It used to be that when a doctor gave a confident recommendation, patients trusted it. A skeptical person might seek a second opinion, or a third. When they all agreed, the best course seemed clear.
Today, America’s major physician organizations are recommending something, strongly and in unison: The latest health-care bill, known as Graham-Cassidy, would do harm to the country and should be defeated.
Coalitions of health professionals that have spoken publicly against the measure so far include the American Medical Association (“Provisions violate longstanding AMA policy”), the American Psychiatric Association (“This bill harms our most vulnerable patients”), the American Public Health Association (“Graham-Cassidy would devastate the Medicaid program, increase out-of-pocket costs, and weaken or eliminate protections for people living with preexisting conditions”), the National Institute for Reproductive Health (“the Graham-Cassidy bill preys on underserved communities ... a clear and present danger”), and Federation of American Hospitals (“It could disrupt access to health care for millions of the more than 70 million Americans”).
This is in addition to the American Academy of Pediatrics, Association of American Medical Colleges, American College of Obstetricians and Gynecologists, and many others.
The exact number of people who would lose care under the bill is unknown; Republicans have indicated that they will not wait for a score from the nonpartisan Congressional Budget Office. But it is not difficult to see that the effects would be vast. In his letter to the Senate, the president of the American Medical Association, James Madara, wrote that the bill would destabilize insurance markets and decrease access to affordable coverage and care. He expressed particular concern over the loss of small-business tax credits, cost-sharing reductions, and the replacement of current Medicaid expansion with “inadequate” grants (which would phase out entirely by 2026).
Over the course of 2017’s string of hasty Republican bills, the rhetoric of these organizations has escalated. Physician groups have actively implored their members to reach out to legislators directly. This week, the AMA wrote that doctors cannot support the bill as it “violates the precept of ‘first do no harm’”—a guiding tenet of the profession.
This is a call for the entire profession to clarify its fundamental principles, and to recognize where policies are doing harm, and to engage with the political system in a way consistent with the ethos of being a doctor.
These groups are not historically liberal—not progressive idealists who demand universal coverage. The AMA has been critical of the Affordable Care Act, and this week asks only that Congress “work in a bipartisan, bicameral manner to increase the number of Americans with access to quality, affordable health insurance.” Similarly, the mental-health professionals wrote, “the APA is ready to work with members of both parties to craft a bipartisan solution that stabilizes the health-insurance market and ensures Americans have access to quality, affordable health care.”
A bipartisan approach had seemed like the next step. Even Mitch McConnell had said it was time to involve Democrats in drafting a bill. Recall the Senate majority leader standing on the Senate floor in the early morning hours of July 27. “This is clearly a disappointing moment,” he said, pausing to find the next words after John McCain had marched in and pointed his thumb to the floor, ending the third attempt to unilaterally pass a health-care bill with no input from Democrats.
“From skyrocketing costs to plummeting choices and collapsing markets, our constituents have suffered through an awful lot under Obamacare,” McConnell said, echoing what has been the Republican narrative for the last eight years: The only solution is to repeal the law and start over. But he then let slip an unprecedented concession, that he was open to a bipartisan deal.
“I imagine many of our colleagues on the other side are ... pretty happy about all this,” he said. “So now I think it’s appropriate to ask: What are their ideas? It’ll be interesting to see what they suggest as the way forward.”
It seemed like a turning point, exactly what the physician groups had been advocating for, and so began work on a bipartisan bill to improve the current health-care system. But this week, Republicans decided to shut that whole thing down, as Paul Ryan and the White House came out against the bipartisan approach. McConnell and his Senate colleagues thus returned to the unilateral tack. They picked up the Graham-Cassidy bill with urgency. Republicans have indicated that they will be pushing for a vote within the next 10 days, before a September 30 deadline, after which the bill would require 60 votes in order to pass, as the Affordable Care Act did.
