Holding Professional Societies Accountable

Shortly after Donald Trump nominated Dr. Tom Price to serve as Secretary of the Department of Health and Human Services, the American Medical Association, the Association of American Medical Colleges, and the American Academy of Family Physicians released statements supporting his nomination without reservation or qualification.

Many doctors were shocked to see these endorsements from their professional organizations knowing Dr. Price’s legislative track record as Representative from Georgia’s 6th district since 2005. As the New York Times editorial board describes in detail, Dr. Price has repeatedly acted against the interest of Americans’ health and well-being during his time in Congress. For example:

  • He repeatedly voted for legislation to dismantle the Affordable Care Act, threatening to eliminate the health insurance of tens of millions of Americans.
  • He introduced legislation to defund Medicaid for millions of low-income patients who rely on it for life saving medical care.
  • He voted against expansion of the SCHIP program which provides health insurance coverage for children.
  • He repeatedly voted for legislative interference in women’s medical decision-making around their reproductive health and is rated at 0% by the Planned Parenthood Action Fund.

In other words, although Dr. Price earned his MD from an accredited institution, his actions have demonstrated little respect for the Hippocratic oath.

The reaction of physicians was swift and fierce. Thousands of doctors publicly denounced the AMA. An equal contingent of medical students condemned the AAMC. The National Physicians Alliance joined the fray. In response, the AMA and AAFP privately sent emails to their members reassuring them that these organizations’ values remained unchanged, but without public advocacy for those values, what meaning do they have?

As physicians, doing everything in our power to promote the health and well-being of our patients is not a corny mission statement to copy-and-paste onto a website and ignore when it’s inconvenient. It is the driving force of our clinical, academic, and political practice.

In 2016, when there is so much at stake for our most vulnerable patients, it is a time for personal and professional courage. It is time to call upon our professional societies to stand with us in the fight to ensure that all Americans have access to high quality medical care without legislative interference in the doctor-patient relationship. It is time for these organizations to state clearly the patient-centered principles that they believe in most strongly, and to advocate for these principles on every level.

Opportunities for action (list will be updated)

  1. Call your congressional representatives and voice your support for the greater access to healthcare services and opposition to Tom Price’s nomination. 
  2. Open letter to the AAFP from family doctors
  3. Open letter to the AMA from physicians
  4. Open letter to the AAMC from medical students

 

Physicians in Solidarity

Since Donald Trump’s election on Tuesday, I have seen a renewed call to solidarity and resistance amongst my friends and colleagues in medicine. As I did with racial justice activism, I wanted to put together a post to consolidate the opportunities for action. This is both to help me clarify my own thoughts on action in the coming years, but also to help anyone else in medical professions who are trying to figure out how they can best work for a healthier and more just America in the coming years. This list is geared toward the particular expertise of medical professionals and is not meant to exclude work that the more general population needs to fight for such as the incredibly important work of dismantling White supremacy.

The Affordable Care Act

One of the more obvious threats of a Republican-dominated legislature is to Obama’s signature piece of legislation. Although it was developed as a near-duplicate of Republican Mitt Romney’s healthcare access effort in Massachusetts, Congressional Republicans decided that repeal of the ACA was the hill they wanted to die on and now that they actually have control of the legislature and the executive branches, they now have the power to follow through on their threat. There’s a lot of great writing on why complete Repeal and Replace would be incredibly difficult and likely extremely politically damaging, but if we’ve learned nothing from this election its that the predictions of experts should not let us become complacent. Here are something things you can do:

  1. Call (not write, not email…call) your congress people at their local offices and talk to their staff member in charge of health policy about what the coverage expansions under the ACA have meant for you and your patients. I’ve been in residency for 6 months and I already have about a half dozen powerful stories of people who only have access to life-saving care because of either Medicaid expansion or subsidized marketplace insurance. Use these anecdotes, This is doubly important if you are represented by Republicans who need to understand just how many people ACA repeal would hurt.
  2. Write op-eds the same and then shop them around and get them published in local or national newspapers. When they publish these letters, work your social media networks and make it go viral.
  3. Call up your professional organizations (AAFP, AMA, ACP, AAP, etc.) and make sure they are going to DC to keep pressure on the legislature to maintain the core benefits of the ACA. If you have time, travel with them to DC to speak to congress in person.

