick people and fewer healthy people in the insurance pool, insurers will have no choice but to jack up premiums for everyone, or simply, decide not to see insurance at all in the individual market.  The American Academy of Actuaries has warned that repeal of the individual mandate would lead to premium increases, weaken insurer solvency, cause an increase in insurer withdrawals from the market, and "lead to severe market disruption and loss of coverage among individual market enrollees." According to a report by the non-partisan Congressional Budget Office, repealing the individual mandate would increase the number of uninsured by four million in 2019 and 13 million in 2027 and "average premiums in the non-group market would increase by about 10 percent in most years of the decade."

2.  Medicare and other vital health care programs will be cut by billions of dollars to pay for the tax cuts that go mainly to corporations.  Under a 2010 law called Statutory Pay-As-You-Go Act (SPAYGO), any law that will add to the federal deficit must be paid for with spending cuts, increases in revenue or other offsets.  Automatic cuts are imposed, through budget sequestration, if Congress does not enact the required offsets.  The Senate tax bill is projected to increase the federal deficit by $1.5 trillion over the next 10 years, so automatic across-the-board cuts will be triggered next year unless Congress passes separate bills to offset the cost in some other way.  Medicare would be automatically cut by $25 billion in 2018, which will result in an average cut of 4 percent in Medicare payments for health care services provided by  doctors, hospitals, clinical laboratories, graduate medical education programs, and other "providers."  For doctors, this cut will be on top of a near 3 percent cut that Congress previously imposed on them in 2013, 14, 15, 16, and 17—combined, Medicare payments to physicians will have been cut 7 percent less as a result.   Many other vital health programs, like the Centers for Disease Control and Prevention (which we all count on to help prevent infectious diseases, whether it is this year’ seasonal flu, or global pandemics that could sicken millions worldwide), will also be subjected to deep, across-the-board spending cuts to pay for the tax bill; some will be completely eliminated.  The New York Times has a very useful list and graphic of what will be cut, and by how much.

Is it any wonder then that the American College of Physicians, the nation’s largest physician specialty society, and second largest physician membership organization, came out today in opposition to the Senate bill? 

Should the Senator ignore ACP’s advice and pass the bill, it doesn’t mean that the fight is over, since the Senate would have reach an agreement on a identical tax bill that both chambers could support (the House passed its own, but different version, several weeks ago).  But any Senator who votes for Tax Cuts and Jobs Act must be held accountable by their constituents for  voting for a bill that is bad for their health, while disregarding doctors’ warnings about the harm it will do. 

Tuesday, October 31, 2017

Before Patients Over Paperwork, there was Patients Before Paperwork

The Centers for Medicare and Medicaid Services’ (CMS) new initiative to reduce the paperwork burden on doctors and patients, deemed Patients Over Paperwork, is remarkably similar to ACP’s campaign, called Patients Before Paperwork, to accomplish the same.   Whether the agency was directly inspired by ACP’s campaign, down to coming up with an almost identical name for it, or came up with a similar moniker on its own, what matters is that the message ACP has been pushing for more than two years now, that doctors are being squeezed by unnecessary administrative tasks that take time away from patients, is being heard now at the highest reaches of the federal government.  What I do know is that prior to CMS’ launch of the initiative last week, ACP has held several meetings with and previously wrote to CMS officials pressing our recommendations to reduce unnecessary regulations and other administrative tasks. 

In her remarks yesterday to the Health Care Learning and Action Network Fall Summit, CMS Administrator Seema Verma explained what CMS hopes to accomplish from Patients Over Paperwork:

Since assuming my role at CMS, we are moving the agency to focus on patients first. To do this, one of our top priorities is to ease regulatory burden that is destroying the doctor-patient relationship. We want doctors to be able to deliver the best quality care to their patients. 

We often hear about this term – “regulatory burden” – but what does it actually mean? Regulations have their place and are important to ensuring quality, integrity, and safety in our health care system. But, if rules are misguided, outdated, or are too complex, they can have a suffocating effect on health care delivery by shifting the focus of providers away from the patient and toward unnecessary paperwork, and ultimately increase the cost of care. 

I saw this during a recent trip to Hartford, Connecticut, where I met with providers.

One told me she was going to close her practice after decades in medicine because spending so much time away from her patients doing paperwork just wasn’t worth it for her anymore. 

