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?