​For those who know me, I’ve had a really awful six years. Like, really awful. My mother had a heart attack. I did grad school. I was assaulted more than once. I struggled with a lot of medical (and consequently financial) issues, including several hospitalizations. We had Hurricane Sandy. I had a painful breakup with the love of my life. I moved a couple of times. I lost two friends to suicide within a period of six months. Republicans took Congress and stole a Supreme Court seat, and Donald Trump won the presidency.
 
Yeah. Fuck the last six years. Especially 2016. Fuck 2016.
 
Sure, there were some upsides. I made some extraordinary friends. I got a PhD. I adopted two darling cats. And I saw a lot of Springsteen shows.
 
But someone else helped me get through these truly shitty times. That person is Carrie Fisher, who is the latest and (for me, at least) one of the more devastating casualties of this truly fucked up year. And as someone who was so transparent about her life in her writing and her interviews, for many of us this loss feels akin to losing a friend whose writings and dramas have provided sources of comic relief and comfort over the years.
 
No, it’s not because of Star Wars (not that I’m Star Wars averse by any stretch – I even did all the midnight showings!). My first times discovering Carrie Fisher was through my love of two of her other films: When Harry Met Sally and Hannah and Her Sisters (I’ve been a Woody Allen die-hard from an early age… perhaps too early an age… it probably accounts for some, let’s call it quirkiness). I then saw her one woman show Wishful Drinking in my hometown of Berkeley, CA before it went to Broadway, a show to which I would come to relate much more a couple years down the line.
 
When you go to the hospital, they ask you to rate your pain on a scale of one to ten. Despite several hospitalizations for thyroid, GI, and cardiac issues, along with a couple of painful hand surgeries, depression has always been my real ten. And Carrie Fisher helped me to better comprehend it.
 
You see, for anyone who has struggled with mental illness or addiction, she provides a uniquely striking and brilliant voice for these sets of challenges and resilience in spite of it. My love for her writing began with the famous opening line to her semi-autobiographical book Postcards from the Edge: “Maybe I shouldn’t have given the guy who pumped my stomach my phone number.” It was reaffirmed in reading her woes laced with wit through such lines as, “I was invited to go to a mental hospital, and you don’t want to be rude, so you go…. But this was a very exclusive invitation.” She was, as she wrote, very sane about how crazy she was, and through her candor provided others (myself obviously included) a great gift.
 
Suffice it to say that depression and PTSD followed the (incomplete) set of challenges of mine that I enumerated above. Maybe it was inevitable. I probably have some biological predisposition to depression, and certainly I was faced with a rather inordinate number of struggles in a fairly condensed period of time. In many moments through which I was struggling through depressive episodes, listening (and re-listening, and re-re-listening…) to the book on tape of Wishful Drinking felt like getting the extra therapy sessions that as a lowly graduate student I couldn’t afford (and who wouldn’t want those extra therapy sessions with Carrie Fisher?).
 
When it feels all too difficult to conceive of tomorrow being better than yesterday, one can’t overstate the value of hearing someone with such humor and wit and perspective talk about working through challenges of mental illness and substance abuse and finding strength and resilience in the end (in an emphatically non-Lifetime or Hallmark movie sort of way). Indeed, she reminded all of her readers and followers that if her life weren’t funny, it would just be true, and that is unacceptable. While we often have to take the bad with the good, when we look at the bad with the right slant, with enough time, we get perspective and eventually laughter (and maybe a book). Location, location, location.
 
There are so many lines from her writing that have been burned into my brain. When facing the uncertainties of dating someone new, I think of Carrie writing, ““What worries me is, what if this guy is really the one for me and I just haven't had enough therapy yet for me to be comfortable with having found him.” The desire for instant gratification is all too relatable. And amid the numbness that can accompany the aftermath of trauma, there was perhaps no line more apt than “I rarely cry. I save my feelings up inside me like I have something more specific in mind for them.”
 
Walking idly through the streets of New York City, one can feel strangely alone despite being surrounded by millions. Yet listening to her read Wishful Drinking, I enjoyed hearing her wisdoms – the distinctions between problems and inconveniences (problems derail your life, while inconveniences involve getting a bad seat on an un-derailed train), the cycling through therapists and treatments, the adaptation to accepting a certain quota of discomfort in her life without resorting to substances (something that I would later realize would be more formally characterized as distress tolerance), and in general realizing that one could derive from these struggles strength (and writing material!) and not simply the weakness and defeat by which one might feel consumed amid crisis. And for someone accustomed to a compulsion to be perfect, seeing a woman so powerfully embrace her imperfections and her struggles – and even more importantly, her strength in working through them – made it feel more acceptable to me to be open about my own struggles.  
 