In Cleveland, Ohio, I heard a story of a physician who was overwhelmed by having to personally fax patient records…in 2017 we are still faxing patient records. Just thinking about that frustrates me…having to do it, I’m sure is even worse. 

Doctors are frustrated because they got into medicine to help their patients. But, paperwork has distracted them from caring for their patients, who often have waited weeks, if not months, for the brief opportunity to see them. 

We have all felt this squeeze in the doctor’s office…we have all seen our doctors looking at a computer screen instead of us. I hear it from patients across the country. This must change.

The primary focus of a patient visit must be the patient. Just last week, CMS announced our new initiative “Patients Over Paperwork” to address regulatory burden. This is an effort to go through all of our regulations to reduce burden. Because when burdensome regulations no longer advance the goal of patients first, we must improve or eliminate them.   

At CMS, our overall vision is to reinvent the agency to put patients first. We want to partner with patients, providers, payers, and others to achieve this goal. We aim to be responsive to the needs of those we serve. We can’t do that if we’re simply telling our partners what to do—instead of listening and—most importantly—having our policies be guided by those on the 
front lines serving patients. 

Touche!  ACP couldn’t have said it better.  Today, we sent a letter to Administrator Verma to pledge our support for her Patients Over Paperwork initiativeWe shared with her our policy paper, Putting Patients First By Reducing Administrative Tasks in Health Care, which proposes an entirely new framework to evaluate the intent and impact of existing or proposed new tasks, so that those that are not justified by their intent, or that have such an adverse impact on doctors and patients that they cannot be justified even if the original intent is sound, can be challenged and then eliminated or at least ameliorated.  We urged that CMS adopt this framework to evaluate its own regulations and administrative tasks.

ACP’s letter also advised her that we were encouraged by her announcement of a new “Meaningful Measures” initiative to ensure that quality measures, which are a critical component of paying for value, are streamlined, outcomes-based, and truly meaningful to clinicians and their patients.  This initiative appears to be well aligned with ACP's comments to CMS last year on the Quality Measure Development Plan. 

Whether it is putting patients before or above paperwork—both are needed—it is great news for doctors that ACP’s two-year plus campaign to reduce administrative tasks on physicians has found support in the highest reaches of government, coming from the head of an agency, CMS, that can do more to ease red tape than any other. 

Today’s question: if you were CMS Administrator Verma, what is the first Medicare administrative task you would recommend she review?

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?

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? 

Thursday, April 27, 2017

How to make a terrible, horrible, no good, very bad bill even worse

It’s BACK—the terrible, horrible, no good, very bad bill to repeal and replace the Affordable Care Act (ACA).  Last month, I blogged about how the bill, called the American Health Care Act, was the worst legislation for health care of any that I have seen in 38 years of advocacy for doctors and patients.  While it was good that this bill was pulled by House Speaker Paul Ryan on March 24 due to a lack of support among Republican lawmakers, he may bring it back for a vote as early as this Friday, April 28. Only, this time, believe it or not, with changes designed to win support from hard-right conservatives that make the original bill even worse for patients.  I guess we will have to call this version the even more terrible, horrible, no good, very bad, bill for patient care. 

On Tuesday, ACP was able to confirm that the House GOP leadership and Trump administration were close to reaching a deal with 20 or so of the most conservative lawmakers, the self-described “Freedom Caucus.” Unfortunately, as explained in a detailed letter that we sent to all members of Congress later that day, the proposed “compromise”  would gut existing law protections for people with preexisting medical conditions and requirements that insurers cover essential benefits by allowing states to opt-out of such requirements.  And today, we joined in a coalition letter with 5 other physician membership organizations, collectively representing over 560,000 physician and medical student members, expressing our combined opposition to the “compromise” bill. 

Let me be clear why the compromise makes a terrible bill even worse:

It would allow states to obtain “waivers” to opt-out of the ACA’s prohibition on insurers charging more to people with preexisting conditions.  That’s right, the “compromise” would return us to the pre-ACA days when states often allowed insurers to charge whatever they wanted to people with conditions like asthma, diabetes or dozens of other conditions that were considered to be “declinable” by insurers.  As ACP explained in its letter to Congress, “Before the ACA, insurance plans sold in the individual insurance market in all but five states typically maintained lists of so-called "declinable" medical conditions—including asthma, diabetes, arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer in the past 10 years. Even if a revised bill would not explicitly repeal the current law’s guaranteed-issue requirement—which requires insurers to offer coverage to persons with pre-existing conditions like these—guaranteed issue without community rating allows insurers to charge as much as they believe a patient’s treatment will cost. The result would be that many patients with pre-existing conditions would be offered coverage that costs them thousands of dollars more for the care that they need, and in the case of patients with expensive conditions like cancer, even hundreds of thousands more.”

