Doctors and other clinicians around the country reacted with dismay a few weeks ago when the American Medical Association, a generally right-wing group representing less than 15% of physicians, endorsed the fringe Rep. Tom Price as Trump's nominee for secretary of the Department of Health and Human Services. (The American Association of Medical Colleges did so as well - dealing academic medical centers a black mark.) His policies and his affiliation with the American Association of Physicians and Surgeons (like the John Birch Society, but for doctors, noted for anti-vax, racist, and conspiracist thinking) are both red flags.

Among the professional societies speaking out against the nomination is my own, the Society of General Internal Medicine. I am proud that, in separate letters, SGIM reacted with evidence-based, productive, but unstinting language, telling the AMA and AAMC in no uncertain terms why they should reconsider their endorsement.

Now comes the AMA's response to SGIM, which I paste in its entirety below. It is notable for several reasons: its deference to Trump ("America chose Mr. Trump, and he gets to pick his team"); its lack of specificity regarding those policies of Price's with which the AMA does not agree; and its disconcerting air of unreality regarding the contradiction between endorsing Price (or as the AMA distances themselves from it, "supporting the nomination") and a stated goal on the part of the AMA of not denying Americans coverage. 

Thank you for your letter. I am on the AMA trail, so I will respond electronically rather than on letterhead. 
​
I appreciate hearing your opinion about the AMA’s support for Dr. Tom Price, President-elect Trump’s nominee for Secretary of the Department of Health and Human Services. We take seriously the concerns expressed by those who do not support the nomination, and our support for it is not an endorsement of every policy position Dr. Price has advocated.

Here is a link to an article by our board chair, Patrice Harris, explaining our decision.  

https://wire.ama-assn.org/ama-news/why-we-support-dr-price-lead-hhs

There is also an editorial in the Washington Post about why the Dems should not oppose the Price nomination. You might find that interesting as well. http://wpo.st/QWhI2

As a physician, Dr. Price has had a relationship with the AMA, and with organized medicine generally, for decades.  Over these years, there have been important policy issues on which we agreed, and others on which we disagreed.  One thing that has been consistent through the years is his understanding of the many challenges facing patients and physicians, and his willingness to listen directly to concerns expressed by the AMA and other physician organizations. I will paste below a summary of policies where we have found common ground.

If confirmed by the Senate, Dr. Price will be charged with pursuing the policy goals of the President he will serve.  Similarly, as a non-partisan organization committed to improving the health of the nation, the AMA is charged with advancing a robust set of policies established by its House of Delegates, including the healthcare reform principles we circulated to our House following our recent Interim Meeting. I have attached that document to this email.

The AMA continues to be driven by our mission statement, which is “To preserve the art and science of medicine, and the betterment of public health. We remain committed to improving health insurance coverage so that patients receive timely, high quality care, preventive services and other necessary medical treatments.  Moving forward, a core principle for the AMA is that any new reform proposal should not cause individuals currently covered to become uninsured.

Democracy is messy. America chose Mr. Trump, and he gets to pick his team. Our job is to work for the principles we believe in. We look forward to continuing dialogue with Dr. Price, and to our collaboration on health care priorities on which we share common ground.

The AMA has in no way abandoned its principles regarding patients, access, quality or equity. The AMA will continue to engage with the new administration on behalf of those principles. It was those principles, in fact, which led us to support the Affordable Care Act, which engendered equally critical emails from people whose world view is quite different from yours.

Thank you again for reaching out, and best wishes for the new year.

Andy

Andrew W. Gurman, MD

President

American Medical Association

Altoona Hand & Wrist Surgery, LLC

1701 12th Avenue, Suite C-2

Altoona, PA 16601

Dr. Tom Price efforts that align with AMA policy/advocacy

 