And so while I had at my disposal limited means with which to numb myself from the pain that I experienced, following Carrie’s example, I put pen to paper through the guise of fiction: “For all its limitations, immediate gratification had never quite lost its allure for her, and distress tolerance seemed antithetical to recovery… There was so much she had once loved about New York City. The liberal intellectualism and appreciation of her humor and the number of people who understood the superiority of vinyl (but also the ready availability of $1 Motown CDs across the street from the Apollo Theater). The crisp air with the sun wafting in and the autumn leaves providing a crunch crunch beneath her feet as she speed-walked past the naked man who lay clutching his bottle of Wild Turkey. She had come, over the months, to regard his degree of nudity to be a makeshift thermostat. Full frontal, and it was safe to go with a skirt and halter. Pants draped loosely, it was a jeans and t-shirt sort of day. Fully clothed, it was time to bundle up. She had come, after years of insomnia, to rely upon the white noise of the above-ground subway, though not necessarily the 3 a.m. debates over who fucked who(m) without whose permission. She had even come to grips with an unfortunate Kafkaesque quality of living in the city that once left her queasy for days on end. Now the city haunted her, and the anonymity in which she had once found solace felt like externally-imposed isolation as she plodded trance-like up Amsterdam past the people who, as she had so many times previously, did not know how to recognize how much she wanted, needed, to feel the calm and comfort of someone who understood her and wanted her not simply to live, but to want to live, and to understand the difference.” (I am still working to emulate Carrie’s wit, but it’s something to which to aspire).
 
In her final advice column for The Guardian, Carrie responded to someone with bipolar disorder and wrote, “We have been given a challenging illness, and there is no other option than to meet those challenges.” To struggle with depression is sub-optimal to say the least, and in many cases can be a daily struggle for far too many people. We should all be so lucky to approach hurdles with such clarity and pragmatism, whether with respect to the trials of illness or the trials of the upcoming Trump Administration. Carrie passed away far too soon, but she left a great mark on how we as a nation talk about mental illness and substance abuse, and I’ll always be grateful to her for providing the wisdom and humor to – admittedly from a distance – help me through my own trials in the aftermath of trauma.
 
Rest in peace, Carrie. I hope that the force is with you, wherever you are now. 

​Among the more common phrases of the 2016 presidential election campaign of President-Elect Donald Trump was “repeal and replace Obamacare.” What many were – and to a certain extent, still are – left wondering is, “with what?” The announcement of Representative Tom Price (GA-6) provides some, but by no means all, of the answers.
 
To his credit, over the course of his long-standing effort to repeal the Affordable Care Act, Mr. Price has offered numerous replacement plans and of unmatched detail, with his Empowering Patients First Act being 242 pages in length. However, absent from his legislation is adequate guarantees against loss of coverage from which over 20 million who gained insurance coverage under the Affordable Care Act and who those benefited its associated Medicaid expansion.
 
Those Who Are Younger but Sick May Suffer
 
In lieu of the marketplace plans, according to his Empowering Patients First Act, individuals would be offered tax credits on the basis of their age rather than their income, with those tax credits allotted toward the payment of health insurance in the private market. This is based largely on the fact that health insurance premiums are determined based on age, with older people expected to use more healthcare, and in turn requiring a more substantial tax credit to support payment for insurance. This, of course, makes important assumptions that those who are younger will also be healthier and thus require less in the way of coverage.
 
Yet there has been in recent years a documented rise in the prevalence of chronic illnesses among children in the United States, rising from 12.8% in 1994 to 26.6 in 2006, in particular with respect to such issues as asthma, obesity, and behavioral conditions such as Attention Deficit Hyperactivity Disorder (ADHD), and rates of many conditions have since risen further. The last decade has seen only greater attention to issues of childhood obesity and relatedly, type II diabetes, with the additional rises in teen depression. (It is worth noting also that mental health conditions often have an age-of-onset in teens and twenties, both age groups allotted the lowest tax credits but potentially in need of many services within this domain). This is not the only time that Mr. Price’s policies have gone against the interest of investing in children’s healthcare. Indeed, in 2007 he voted against the reauthorization of the Children’s Health Insurance Program (CHIP), which provides medical care to approximately 8 million low-income children. This Children’s Health Insurance Program and Medicaid combine to provide health coverage to approximately 1 in 5 Americans.
 