The bill does say that states would have to set up or participate in high risk pools for people with preexisting conditions in order to be approved for a waiver.  But we know from experience that underfunded high-risk pools, which were common before the ACA, typically had very high premiums and deductibles, long wait lists, and limited benefits, making the coverage unaffordable for those who need it most. And the amended AHCA does not provide anywhere near the amount of money that could make high risk pools viable, and does not set any standards or funding levels that states must meet to ensure that coverage under the pools are affordable and benefits are adequate.

It would allow states to obtain “waivers” to opt-out of the ACA’s requirement that all insurers cover 10 categories of essential medical care services.   We know from the pre-ACA days what this could mean for patients: in many states, insurers will once again be allowed to decline coverage of needed benefits like physician and hospital visits, maternity care and contraception, mental health and substance use disorder treatments, preventive services, and prescription drugs. “Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance-use disorder services, 18% did not have mental-health services and 9% did not have coverage for prescription drugs,” ACP wrote to Congress.  “A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 more for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care. Such increased costs would make it practically impossible for many patients to avail themselves of the care they need. The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.”

And repeal of the essential benefit requirements would mean that insurers would no longer be required to cover substance use disorder treatments.  “Allowing states to eliminate the [Essential Health Benefits] will threaten our nation’s fight against the opioid epidemic,” ACP told Congress. “A study concluded that with repeal of the ACA, ‘approximately 1,253,000 people with serious mental disorders and about 2.8 million Americans with a substance use disorder, of whom about 222,000 have an opioid disorder, would lose some or all of their insurance coverage.’”

And the “compromise” would even gut the ACA’s ban on insurers imposing annual or lifetime limits on coverage, because under current law insurers are only banned from imposing dollar limits on services that are included in the mandatory essential health benefits package.   If a state, for example, decided that chemotherapy was no longer an essential benefit in your state, there would be nothing stopping insurers from putting a $100,000 lifetime dollar limit (if even that much) on coverage for your cancer treatment.  After that, sorry, you’d be on your own, forcing choices like lose your house, or lose your health care, you decide. 

The bill’s gutting of prohibition on annual and lifetime coverage limits would affect not only people who get coverage  through health plans sold through the ACA’s marketplaces, but also the vast majority of people who get coverage from their employer, as analyst Tim Jost explains today in a Health Affairs blog.  “Since the ACA’s prohibitions of lifetime and annual limits and cap on out-of-pocket expenditures also only apply to essential health benefits, states granted a waiver would be able to define these protections as well. The changes to the lifetime and annual limits and to the out-of-pocket caps could potentially apply as well to large group and self-insured employer plans.” Jost also observes that although the amendment says that “’nothing in this Act shall be construed as permitting insurers to limit access to health coverage for individuals with preexisting conditions,” but that is precisely what health status underwriting [which could return in states that obtain waivers] does. Health status underwriting could effectively make coverage completely unaffordable to people with preexisting conditions.”  

And remember, even before the proposed compromise made the AHCA even worse, the original bill was unacceptable because it cut, capped, and block granted Medicaid, ended funding for Medicaid expansion, and replaced the ACA’s income-based premium and cost-sharing subsidies with regressive age-based ones that would make premiums and deductibles unaffordable for older and sicker patients, resulting in 24 million more uninsured persons, according to the Congressional Budget Office.

So if politicians tell you that people with preexisting conditions are protected by the amended AHCA, don’t believe them.  They are either lying, or more charitably, don’t understand what is being proposed.  And if they say premiums will be lower, keep in mind that while this might be true for some young and healthy people, it would be at the expense of making health care unaffordable for older and sicker patients.

Yet Speaker Ryan is counting votes right now in the hope of bringing the bill to a vote by Friday so it can be passed by the House of Representatives during President Trump’s first 100 days.

Don’t let Speaker Ryan and President Trump bring their even more terrible, horrible, no good, very bad bill back from the dead.  Call your member of Congress today, especially if he or she is a moderate Republican or one in a competitive district, at 202-224-3121 and help us put a nail in the AHCA’s coffin.  (And even if you have called before, they need to hear from you again).  Don't put this off, tomorrow could be too late.  Patients are depending on you.