Leader on efforts to improve the Meaningful Use (MU) regulations:
Led the bipartisan effort to extend and expand the MU hardship exception for the 2015 reporting year.   Introduced H.R. 3940, the “Meaningful Use Hardship Relief Act.”  This was enacted as a part of S. 2425, the “Patient Access and Medicare Protection Act.”
Led an MU sign-on letter in the House (signed by 113 members) which was sent to the Office of Management and Budget (OMB) and the Department of Health and Human Services (HHS) (9/28/15).
Participated in an AMA/Medical Association of Georgia MU town hall in Atlanta, GA in July 2015.
Led efforts in 2015 and 2016 to have a 90-Day reporting period.
Leader on efforts to reverse Centers for Medicare and Medicaid Services (CMS) regulations to unwind global surgical codes (language was included in the Medicare Access and CHIP Reauthorization Act (MACRA) which accomplished this objective).
Leader on efforts to delay and improve the Comprehensive Joint Replacement (CJR) rule (led a House sign-on letter on the CJR Rule – 9/21/15).
Leader on House efforts to improve the proposed MACRA regulations.  Led numerous stakeholder calls; led a House sign-on letter to CMS and OMB on improvements to the MACRA regulations (10/6/16).
Led House efforts to push back on the proposed Part B Drug Model; led House sign-on letter to CMS (5/2/16); co-introduced H.R. 5122, to prohibit further action on the proposed rule regarding testing of Medicare part B prescription drug models.
Introduced in multiple Congresses the “Medical Freedom of Practice Act” (H.R. 3100 in the 114thCongress) which would  ensure that physicians are not required to participate in any health plan or comply with MU requirements for electronic health records (EHRs) as a condition of licensure in any state.
Led a House sign-on letter opposing a proposed demonstration on prior authorization for home health services (5/25/16).

I feel an acute lack of expertise in useful questions; sometimes I had gotten a PhD not in epi but in sociology or political philosophy. A friend of mine recently introduced me to the term "meta-history", which I think means something Rashomonic: different people can lay equally convincing frames of historical explanation on the same sequence of events. E.g., the events of 11/8/16 can be explained by O-Care, or the opioid epidemic, or Jim Crow, or….
 
Depending on what scale one looks at, different combinations of factors could be adduced. My bias / favored explanation tends toward a combination of economic and health stress which potentiates underlying implicit racism/bias, the latter empowered by systemic racism — and the whole turbocharged by a certain set of "safe ways" or dog whistles in which it's "permitted" to encode misogyny/racism in public but are potentially invisible to pollsters ("I don't trust her," e.g.).
 
I wish I had some idea of what to do. On the Thursday of election week I cried behind my locked office door. I still feel desperate and depressed and rage-y, but perhaps I have reached some sort of equilibrium in my professional and personal life taking account of the new realities. I also assume that the what-to-do question hinges to some extent on the what-will-happen question. No prophet I , I estimate that the chance of something absolutely awful happening (war, pogroms/camps, ….) is about 10%, the chance of everything staying more or less the same is 5%, and the chance of everything getting substantively worse in non-catastrophic but insidious ways makes up the rest of the dial.
 
I see everything in terms of levels (too many conceptual models maybe!).
 
On one level I want to continue to provide excellent care, and precept with residents — but more and more, at least with residents, I feel comfortable and bound to mention SDOH and the patient's identity as an individual. I am less and less patient (ha) with patient blaming and stigmatization and lumping.
 
Educationally, I more and more want to emphasize such things as well.
 
Research wise, well I'm always at a bit of loose ends b/c my interests are varied and my support ~0, but I want to characterize peoples' decision making as individuals b/c I think vulnerable people are most likely to be "bucketed" and algorithmized out of independent existence.
 
The new element is advocacy which I think I rolled my eyes at just a few months ago. No offense if you're a single payer person (it's a strong argument and an ideal!), but I used to put that sort of advocacy in the same category as give-me-a-pony-for Christmas. Now, with everything upended, it has become something I pay attention to. Probably too much time to.
 
I have no idea if any of this will help anything.
 
There's a big discussion about how best to approach racial disparities. Does a rising tide lift all boats, and so we need to pursue a class-conscious politics? Or are we better off with more racial consciousness? Easy for me to ask, I think, as a white guy. Would an African American consider the national/racial liberation thing self evident?
 

List assembled by Andrew Goldstein.