“Block Granting of Medicaid” = Medicaid Cuts
 
It is presently the case that the federal and state governments share the cost of Medicaid allocations, with 32 states adopting the Medicaid expansion under the Affordable Care Act. In addition to an ACA repeal doing away with its expansions of Medicaid and CHIP, Medicaid block grant proposals (which Price supports) have been estimated to reduce the extent of Medicaid spending, with Medicaid spending currently having a 7% growth rate compared to an estimated 3% when delivered via block grants. Indeed, in the 2017 House Budget, which Mr. Price oversaw as Budget Chair, the Congressional Budget Office estimated that the block grants would reduce Medicaid spending by $1 trillion over the course of a decade.
 
While the role of government in program delivery is an issue over which well-reasoned partisans disagree, it is important to note the medical consequences of these program outcomes, particularly in light of Mr. Price’s medical expertise. But The Medicaid programs that Price seeks to restrict not only are more cost-effective in the long run to administer – with the Robert Wood Johnson Foundation estimating that Medicaid coverage expansion reduced hospitals’ uncompensated care by 21 percent, with states saving in costs of caring for the uninsured – but have had demonstrably positive health outcomes for vulnerable populations. For example:
 
A Health Affairs study revealed that in the aftermath of Wisconsin’s 2009 creation of a new public insurance program for low-income adults, not only did outpatient medical appointments increase 29% – indicating a greater access to care among this population – but preventable hospitalizations fell 48%. Thus, the introduction of this government program had a cost-saving outcome of shifting care from hospitalization to outpatient treatment, in addition to expanding overall care to those in need.
 
The Kaiser Family Foundation reported that Medicaid expansion under the Affordable Care Act not only reduced the uninsured rates of those states, but in many (though not all) cases improved access to care and utilization of some physical health as well as behavioral health services.
 
Moreover, the Urban Institute’s 2012 report on outcomes related to Medicaid revealed striking differences between the Medicaid and the uninsured patient populations, with 89% of Medicaid recipients having had an outpatient doctor’s visit in the last 12 months compared with 53% among those without insurance; 8% of Medicaid recipients delaying medical care due to cost, compared with 34% of the uninsured delaying care due to cost; and 27% of Medicaid recipients having unmet healthcare needs due to cost, compared with 56% among the uninsured. There are few if any policies in which the human consequences of policy delivery are so bold. Indeed, it can be difficult to reconcile restricting this access to medical care with the principle of “do no harm,” a central tenet of the Hippocratic Oath, according to which Mr. Price presumably operated as a practicing physician.
 
Continuing Protection of Those with Pre-Existing Conditions Won’t Be Easy (Feasible)
 
In the aftermath of his meeting with President Obama, President-Elect Trump indicated some interest in preserving some of the more favorable aspects of the Affordable Care Act – namely, ensuring that people not be denied insurance coverage due to preexisting conditions, as well as the ability for one to stay on their parents’ insurance plan until age 26. A challenge in doing this, however, is the reality that insurers’ ability to guarantee coverage regardless of preexisting conditions came in no small part from the ACA’s mandate that all individuals enroll in at least some baseline level of coverage, the effect of which was to bring healthy patients into the risk pool. Absent the mandate, of which the Republican Party has been vocally critical, and thus with a sicker risk pool, much of the Act becomes infeasible.
 
Within Mr. Price’s Empowering Patients First Act, there is minimal discussion of pre-existing conditions, and while it provides that insurers will not deny on those grounds, it does not guard against insurers charging patients with pre-existing conditions higher rates if they do not maintain continuous coverage for at least 18 months. Thus, should should one not have a lapse in coverage, one would not be adversely affected in this regard, but should one be rendered unemployed for some period of time and unable to afford coverage in between jobs (e.g., through COBRA, which is very costly), they would be rendered vulnerable under the Empowering Patients First Act if they have a history of medical conditions.
 