Today’s question: did you make your call to Congress to urge them to vote no on the even more terrible, horrible, no good, very bad AHCA!

Thursday, March 23, 2017

In 38 years advocating for doctors, patients I've never seen a bill that will do more harm to health

When I tweeted this on Monday morning about the House GOP bill to “repeal and replace” the Affordable Care Act, I had no idea that it would result in me appearing on MSNBC’s Last Word with Lawrence O’Donnell or that it and my other tweets would be referenced by NBC News, a New York Times editorial, or for that matter, a retweet from singer-songwriter John Legend!

I mention all of this not for reasons of self-promotion, but to share with readers of this blog why I firmly believe that the GOP “repeal and replace” bill, expected to be voted on later today in the House of Representatives, will, if enacted, do more harm to health than any I have seen in nearly four decades of advocacy on behalf of internal medicine.

Here are my reasons:

First, never before I have I seen legislation advanced to the floor of either the House or Senate that would take health insurance coverage and consumer protections away from tens of millions of Americans; not once, not ever.  In fact, I doubt there is any time in history where Congress is being asked to vote to take health care away from so many.  Instead, the trajectory has been to expand health insurance coverage, not take it away: from enactment of Medicare and Medicaid in 1965, to the bipartisan Children’s Health Insurance Program becoming law in 1997; to creation of the Medicare Part D prescription drug program, signed into law by President George W. Bush on December 8, 2003; to the Affordable Care Act becoming law on March 23, 2010, exactly seven years ago.   Up until now, no President of either political party, and no Congress, has championed a measure that would result in a wholesale rollback of coverage and access to care for people who have gained it under prior laws.

Second, and most importantly, the American Health Care Act would do incalculable harm to the health of tens of millions of Americans.  This is not a political assessment, it’s based on what the bill actually proposes to do and evidence (from independent and non-partisan researchers) on how patients will be affected.

  • It makes radical changes to the Medicaid program’s structure and financing; the non-partisan Congressional Budget Office (CBO) estimates that 14 million low-income kids, adolescents and adults will lose their Medicaid coverage as a result. By putting a per-enrollee cap on the federal contribution to Medicaid, or offering states a “block grant” option (both of which means that the states are left having to make up any difference between the federal contribution and the costs of providing benefits to Medical enrollees), and phasing out the higher federal contribution for states that have expanded Medicaid to persons with incomes up to 138% of the Federal Poverty Level (FPL), the CBO found that the total federal contribution would be cut by $890 billion over the next decade, a whopping 25% cut!  Because most states are required by law to balance their budgets, a reduction in and/or a cap on federal matching funds will necessarily require them to greatly reduce benefits and eligibility and/or impose higher cost-sharing for Medicaid enrollees, most of whom cannot afford to pay more out of pocket—or alternatively and concurrently, reduce payments to physicians and hospitals (including rural hospitals that may be forced to close), enact harmful cuts to other state programs or raise taxes.  The phase-out of funding for Medicaid expansion, and the retroactive (to March 1) freeze on providing enhanced funding to any additional states that might have expanded the program, will eliminate one of the most effective programs ever in driving down the uninsured rate to historic lows.  Some Republicans surely recognize the importance of preserving funding for Medicaid expansion in their states: just yesterday, Michigan (GOP) Governor Rick Snyder wrote to the state’s congressional delegation urging them to vote against the AHCA.

  • It would reward states with higher federal funding if they impose punitive work or job search requirements on certain Medicaid enrollees.  If states adopt such requirements, current Medicaid enrollees (or those seeking to enroll) would not be eligible for the program if they are unable to prove to state Medicaid officials they have a job or are in job-training, or that they meet the conditions specified in the statute to be exempted from the requirement.  Medicaid is not a cash assistance or job training program; it is a health insurance program and eligibility should not be contingent on whether or not an individual is employed or looking for work.  While an estimated 80% of Medicaid enrollees are working, or are in working families, there are some who are unable to be employed because they have behavioral and mental health conditions, suffer from substance use disorders, are caregivers for family members, do not have the skills required to fill available positions, or there simply are no suitable jobs available to them.  Skills- or interview-training initiatives, if implemented for the Medicaid population, should be voluntary, not mandatory.  ACP’s Ethics, Professionalism and Human Rights Committee has stated that it is contrary to the medical profession’s commitment to patient advocacy to accept punitive measures, such as work requirements, that would deny access to coverage for people who need it.