Women’s Health

Another prominent goal of the Republican party is to make it more difficult for women, especially poor women, to have access to birth control and abortion. As physicians, we bear witness to the impact of unintended pregnancy and cannot stay silent on this issue.

  1. As above, call your congress people, write op-eds, and work with your professional organizations to keep pressure on the legislature to protect access to affordable birth control. A great talking point here is emphasizing that access to affordable birth control is the most effective way we know of to decrease the rate of abortion.
  2. Set up a recurring donation to Planned Parenthood. With public funding under threat, private financial support of Planned Parenthood is more important now than ever. This is a vital organization which provides

Social Determinants of Health

As much pride as we take in our work in the diagnosis and treatment of disease, when it comes to improving the quality and quantity of our patients’ lives, healthcare is a drop in the bucket. Directly addressing many of these social determinants of health may feel like it is outside your purview as a medical professional. However, we also have an obligation to Do No Harm and without an understanding of social determinants of health we can inadvertently counteract the health gains we make through our clinical work. Hopefully I can do more to flesh out this list over the next few weeks. Please send me items you think I should include here!

  • Anti-Racism
    • As a society founded on the mythology of White supremacy, every one of us is socialized into White supremacist beliefs. This is not a question of being a Good or Bad person, but rather about the cognitive biases we can’t help but internalize. The first step in any anti-racist work is introspection into the ways in which we’ve been socialized into White supremacy and act on that socialization without realizing it.
    • White Coats For Black Lives has put out a call for medical professionals to commit their time and energy to anti-racism. Answer that call here.
    • Learn more about anti-racism efforts by following these people on Twitter.
    • Wear a Black Lives Matter lapel pin. However, make sure that it’s not performative allyship but rather a constant reminder to demonstrate that Blacks Lives Matter through your clinical and public works.
  • Immigrant Health and Rights
  • Anti-Poverty
    • Welfare programs and their beneficiaries are easy political targets. Using the above methods, speak up for high quality programs to promote economic safety net programs, especially cash assistance. A promising advocacy target here is cash assistance for all children which you can read about here.
  • Housing
    • Housing is very much a hyper-local issue. Seek out housing-first programs in your city and advocate for them.

Get on Twitter

I know it’s fun to dismiss social media, but there are some amazing physician activists on there whose writing has been incredibly helpful in broadening my thinking about where healthcare fits into the larger goals of a just society. Here’s a follow list of medical activists to start with. While you’re at it, check out this list of great anti-racist writers.

Welfare and Wellbeing

I’ve been listening to The Uncertain Hour by Marketplace’s Wealth and Poverty Desk. This season, they’ve taken a deep dive into the United States’ welfare system and the consequences of welfare reform in the 90s.

The podcast provides a great introductory education about American poverty, a topic where opinions are strong and facts are frequently scarce. Interviews with families receiving cash welfare benefits reveal the daily compromises and anxieties which are the lived reality of America’s poor.

Equally disturbing, however, are the interviews with the middle and upper class people who maintain political control of America’s welfare system and the profound contempt for the poor which suffuses their conversations about poverty and welfare.

It’s easy to understand why we have failed to develop a coherent, evidence-based system for addressing poverty in America when you listen to these people and realize that their primary goals are to shame and punish the poor for daring to seek joy or create life, actions that lie at the core of our common humanity.

Two thousand years ago, Jesus of Nazareth pushed back on the prevailing idea that poverty was God’s punishment for sinfulness. Today, in a country where nearly half of the population claims loyalty to his Good News, we remain in this punitive mindset.

I am biased in this conversation because my daily work brings me face-to-face with the suffering that poverty creates, the shorter and sicker lives the poor live out in the midst of abundance. But I truly believe that if our anti-poverty initiatives were crafted by people with direct experience with poverty and designed specifically to promote joy and reduce suffering in our fellow human beings lives that they would be radically different than the systems we have today.

Unintended Pregnancy: Common Ground in the Abortion Debate

Screen Shot 2016-03-13 at 4.27.03 PMThis chart is a big deal because unintended pregnancy is a big deal.