It is difficult to overstate the magnitude of this impact for those who lack the income to support potentially dramatically increased healthcare premiums. After all, the Centers for Disease Control and Prevention estimated in 2012 that about half of the American population (117 million) had at least one chronic health condition, with one in four adults having two or more chronic health conditions, with seven of the top ten causes of death being chronic diseases.
 
Consider the magnitude for only the 20 million who newly obtained insurance through the Affordable Care Act. In expectation, 10 million would be subjected to higher (potentially unfeasibly higher) healthcare premiums with Mr. Price’s replacement option. Indeed, the Government Accountability Office investigated numerous studies of pre-exiting conditions and found ranges of estimates ranging from 20 percent to 66 percent, neither of which is a trivial share of American adults. And should an individual who is deemed to be “high risk” suffer a lapse in coverage, such as a period of time between jobs, the Empowering Patients First Act would allow insurers to charge the individual up to 150 percent of their standard premium. Amid high costs of prescription drugs and other treatments for their conditions, such a marked premium increase could in some cases be devastating.
 
The Mental Health Care Expansion of the ACA will Face Setbacks
 
Within the context of pre-existing conditions, it is worth emphasizing also that the CDC estimate above focused on behavioral and not mental health, the diagnosis of which would also constitute a pre-existing condition. Yet it is estimated that 16.1 million Americans had a major depressive episode in the past year, a rate that does not account for milder forms of depression, or other behavioral health conditions such as anxiety or psychotic disorders. Indeed, it has been estimated that 1 in 5 American adults will struggle with mental illness in a given year. Mental health – for reasons pertaining to both access and stigma – remains woefully undertreated, though the Affordable Care Act provided a marked expansion in access to care, requiring that most individual and small group plans and all marketplace plans provide mental health benefits. Price’s repeal of the Affordable Care Act both leaves the state of mental health care very much in question, and renders particularly vulnerable those who have capitalized on the ACA’s access to mental health coverage and in doing so, accumulated preexisting conditions. 
 
Consequences of Price’s Opposition to Reproductive Rights
 
Within the domain of women’s health, Mr. Price is far from the first Republican to be outspokenly opposed to federal funding of Planned Parenthood given a staunchly pro-life political standpoint. Indeed, Republican majorities and other social conservatives have coalesced strongly around the issue. However, it is worth emphasizing a couple of points that make Mr. Price’s case unique. First, he did not simply vote for the legislation to defund Planned Parenthood (HR 3134 in 2015), but co-sponsored it. But Mr. Price is also a physician, and thus – while an orthopedic surgeon and not an OB-GYN – possesses the medical expertise to balance against his partisan preferences.
 
Abortion introduces many political and religious conflicts, with many holding deep personal religious convictions as to when life begins. Mr. Price has signed on to the more extreme elements of this domain, cosponsoring his first term in Congress the Right to Life Act, which afforded 14th Amendment personhood to a fertilized egg, without providing exceptions such as rape, incest, or the health of the woman. But even beyond the realm of abortion, his efforts to defund Planned Parenthood have broader public health ramifications given the wealth of other services that they provide, such as contraception, STD testing, cancer screenings, and prenatal care. Indeed, increasing access to these services helps to curb rates of teen childbearing and sexually transmitted diseases, both of which are highly costly to American taxpayers, both in treatment and in costs associated with teen childbearing such as welfare and increased chance of incarceration.
 
To be sure, women can in theory obtain contraceptive care from many sources, particularly in more urban regions in which there are broader ranges of services at one’s fingertips. Yet nonpartisan analysis revealed that in two-thirds of the 491 counties surveyed, Planned Parenthood clinics served at least half of the women who obtained contraceptive care from safety-net health centers, with Planned Parenthood being the sole provider in one fifth of those counties. And unsurprisingly, increased contraceptive use has been the main cause of observed declines in teen pregnancy in recent decades. Thus, while tabling the more controversial issue of abortion, with Planned Parenthood serving as the sole provider of contraception for many women, the impact on women’s health and in turn, the American healthcare system and economy, could potentially be dramatic absent the introduction of legislation to provide comparable women’s health services absent the provision of abortions. Such an addition to his healthcare agenda would be a welcome form of moderation of his efforts to scale back access to women’s healthcare, though such legislation has not yet been crafted.  
 