  • Although not final, it’s been widely reported that Speaker of the House Paul Ryan will add to the version of the bill being voted on today a repeal of the ACA requirement that private insurers in the individual insurance market must cover 10 categories of essential services including physician and hospital visits, prescription drugs, cancer screening tests and other preventive services, mental health treatment, and many other services.  Even before this change, the AHCA repeals the requirement that Medicaid programs cover such benefits.  Any reduction in Medicaid coverage for substance use disorder treatments would exacerbate the grave opioid misuse epidemic that is devastating individuals, families and communities across the country.  Women’s access to health care would particularly be at risk, because the AHCA eliminates required coverage for childbirth and maternity and for contraception. 

  • Prior to passage of the ACA, 62% of individual market enrollees did not have coverage of maternity services, 34% did not have substance use disorder services, 18% did not have mental health services and 9% did not have coverage for prescription drugs. A recent independent analysis found that the AHCA’s repeal of current law required benefits would result in patients on average paying $1,952 for cancer drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient admission for mental health; $4,555 for inpatient admission for substance use treatment; and $8,501 for maternity care.  Such increased costs would make it practically impossible for many patients to avail themselves of the care they need.  The result will be delays in getting treatment until their illnesses present at a more advanced, less treatable, and more expensive stage, or not keeping up with life-saving medications prescribed by their physicians.

  • The AHCA’s regressive age-based tax credits, combined with changes that will allow insurers to charge older people much higher premiums than allowed under current law, will make coverage unaffordable for poorer, sicker, and older persons, as well as for persons who live in high health care cost regions. The AHCA replaces the ACA’s income-based and cost-sharing subsidies with age-based advance refundable tax credits worth only $2,000 to $4,000 for an individual.  These subsidies will be inadequate for most people to be able to buy affordable coverage, and would especially put vulnerable persons at risk, including low-income families and children, children and adults with special health care needs, and older persons with chronic illnesses who are not yet eligible for Medicare.  Indeed, a study based on the value of these tax credits determined that only 34% of a beneficiary’s medical costs would be covered. This is much less than the ACA, which ranges from about 60% to 94%, depending on the level of plan. By repealing the current law cost-sharing subsidies for persons with incomes up to 250% of the FPL, the AHCA would make out-of-pocket costs too high, and health care unaffordable, for many poorer patients. Without cost-sharing reductions, enrollees will be exposed to higher deductibles, co-payments and other cost sharing, potentially discouraging patients with limited financial means from seeking medically necessary care.  The AHCA also establishes a set amount for the tax credits per individual, without any adjustment for differences in the cost of care by locality.  This will result in the tax credits being insufficient to make coverage affordable for patients in high health care cost areas, especially older, poorer  and sicker ones.

  • The AHCA discriminates in the awarding of federal grant funds and/or Medicaid and Children’s Health Insurance Program funding to women’s health clinics that are qualified under existing federal law for the provision of evidence‐based services including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.  This provision, targeted at Planned Parenthood, reduces women’s access to evidence‐based services offered through the clinics including, but not limited to, provision of contraception, preventive health screenings, sexually transmitted infection testing and treatment, vaccines, counseling, rehabilitation, and referrals.

  • The AHCA eliminates funding for Prevention and Public Health Fund, which provides billions in dollars to the Centers for Disease Control and Prevention to prevent and control the spread of infectious diseases like flu, Zika, and epidemics and pandemics.  

I could go on and on with other reasons why Congress should vote down the American Health Care Act but I think (hope) you get the point: this bill is a monstrous and unprecedented assault on coverage and access to care for many millions of Americans, and especially, the most vulnerable of our neighbors: those who are older, poorer and sicker.  It is by far the worst piece of health-related legislation I have seen since I first started working for the American Society of Internal Medicine (which merged with ACP in 1998) when Jimmy Carter was president.  It must be stopped, now.

Today’s questions: What do you think of the AHCA, and what are you doing about it?

Wednesday, February 22, 2017

Mr. President: are foreign-born doctors and sick children “bad people”?

President Trump argues through his Twitter posts that his administration’s travel ban on immigrants and refugees from 7 majority-Muslim countries, currently on hold because of court rulings against it, is about keeping “bad people” out of the country.  Commenting on the initial ruling by a federal judge suspending the ban, which was then upheld by a 10-1 ruling by a federal appeals court, President Trump tweeted: 

“The judge opens up our country to potential terrorists and others that do not have our best interests at heart. Bad people are very happy!” 

