Liberty and Justice for All, but Really

President-elect Trump has promised to repeal the Patient Protection and Affordable Care Act (PPACA), or ACA for short. The legislation expanded insurance coverage to millions of Americans, and perhaps more significantly, symbolizes our right as Americans citizens to access to affordable healthcare. Obama is pleading with physicians to stand up. 

More affordable health care would benefit all Americans, but it is misleading to imply that cheaper insurance means healthier lives. The ACA provides concrete benefits and there are opportunities for even greater improvement. For example, it it has been difficult to incentivize young, healthy enrollees to balance the more expensive enrollees. Additionally, there are still millions of undocumented people in this country that need access to basic medical needs, which are not covered under the ACA. 

In an effort to revoke the ACA as soon as possible, the US Senate voted (51-48) this week to open discussion on how to “fast-track” dismantling of the ACA. Reform talks include open state borders for insurance exchange markets and stricter immigration regulations in order to trim healthcare spending.  There is also movement to reign in the power of the central government by revoking the individual mandate. House Speaker Paul Ryan (R-WI) also announced this week that Planned Parenthood would be defunded until a reconciliation bill was approved. To get a sense of what this mean could mean for reproductive health, watch this documentary: Trapped.

Without a carefully crafted alternative to the ACA, millions of Americans could lose their health insurance and become sicker. Unfortunately, the critics of the ACA want to repeal first, and to debate the reconciliation bill later, perhaps over the next 2-3 years. Repealing the individual mandate without a logical alternative sends a message to the American people: it’s up to you, the individual, to navigate the health insurance industry. Revitalized self-determination will make America great again, as the Trump Administration leads us into an era of political individualism.

The rhetoric of Trump’s reform hinges on the ideas of individualism and nationalism within a liberal democracy. Unequivocally, the government should let individuals decide how to prioritize their needs and spend their money. We all deserve to exercise autonomy. It is individualism in action. The principle extends beyond just people, and into business practices and regulations as well. 

Individualism is one the earliest conceptions of an American identity as well as the central tenet of healthcare ethics. It protects our humanistic freedoms, but it oversimplifies an important aspect of society: the interrelatedness of our fates. For example, one need to look no further than the ACA itself to see that access to care for the sick is inextricably linked to the behaviors and spending of the healthy and wealthy. We should be wary when when our leaders oversimplify and distort power to self-determine. 

The Trump/Paul paradigm for health care reform does not reflect the power struggles behind the facade of American democracy and capitalism. It does not adequately address the discrimination people face when seeking healthcare. Neither does it recognize that some people will not be able to act in their own self-interest. Be it educational, geographic, cultural, or something else, I want to highlight that people do not have the same ability to be effective autonomous individuals, and we struggle collectively to isolate root causes or remedy them.

Americans, especially BIPOC (Black, Indiginous, People of Color) face systematic oppression on a daily basis, access to healthcare is just one example. For those who wanted affordable healthcare, the ACA was a useful tool for overcoming systematic oppression. It guarantees access to an office visit, a vaccine, or a mammogram, and it protects those with preexisting conditions from exorbitant healthcare fees. 

Herein lies an important inconsistency of the ACA reform discussion: liberty is not only the ability choose from someone's menu of options. Liberty is about self-determination. Without overhauling the actual health care structures and the underlying attitudes, beliefs, and values of its gatekeepers, the the oppression ensues. This is the conundrum of America’s healthcare future: can we be a society that values self-actualization and healthy development for all? What role do we play in each other’s developmental processes?

Medicine as a practice itself evolved under colonial imperialism. This is likely in part why physicians are so ineffective in addressing complex, ever-evolving psycho-social-behavioral-spiritual-cultural issues. This is why guaranteeing access to a doctor's appointment is only a small suture in the gaping wound that is American Health Care. Physicans are taught self-preservation through their grueling training, which curbs any opporuntiy for curiousity of or reflection on their practice.

Physician burnout was recently discussed in a NEJM article, “Tolerating Uncertainty — The Next Medical Revolution?” The authors point to physicians’ discomfort with uncertainty as a root cause of medicine’s shortcomings as well as a barrier to placing humanity at the core of clinical practice.

They highlight a cognitive flaw in the collective medical mind of clinical practice: a refusal of multidimensionality, or multiple competing truths. Physicians are trained to narrow possibilities, and this paradigm works well for extending life in patients with faulty mechanics, like infections, early-stage cancer, end-stage renal disease, or coronary artery disease. We can mend broken bone and replace worn-out joints, but intolerance of uncertainty does not help treat societal injustice. 

Intersectionality, or the confluence of multiple identities and experiences as related to how these identities are treated within oppressive structures, can interrelate culture, power dynamics, and multidimensionality in order to synthesize health care reform that is fair and equitable, instead of antiquated beliefs of individualism that are romanticized despite their harm.

The American Public Health Association (APHA) issued a notice to congress this week demanding that no one lose their existing insurance coverage and that adequate public health funding be continued. In addition, I would like to stress that if the ACA reconciliation bill does not address physician development and wellness, medical student and resident training curriculum in the history of medicine, then reform will not be effective in getting people quality medical care. We need a comprehensive plans that deals with the ethics of what health care actually supplies.

If Trump wants to make America great again, starting with a better health care system, then tackling complex systemic issues within clinical medicine will be one of the priorities of the reconciliation bill, and not just dollars and cents.