- AHCA —
- American Health Care Act
The current Congress and president have brought about uncertainty and unease as to where policies and rhetoric will lead us. Questions abound across a range of perspectives and issues. Many wonder whether our divided country, characterized by demonstrations and marches across a range of perspectives, can come together with any consensus. Health care is 1 issue with a particularly cloudy future. Amid this haze, we, as physicians, must consider our role as stewards of patient and population health. How can we make our voice heard as advocates for our patients as well as for (or against) policies affecting those patients and our profession?
For guidance, I looked to words I spoke aloud on my first day of medical school. Many of us begin our careers this way, reciting an oath that serves as a professional and ethical guidepost. Versions of these words have served our profession for generations. How might they now provide us with direction? As I reread the Modern Hippocratic Oath, the one I recited, I gleaned a deeper appreciation for our profession’s finest traditions1 in support of prevention, social justice, and advocacy. I found the oath’s implicit messages to be timely, as though its author had foreseen current shifts in the American political landscape.
The phrase, “I will prevent disease whenever I can, for prevention is preferable to cure,”1 feels undeniably relevant today. Prevention of disease and promotion of health are at the core of the policies being debated, including components of the now at risk Patient Protection and Affordable Care Act. Many who voice opposition to the Affordable Care Act express reasonable concerns about limited access to affordable health care services. The American Health Care Act (AHCA), passed by Republicans in the House of Representatives, and many more recent proposals (eg, the Senate's Better Care Reconciliation Act and the Graham-Cassidy health care bill currently under debate), were built on the premise that by making insurance less expensive, it and health care services will become more accessible. Still, experts note that proposals like the AHCA may make certain plans more affordable, in part by limiting covered services, including many evidence-based preventive services (so-called essential benefits). Thus, this places prevention at risk,2 which is at odds with the oath we stand to uphold. This risk may be particularly stark for lower-income individuals, who may find themselves able to afford only those plans with limited, insufficient coverage.
This is when prevention meets social justice; the former is unlikely to exist without the latter. Barriers, frequently rooted in poverty, can challenge children and families as they pursue social, emotional, and physical wellbeing. A patient may live blocks from a health-promoting resource but lack the transportation needed to traverse that distance. A patient may live in a crumbling building with an unresponsive landlord. Structural racism and xenophobia may push them indoors, out of public view. With such social injustice ever present (and seemingly growing), the prevention of disease and achievement of wellness will be more challenging, causing inequities to grow. As we seek to uphold the tenets of our oath, I suggest we follow our more progressive professional organizations (including the American Academy of Pediatrics), those that support those programs and policies inside and outside of the health care system that aim to improve outcomes and narrow equity gaps.3
Promoting prevention and realizing social justice requires advocacy. Advocacy begins with the realization that we are members of a society with “special obligations to all [our] fellow human beings,”1 not some, but all human beings. Of course, we could debate the content and context of these obligations, what they represent, and how they are to be met. The clinicians who support their patients through a difficult illness, the educators who teach the next generation of physicians, and the researchers who expand our evidence base each fulfill this sacred duty every day. However, I would push us to extend these obligations, when possible, beyond that which we find most comfortable to those social, economic, and environmental ills that plague our fellow human beings. As a start, this may push us to contact our elected representatives about issues of importance; it may similarly lead us to march in support of that which we hold dear. We may also extend these efforts, motivated to become more civically involved; we could participate in roundtable discussions with legislators, promote voter registration drives (perhaps even in our waiting rooms), and volunteer with partnered, community-based agencies. We may also consider structural changes inside or outside of the health care environment that promote tolerance, understanding, and inclusivity, ensuring that our patients, colleagues, and neighbors see us as their trusted advocates and partners no matter what their (or our) race, ethnicity, religion, socioeconomic status, or sexual orientation may be.4 Such activities may bring benefits to our patients, potentially outweighing any medication or laboratory test we might order. We may also change as physicians, opening our eyes to our own priorities, whether in an examination room or in our communities.
To this end, I was particularly struck by the powerful dichotomy raised by Glied and Frank5: Are we, as physicians, more committed to care for the vulnerable or cash for the powerful? Although they posed this question in the context of the nomination of then-Representative Tom Price for secretary of health and human services, it could equally be asked of any of us. I suggest that if we are true to our profession, then there is just 1 answer. The Modern Hippocratic Oath tells us that “warmth, sympathy, and understanding [must] outweigh the surgeon’s knife or the chemist’s drug.”1 I propose that it, too, must outweigh greed, special interests, and bigotry; it must extend to prevention and social justice through advocacy at the bedside and in the community.4,6,7 Imagine a boy with asthma coming to a clinic, which is a daily encounter for many of us; he breathes air saturated with pollutants, and his parents navigate challenging work schedules. With additional assistance (medical, social, and environmental), this child and family may breathe easier. Without that assistance, related problems1 will mount, impeding this child’s upward trajectory. How might we perfect the care we provide by more consistently taking this family’s context into account? In parallel, how might we influence policies that would ease the burdens felt by this family and others like them? How might we advocate for a just society that gives this boy the best chance to reach his true potential? With this end goal in mind, we might identify areas in need of our support: research funding to generate best practices in the management of his asthma, education supporting the next generation of physicians, and policies that promote a safe, accepting place for this child and his family to grow and thrive.
This challenging, uncertain time warrants a reconsideration and reaffirmation of our role as physicians within an evolving society. We should look to our predecessors, to Hippocrates, Maimonides, Virchow, Blackwell, Jacobi, and Lasagna, and to the same words that have guided our profession for generations. If our currently seated political leaders opt to move us forward, I suggest that we be the first to provide them with our support. However, if their policies and rhetoric take us backward and denigrate those we serve and serve with, may we quickly and confidently stand up for what is right and good. May we return to that first day of our training, when we vowed to uphold our sacred duty to treat, to heal, and, when necessary, to march.
- Accepted June 16, 2017.
- Address correspondence to Andrew F. Beck, MD, MPH. E-mail:
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
- McMaster University Health Sciences Library
- Council on Community Pediatrics
- Szilagyi PG,
- Dreyer BP,
- Fuentes-Afflick E,
- Coyne-Beasley T,
- First L
- Arya N
- Copyright © 2017 by the American Academy of Pediatrics