The fundamental problem with the American Health Care Act

As the immediate past-president of the Society of General Internal Medicine (SGIM), the major professional association of academic general internists, I participated in SGIM’s Hill Day on March 8, 2017.  Hill Day is when an organization mobilizes its members to visit the offices of Senators and Congresspersons on Capitol Hill in Washington, DC to discuss key issues.  Coincidentally, March 8 was also the day two House Committees began deliberations on the American Health Care Act (AHCA), and the day the American Medical Association (AMA) publicly voiced strong opposition to the proposed legislation.  SGIM focused its Hill Day efforts on educating legislators about key principles for health care reform, as well as advocacy for evidence-based primary care reimbursement fee schedules, and funding for health services research and primary care training.

I have now participated in four Hill Days, visiting both Democratic and Republican legislators, including those from very liberal and very conservative districts and states.  There’s heterogeneity between and within parties.  Some legislative staff are literally brand new to health policy.  Others have deep expertise and understanding of issues.  No one party has a monopoly on competence and quality.  One of the most impressive legislative staff I’ve met was a Republican committee staffer.  She was smart, knowledgeable, pragmatic, and transparent.  One of my biggest disappointments has been one of Illinois’ Democratic Congressmen who has been extremely difficult to reach.  Three out of four Hill Day visits no staff person from his office was available to meet with me, highly unusual in the experience of SGIM members participating in Hill Day.

I have grave concerns with the current version of the AHCA.  The most vulnerable Americans are at highest risk for not being able to afford health insurance and losing access to care.  Older persons not yet eligible for Medicare, the poor, and people with multiple chronic medical conditions are at highest risk of losing insurance.  The proposed tax credits are insufficient to make health insurance affordable for many of the poor, premiums for the chronically ill on the health exchanges would likely rise significantly, and per capita Medicaid block grants to states would probably result in major cuts to health care funding for the underserved and cannibalization of funds for non-health purposes such as closing state budgetary deficits.  Many people would be harmed and would suffer.  The Congressional Budget Office estimates that 24 million more Americans would be uninsured by 2026.

When I think about the many smart, thoughtful, well-meaning legislative staff I have met from both parties, I wonder how a significantly flawed bill such as the AHCA could have been crafted with such deleterious effects on the vulnerable.  Considering the language the Congressional staff used during our meetings, I’ve concluded it comes down to a fundamental clash of core values and principles: access to healthcare as a right with the beneficial effects this has for health, the economy, our families and communities, and our vulnerable, versus prioritizing the free market, minimizing the role of government in society, and decreasing growth in government entitlement programs.  One reason so many clinicians and organizations such as SGIM oppose the AHCA is that we see the effect of poor access to quality health care on real people.  In fact, seeing this pain and hardship, clinicians ultimately do whatever they can to care for these patients under less than ideal circumstances.  We have no choice when we see people suffering.  It is a moral imperative for us, as it should be for our society.

I have previously argued that health disparities exist because we as a society tolerate them.  There are thoughtful liberal and conservative approaches to ensuring access to high-quality care.  In fact, I believe we need to do more to create a business case for achieving health equity and to incentivize and support the reduction of disparities.  But, the AHCA does not incorporate the most thoughtful, carefully designed approaches.  The AHCA tolerates significant health disparities and would make them worse.

At the end of SGIM’s Hill Day, as I took the Metro yellow line train to National Airport and flew home to Chicago, I felt optimistic about the democratic process.  On one hand, commentators across the political spectrum have argued we cannot take democratic principles for granted in an era where those in power attack the press, attempt to discredit non-partisan analytical groups such as the Congressional Budget Office, and create alternative facts.  These are wise reminders that democracy can be fragile.  Especially in our polarized political environment, we need to rely on facts and use evidence in our policymaking.

And yet, I saw March 8, 2017, that democracy in the United States is strong.  One of my SGIM colleagues noted that it was remarkable that we as an academic general internal medicine organization, a society that does not provide donations to politicians, had access to key legislators from both parties serving on important Congressional health and appropriations committees.  By chance, SGIM Hill Day also happened to be International Women’s Day.  As I walked across the Capitol grounds moving from the Senate office buildings to those of the House, I saw a rally of women and men dressed in red advocating for women’s health on the steps of the Capitol.  In the basement cafeteria of the House building, an eclectic mélange of advocates mixed and later walked the halls of Congress.  I ran into diverse groups including advocates for the disabled moving in wheelchairs and accompanied by guide dogs, bicycle advocates distinguished by their plastic bike pins on their lapels, a group of young advocates seeking to reduce violence, an elevator full of Ukrainian rights advocates, plus my SGIM colleagues.  We do have a voice in America.  We need to speak out to eliminate health disparities.  It’s a question of values and priorities.  It’s why groups such as SGIM, AMA, American Hospital Association, and AARP, and I and many others believe that the AHCA in its current form is not in the country’s best interest.  Many of our most vulnerable neighbors would suffer if it is passed.  We can do better as a nation.

Marshall Chin is the Richard Parrillo Family Professor of Healthcare Ethics, department of medicine, University of Chicago and director, Robert Wood Johnson Foundation Finding Answers: Solving Disparities Through Payment and Delivery System Reform Program Office. The views expressed here do not necessarily reflect the views of the University of Chicago, Robert Wood Johnson Foundation, or the Society of General Internal Medicine.

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