The physical and emotional stress of unintended pregnancy is reason enough to desire its reduction. However, it’s also notable that unintended pregnancy is associated with inadequate prenatal care, smoking and drinking during pregnancy, and giving birth to premature or low birth-weight infants. Thus, by creating conditions in which a women can choose if and when she becomes pregnant, you can improve the health and well-being of both women and children.

Because of this, the National Survey of Family Growth has been a frequent cause for consternation among public health-minded folks as it has previously shown an unintended pregnancy rate that just wouldn’t budge. Results from 2001 allowed for some hope when there was a modest decline in the rate, but when 2008 results showed an increased rate of unintended pregnancy, those hopes were dashed.

Two weeks ago, the New England Journal of Medicine published the latest data on unintended pregnancy in the United States showing a 18% decline in the rate of unintended pregnancy between 2008 and 2011 to an all-time-low of 45 unintended pregnancies for every 1000 women between the ages of 15 and 44. This is still far too many unintended pregnancies, but it’s progress.

tThe report also contains lots of interesting information about the use of abortion in the United States. The percentage of unintended pregnancies that ended in abortion ticked up slightly from 40% to 42%. However, because the rate of unintended pregnancy dropped over this same time period the abortion rate actually decreased from 19.4 to 16.9 per 1000 women aged 15-44 between 2008 and 2011. 

I really can’t emphasize enough how important it is to recognize that one of the most effective tools we have for reducing the rate of abortion is to reduce the rate at which women need abortions by providing effective and affordable birth control to all women who desire it. In these times when political common ground is scarce, this strikes me as an area where people with different value systems can agree on a policy that would be a win for everyone.

Finally, the report also emphasizes a fact that I believe doesn’t get enough play which is that abortion is incredibly common amongst all types of women. Amongst Catholic women, 48% of unintended pregnancies end in abortion. Evangelical Christians, the religious group which utilizes abortion the least, still terminate 32% of their unintended pregnancies. Although people from these groups are often fighting to restrict access to abortion, there is a deep irony to the fact that this is a procedure that they themselves use at roughly the same frequency as the general population.

Even if it is ironic, it is not surprising. After all, abortion is a safe procedure which allows women to be in control of whether or when they raise a child. Of course women from all walks of life avail themselves of it.

Facts to take with you:

  1. 45% of all pregnancies are unintended
  2. 42% of unintended pregnancies end in abortion
  3. 21% of all pregnancies end in abortion
  4. 1 in 3 women will have an abortion at some point in their life

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Why do we pay more to treat illness than prevent it?

(The following has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

David Asch, Mark Pauly, and Ralph Muller have a great piece in this month’s New England Journal of Medicine on how we as a society think about preventive versus cancer care. They observe that whenever preventive care strategies are studied, there is an obsessive concern with the return on investment of these strategies and that this same scrutiny is not applied to cancer care.

The entire article is well worth reading, but in summary their argument is that this difference occurs because:

  1. Cancer care is more profitable for healthcare providers than preventive care.
  2. There are more well-defined and evidence-based strategies for cancer treatment than for preventive care.
  3. Seeking reward for treating illness is a much stronger motivator than avoiding penalty for failing to prevent illness.

Continue reading “Why do we pay more to treat illness than prevent it?”

Early results from Mexico’s sugar tax

Mexico has one of the highest rates of soda consumption, overweight, and diabetes in the world. The average Mexican adult drinks 163 liters of soda. 72% of adult Mexicans are overweight, and 15% have diabetes.

In the fall of 2013, the Mexican federal government passed a 10% tax on sugar-sweetened drinks. The following year, purchases of these beverages decreased an average of 6% relative to the counter-factual (controlled for seasonal and pre-existing trends), indicating that this tax was an effective deterrent. Evaluating the public health benefits of this tax will require more time, but this is a promising early result.

While hard evidence for dietary interventions is difficult to gather, much of what we know already argues for a compelling public interest in curbing the consumption of refined sugar similar to the public interest in decreasing smoking or excessive alcohol consumption.

A tax on refined sugar with proceeds going to consumer-level fresh produce subsidies would be a great way for us to invest in a healthier future for ourselves.

“Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study”