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After the election, a time for reflection

From the January ACP Internist, copyright © 2017 by the American College of Physicians

By Nitin S. Damle, MD, MS, MACP

The presidential election in November opened our eyes to the divergent views of people across America. The new administration and Congress will force us to rethink our priorities, values, and approach to economic, geopolitical, environmental, educational, religious, and social issues. The health care sector is not shielded from this shift, and the American College of Physicians will need to reassess its policy priorities.

If there is any reason to question why, consider these examples. Daily, I see patients on multiple medications who are in their insurance plan's “doughnut hole,” or who have high deductibles and can no longer afford their medications, which may cost $500 per month. During the week after the election, a patient with diabetes and heart disease came to the office after a year without having sought health care. For the first time she was able to enroll in our Medicaid program through our state's health care exchange. Finally, one of my favorite patients came to my office in tears and anxious about her status at our local university because she is an undocumented student. I spent a significant amount of time recognizing these patients' concerns and trying to relieve some of their fears in this challenging time. Maintaining our commitment to this doctor/patient relationship as individual internists and collectively as ACP will help us meet the challenges and perhaps seek opportunities in the new environment.

The College, as a matter of U.S. law and practice, is nonpartisan. We engage in advocacy based on policies that have been adopted by our Board of Regents, through a deliberative, consensus-building process involving our policy committees, councils, and elected Board of Governors and Regents, supported by a rigorous review of the evidence of how different policy options will affect patient care. We are obliged to pursue these policies no matter the results of any given election.

Accordingly, ACP will strive to engage in a constructive and bipartisan way with President Trump and his administration as well as Congress to achieve bipartisan progress on the College's policy objectives. Our hope is to find common ground. If policies are proposed by the new administration or Congress that in our judgment would be detrimental to our profession and our patients, we won't just seek to prevent them from being implemented, we'll offer better alternatives. We remain steadfast in our mission to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine and supporting the critical role played by internists in the health care system.

ACP feels that the following areas may have bipartisan support:

  • Supporting the successful transition to quality-based payments and new physician-led alternative payment models, as authorized by the bipartisan Medicare Access and CHIP Reauthorization Act. Further, this may be a good time to reiterate the importance of the internist in diagnosing and treating complex and chronic disease and being the guardian of high-value, team-based, patient- and family-centered care with appropriate payment.
  • Redesigning quality measurement to make it clinically relevant, actionable, and meaningful for doctors and patients alike.
  • Reducing administrative burdens that interfere with the patient-physician relationship.
  • Improving access to mental health services and integration of behavioral health into team-based primary care.
  • Expanding access to telehealth services in the context of a physician-patient relationship.
  • Implementing and funding initiatives to address the opioid epidemic, building on the bipartisan Comprehensive Addiction and Recovery Act signed into law earlier this year.
  • Addressing the high cost of prescription drugs.
  • Strengthening graduate medical education funding and primary care training programs to ensure that the U.S. is training a sufficient number of internists with the skills needed to provide the highest-quality care.
  • Fixing tort reform with no-fault health courts and safe harbors for following evidence-based practice guidelines.

There are differences with the new administration and Congress:

  • We must remain committed to sustaining the gains that the Affordable Care Act (ACA) has made in expanding coverage to tens of millions and driving down the uninsured rate to historic lows, as in the case of my patients. While we will consider new approaches to help people get and keep coverage, the result should not be more Americans having to go without coverage or the loss of other key patient protections, such as removing the prohibition on health plans excluding or charging higher premiums to patients with pre-existing conditions. We will seek to address barriers to care created by high-deductible plans, narrow networks, and rising premiums. We will also continue to advocate for expanding the Medicaid program to all persons up to 138% of the federal poverty level in all states.
  • We must do everything possible to prevent a rollback of the commitments made by the United States and other countries to combat global climate change. Toward this end, I have been lecturing nationally and internationally on the health impact of global climate change with universal concern and resolve to transition to clean energy and avoid the catastrophic consequences to the health of humans and the earth.
  • We will continue to advocate for evidence-based policies to reduce injuries and deaths from firearms, included closing loopholes in the U.S. background check system at both the federal and state levels, banning semiautomatic weapons, and opposing any infringement on the patient-physician relationship to inform about the dangers of firearms.

There are members who have written to me and taken the position that firearms, global climate change, and immigration are political issues and that advocacy in these areas is inappropriate for a medical organization such as ACP. I think these are issues that involve the doctor-patient relationship and public health. We have an obligation to speak out on topics that will negatively affect our individual patients and the population as a whole.

ACP affirms the principles of ethics and professionalism. We affirm our commitment to equal access to affordable high-quality care. We affirm our commitment to nondiscrimination against persons based on gender, gender identity, race, ethnicity, religion, or sexual orientation. If policies are proposed that are counter to our patients and/or profession, we will stand, oppose them, and offer other alternatives.

Over the next few weeks, we will assess our advocacy priorities to determine how best to proceed given the election results. I welcome your comments and suggestions.

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