1) If a member of AMA, call and express disagreement, mention considering ending membership. 1-800-262-3211. Hit 2 then 1 to speak with Member Relations. May be overwhelmed by calls, but try first, otherwise member.feedback@ama-assn.org

2) If NOT a member, call and explain this is why you are not a member. 1-800-262-3211. Hit 2 then 1 to speak with Member Relations.
3) Member or not: All American physicians are by default registered in AMA's Masterfile, which is sold to third parties for AMA profit and allows pharma reps to monitor your prescribing data, etc. Submit a Do Not Release restriction to your Masterfile record, found here: https://www.ama-assn.org/…/dbl…/dnr_authrztn_ltr1_0_PDRP.doc or sign up for the Physician Data Restriction Program, which allows you to opt out of having your prescribing data released to the pharmaceutical industry. The website appears to be malfunctioning so you can also call or email: https://apps.ama-assn.org/PDRP/locate.do
4) Call any of these organizations you are a member of. They are represented in the AMA. https://www.ama-assn.org/member-organizations-ama-house-delegates

5) Write an op-ed in your local paper.

6) Join and/or donate to Doctors for America and National Physician Alliance.
7) Call the AAMC is you're an academic physician. Their support is far more surprising.
8) Add your name to an open letter:
Doctors: https://medium.com/@ClinicianAction/the-ama-does-not-speak-for-us-d697511267d5#.gf70l7kcm
Medical students: https://medium.com/@FutureDocsUSA/national-medical-student-open-letter-concerning-the-nomination-of-rep-tom-price-for-hhs-secretary-2a27232f2be8#.i55sjj4nw

9) Encourage your physician friends to do these actions. You could even share this post :)

If you have other ideas, please comment and I'll add them.
Here's the case against him:
- Defund Children’s Health Insurance Program
- Supports Medicare privatization
- Opposes Medicare power to negotiate drugprices
- Wants to dismantle the Affordable Care Act
- Wants to defund Medicaid via block grants (estimated 18-20 million will lose coverage)
- Zero rating from Planned Parenthood
- Marriage equality a "sad day for marriage" and "judicial destruction of checks and balances"
- Against transgender rights, called it "absurd" to have a guideline to schools
- Voted NO on reauthorization of the Violence Against Women Act
- Voted NO on prohibiting job discrimination based on sexual orientation
- Voted NO on a bill to fight hate crimes based on sexual orientation
- Voted YES for constitutional amendment defining marriage as "one man and one woman"
- Supported Atlanta Police Chief Cochran after he was suspended for remarks referring to homosexuality as a sexual perversion and equating it to bestiality
- Voted YES on prohibiting product misuse lawsuits on gun manufacturers.
- Ban gun registration & trigger lock law in Washington DC.
- Voted YES on opening Outer Continental Shelf to oil drilling.
- Voted YES on barring EPA from regulating greenhouse gases.
- Voted NO on enforcing limits on CO2 global warming pollution.
- Voted NO on protecting free-roaming horses and burros.
- Voted NO on providing $70 million for Section 8 Housing vouchers.

Those who care about health care based on evidence and not merely on economic incentives, and primary care that considers the balance of the science in service of the whole person, should be very concerned about a bill before the House Energy and Commerce Committee.

A hearing on November 30 can decide if evidence-based health care is going to be yanked in the direction of economic incentives and special interests. I think this is the leading edge of anti-science and anti-medicine legislation.

Called the USPSTF Transparency and Accountability Act, the bill significantly weakens the US Preventive Services Task Force, a respected source for unbiased summaries of the evidence--and used by physicians every day-- in three significant ways:

1. It replaces generalist members of the Task Force with specialists, who are less likely to take a broad view and balance risks and benefits in the whole population.
2. It establishes a review board to counterweight, and possibly counteract, the Task Force's recommendations, making evidence-based healthcare yet another political football.
3. It mandates reconsideration of any given past Task Force recommendations if requested by any specialist or other organization.

This is a serious step backwards for evidence-based, patient-centered, resource-sensitive health care in the US. Please reach out to your representative if they sit on the committee and ask them to vote against the bill.

New York friends, please come on Tuesday at 6pm to my reading at the NYU Bookstore, 726 Broadway, Manhattan. The reading and question-answering goes till 7:30. It'll be great to see you there!