Which Patients Are Empowered? (Probably Wealthy and Healthy)
 
While Mr. Price may seek to respond to some physicians’ frustrations with respect to the arduousness of the American healthcare system’s complex reimbursement procedures and associated administrative burdens, his challenges to much of the healthcare status quo has sparked outrage among many in the medical community. In the aftermath of the American Medical Association’s endorsement of Mr. Price, an open letter by physicians was drafted to challenge the AMA’s support of Mr. Price, and the letter has since received over 5,000 signatories in the American physician community.
 
Mr. Price’s vision for American healthcare is one that is market-based and restricts the extent of government involvement. Such an approach is by all means consistent with the preferences of those within his party. However, the empirical evidence in favor of the programs that he seeks to scale back or eliminate altogether, and his medical expertise having treated patients who may have benefitted from receiving these health programs, should temper the vigilance with which he is approaching the overhaul of the American healthcare system. Such tempering is not yet apparent. How Senate Democrats and moderate Republicans – perhaps those in states that accepted and benefited from Medicaid expansion –  respond to Price in the looming confirmation battle may provide some answers to who is empowered first under Mr. Price’s leadership. 

Note: An abridged version of this piece appeared in The Conversation on December 8. 

Dear Congressman Price,

If you and your family are healthy, I truly am happy for you.

But if you would be willing to indulge me, I’d like to discuss with you just a few concerns from the perspective of someone who has not had such luck.

When I was a young child, I was constantly sick and shuffling between doctors. Between chronic ear infections and chronic kidney infections, I was near constantly on Amoxicillin and Septra. Thankfully, my mother had extraordinary medical benefits at the nonprofit organization at which she worked, allowing for the out-of-pocket costs to be relatively minimal. That is not true of many Americans, which is difficult enough when it is one’s own health, and devastating when it is the health of one’s child. Sadly, your health plan — and indeed, the health plans of all members of your party — have been estimated to reduce coverage and thus access to care for those who are cost-conscious, making these decisions of whether one can afford to go to the doctor all too heart-wrenching.

My final year of college, while spending a semester in Washington, DC, I fell very ill and had to go to the emergency room for what ultimately was a three-day hospital admission for a rare condition that would not become diagnosed for years later. My electrolytes were critically abnormal and no one knew why. Unfortunately, my health insurance was an HMO whose networks were broader in the San Francisco Bay Area, where I had been living and going to college, than in Washington, DC, where I was studying for the semester. Every endocrinologist in the hospital at which I was admitted was out-of-network, and rational or not, my financial concerns exceeded my medical concerns. Absent in-network specialists with whom to consult, I was discharged when no longer critical, though without a diagnosis let alone a treatment plan.

As a graduate student at Columbia University, I benefited from outstanding health insurance with which to benefit from my proximity to some of the best medical care in the nation and indeed the world. It was there that I made my long-awaited specialist appointments, and obtained my long-awaited diagnoses, all the while aggregating pre-existing conditions that would constitute grounds for insurance denials in the absence of the Affordable Care Act and in the event of a loss of university-provided insurance. And were I relying on your plan rather than coverage supplied by the university, with your refundable tax credits allotted based on age rather than income, I would have obtained only minimal coverage with which to treat these conditions despite my earning merely $28,000 per year in New York City at the time.

Following a violent assault my second year of graduate school, I fell into a deep depression and for the first time in my life, I began to spend time every week “on the couch,” in addition to having some combination of adventure and misadventure with the world of psychopharmacology. Such resources would surely have been unattainable absent insurance coverage given my limited financial means as a graduate student. With the passage of the Affordable Care Act, these highly valuable mental health benefits became requirements of far more individual and small group insurance plans, as well as all marketplace insurance plans. People around the nation still struggle to find in-network providers, with psychiatrists among the physicians least likely to accept insurance. This struggle is indicative of a need for an expansion rather than reduction of mental health benefits for our nation.And moreover, had this assault rendered me pregnant, which thankfully it did not, under the Right to Life legislation that you cosponsored your first term in the House of Representatives, you would have sentenced me to motherhood because I experienced, rather than perpetrated, a crime. That is not medicine. That is cruelty.