“Because the ban was lifted by a judge, many very bad and dangerous people may be pouring into our country. A terrible decision.”

“What is our country coming to when a judge can halt a Homeland Security travel ban and anyone, even with bad intentions, can come into U.S.?”

Rather than continuing to fight it out in court, though, the administration has announced that it will issue a revised executive order this week, one that it believes will pass muster with the courts. We will see what the new order says and if the courts agree.

From the standpoint of what’s best for health care, though, ACP believes that it is essential that the revised order discontinue the policy of discriminating against foreign-born physicians and medical students, especially Muslims, from the 7 designated countries, and thousands of refugees from them seeking shelter in the United States.

The fact is that rather than keeping out “bad people” who want to do us harm, President Trump’s executive order denied travel to many physicians who live in the United States with valid visas, physicians who provide care to hundreds of thousands of patients.  Among them are:

Dr. Chalak Berzing, an Iraqi Muslim immigrant physician/cardiologist who has won the trust of an overwhelmingly conservative, working class town in Appalachia. President Trump, is Dr. Berzingi among the “bad people” you want to keep out?

Dr. M. Ihsan Kaadan, a Syrian doctor who treated patients suffering from the horrors inflicted on the civilians of Aleppo, Syria; he later was granted a visa to enter the United States to continue his studies at Brandeis and his internal medicine residency training at Massachusetts General.  “In hopes that leaders and politicians around the world reconsider any plans to ban refugees who seek to escape brutal wars and other human tragedies” Dr. Kaadan recently wrote of his experiences:

“I am a Muslim and I am from Syria, I came here fleeing a brutal war that has killed more than 400,000 men, women, and children. I have the features that make me look like what some people think of as terrorist. But I am not a terrorist. In fact, I’m the opposite — I am a patriot for America and for Syria. I want to serve the country that opened its doors to me and also help my home country.” 

President Trump, Is Dr. Kaadan among the “bad people” you want to keep out?

Drs. Kaadan and Berzing are hardly alone.  There are 15,000 physicians from across the United States that are from the 7 countries subject to the travel ban, many of whom are providing care to Americans in underserved communities.  Even if the executive order would allow them to remain in the U.S. as long as they had valid visas, the travel ban placed them at risk of not being able to reenter the U.S. if they traveled home to see their families—say to see an ailing aged parent. In fact, there were at least three physicians in U.S. internal medicine residency programs, ACP members, who were traveling abroad at the time the executive order was issued and were turned away from re-entering the United States. And, according to the Association of American Medical Colleges, there are currently 260 applicants from the affected countries among the 35,000 people seeking residency and fellowship positions in this country. 

President Trump, are these 15,000 physicians seeking to train in the U.S. and provide care to the most underserved Americans among the “bad people” you want to keep out?

Let’s also not forget the sick refugee kids and their families, already vetted and approved for visas, who were denied entry to U.S. borders, including tens of thousands of Syrian children and their families seeking shelter from horrible violence, deprivation and death, and babies like this four-month-old Iranian child in urgent need of brain surgery who was turned away when the executive order went into effect. 

President Trump, are these children among the “bad people” you want to keep out?

The American College of Physicians has taken a firm stance against discrimination in immigration policy based on religion and in strong opposition to the President’s executive order, and in support of comprehensive policies to reform immigration laws and policies to allow physicians and medical students with approved visas to travel freely to and from the United States, to protect “Dreamers” from deportation, and to expand the number of refugees accepted into the United States, particularly those with urgent medical needs. We have also joined with 11 other internal medicine membership organizations to urge the Department of Homeland Security to immediately implement changes to lift restrictions on travel for physicians and medical students with approved visas and to prioritize admitting refugees who need medical care.

The Trump administration still has a chance to get things right this time in its revised executive order, by lifting discriminatory travel restrictions on Muslim physicians and medical students and refugees who have been thoroughly vetted and approved for visas to travel to and from the United States.  Let’s hope it does, because maintaining the current policy in some other form is bad for health care, bad for medical education, and bad for the millions of patients who get their care from foreign-born physicians—and for many refugees, it’s a matter of life and death. 

Today's question: What do you think of President Trump's travel and immigration ban and ACP's advocacy to overturn it?