In the spirit of urgency on Tuesday, Senator Lindsey Graham said that voting for his proposed health-care bill is “the only process available to stop a march toward socialism.” This word that has come to characterize the most desperate and disingenuous hours in U.S. health-care discourse. “Here’s the choice for America: socialism or federalism?"
This is not the choice—though many wish it were. Socialists on Twitter thrilled at the suggestion, as many have little love for the Affordable Care Act, which was intended to create competitive marketplaces for private insurers, a middling solution that many progressives still find wanting. Even the single-payer bill proposed by Bernie Sanders, who identifies as a democratic socialist, is distinct from “socialized medicine”—in which the state would not simply be a payer but an operator of the health-care system. The Affordable Care Act is indeed many steps removed from socialism. The law was a compromise almost no one deemed ideal, including Obama—but many deemed better than the Bush-era system, which many in both parties agreed was broken.
Even though the bill’s sponsors are Republican senators, their colleagues in the party have yet had difficulty articulating a single way in which the bill would directly benefit Americans. Supporters have instead voiced two basic, sweeping arguments for this bill. The first is that it serves to “repeal Obamacare,” and so it is worthy of support. A majority of Republican senators have proven willing to repeal the law with no replacement at all, despite projections of widespread harm. As McConnell said in July, “We told our constituents we would vote that way ... We kept our commitments.” This argument from fidelity offers opportunity to claim moral high ground while voting for a bill that would, by objective measures, do much harm.
The other argument is at least feasibly somewhat related to policy: that the bill would empower states. This argument is bizarre in that an aim of the Affordable Care Act was to incentivize states to expand Medicaid, and yet many didn’t, leaving millions of their own citizens uninsured. Republicans then complained that these states were suffering under Obamacare. Graham-Cassidy would work to redistribute some funds to these states, which has led some Republicans to argue that state funding will increase under Graham-Cassidy. It will, in some states, at least until funding ends in 2026.
In the midst of defending this phasing-out of Medicaid, it was revealed that last week Tom Price, the Secretary of Health and Human Services, took several flights in a private jet. Price rose to power in the Tea Party movement based on sweeping proclamations about the need to limit government spending, including a 2009 CNBC appearance in which Price excoriated public officials for use of private jets. “My goodness gracious,” he admonished at the time, “especially in this time of fiscal crisis that we have.”
Both private jets and calls for limited government are departures from the norm for the Secretary of Health and Human Services. The position was created in 1980 and charged to “enhance and protect the health and well-being of all Americans.” It was to serve as a counterweight to the influence of powerful corporate interests in the health of the citizenry. The United States was late in making this a priority. In 1946, the World Health Organization had been founded on the premise that health is “one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” What’s more, the group defined health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”
By 1953, health got a seat in the U.S. president’s cabinet with the formation of the Department of Health, Education, and Welfare—formerly the Department of Education and Welfare—under President Eisenhower. The 1978 Alma-Ata Declaration brought a new focus to primary care and mitigating environmental causes of disease. This required systematic, collaborative approaches. HHS became its own department in 1980. The United States had just led the global eradication of smallpox, marking a transition for the field of public-health from doing the work of containing outbreaks to preventing them from ever happening again. This proved more efficient.
The effect over the course of the century was a comprehensive understanding that health is much more than an individual pursuit; it is a quality of an ecosystem.
This is not a political opinion but a matter of biology and pathology. Graham-Cassidy is scientifically regressive, evading or denying the fact that human health is determined by the health of those around us. In justifying the slow dismantling of the country’s health systems—ostensibly transferring control to states before phasing out funding—the bill is predicated on the obsolete understanding of health as an individual endeavor. It shrinks the definition to something pre-1946. It even literally eliminates the Prevention and Public Health Fund, which was established in the Affordable Care Act as the first-ever mandatory funding stream focused on public health and prevention.
Graham is disingenuous in likening Obamacare to socialism, but he is right in noticing that the course of history and public-health science is bending toward a universal understanding of health—in the interest of cost, efficiency, and justice. As doctors have come to understand that individuals’ health depends on the health of others, the profession is forced to find a way to do no harm.