As a postdoctoral fellow at Washington University in St. Louis, I fell seriously ill due to a medication problem the details of which I will not go into but which left me severely hypotensive and bradychardic, among other issues. I was taken to the hospital by an ambulance that I did not call (and the insurance coverage of which has not yet been resolved), and was in the hospital for seven days, the first two of them in the intensive care unit. While all of the medical care was without regard to insurance but rather what was viewed as medical necessity — from CPR and intubation to head and abdominal CTs to EKGs to many rounds of IV medications — the costs aggregating well beyond $30,000 would have induced in me a heart attack had I not had the insurance to account for all but $300 of the expenditures. To be sure, I aggregated that week a medical history sufficient to preclude insurance coverage absent employment and the Affordable Care Act’s safeguards. Had I lacked insurance with which to treat these conditions and been conscious at the time, I doubtless would have resisted going to the hospital, a financial anxiety that would have produced life-threatening consequences.

Between the conclusion of my position at Washington University in St. Louis on June 30 and the commencement of my position at Yale University on August 1, I lacked health insurance. Having been in and out of the hospital, I was reluctant to run the risk of being vulnerable in this regard. I was lucky to have the credit limit to permit my enrollment in the (exceedingly expensive) COBRA insurance to extend my coverage. Under most circumstances in my life, such an investment would not have been financially feasible, and for many Americans, this would not be feasible (consider, for example, that my monthly contribution toward my health premium had been about $90, while the COBRA premium was about $700).

Ultimately, I was very lucky to have made this investment, because on July 9th (not an optimal month for a hospitalization…), I became sick yet again, went to the emergency room, and consistent with my dread upon entering those doors, I was admitted for three days, until my electrolytes and EKG became less severely abnormal. For all of the treatment — from the emergency room, to the intravenous medications to the EKGs to the board in a semi-private room — with my insurance I faced (admittedly in addition to the excessive COBRA premium) a total hospital copay of $300. Had I lacked that coverage, the total amount of the hospitalization was $18,700 (though admittedly were I absent insurance, I would not have been wiling to go to the emergency room in the first place, but that could have carried potentially more egregious health complications such as greater cardiac effects of the hypokalemia and hypocalcemia, potentially yielding even greater medical costs down the line). And had I been unable to afford COBRA and had less guarantee about future health insurance, thus instead seeking to apply for individual health insurance, absent the ACA guards against denials for preexisting conditions (of which I have many), I would have been unable to secure coverage. And even with the coverage that I have had over the years, I still have thousands in medical debt, which remains a consistent stressor.

From thyroid to gastrointestinal to hematological problems (not to mention a predisposition to depression that was activated by a traumatic event), I live every day knowing that absent employment with healthcare benefits (and in a region of the country with access to good care), I am at risk. I live knowing this because your plan would eliminate safeguards against loss of insurance coverage due to the preexisting conditions that make individuals vulnerable and thus all the more deserving of care, yet too often denied it. You may say that your plan would prevent insurers from denying coverage on these grounds, but you do not preclude insurers from charging higher rates. And until you have had to wait until your paycheck clears to purchase groceries and prescriptions, or have put off needed treatment because it would compromise your ability to pay for other necessities, you cannot make a legitimate claim to offer Americans insurance while enabling the charging of exorbitant fees for it.

Healthcare is meant to protect the vulnerable. I believe that the United States’ intertwining of medicine and business is deleterious to the well-being of its citizenry. You disagree and are entitled to do so. But as a physician who as a resident at Emory and as an attending at Grady Memorial, I know that you would have seen patients whose medical care — whether Medicare, Medicaid, or private insurance — enabled them to obtain medical services that would otherwise be foreclosed, with Medicaid and CHIP (whose reauthorization you voted against in 2007) providing health coverage to 1 in 5 Americans. I also know that you treated patients whose conditions would preclude their being covered at anything but exorbitant rates under your insurance plan, and who might well have suffered as a result. Such patients — stripped of many medical benefits and the adequate subsidies with which to obtain them — would be, if anything, disempowered.

While often called “Obamacare,” we too often ignore the full title of the legislation that you attack so virulently: the Patient Protection and Affordable Care Act. It is true that for too many Americans, affordability remains a goal that is yet to be achieved. While 20 million more Americans have health insurance, bringing the insured rate to a historic low, it is likewise true that millions continue to be underinsured, leaving many healthcare services out of reach. But these problems point to a need for the Act’s expansion, not its rescission. Because while we talk so often of the Affordable Care Act, we must also remember the core concept in the Act’s title: patient protection.

Decent and intelligent people differ over the proper role of government and its relationship to private markets, but I do not believe that it protects patients to strip them of the legislation that expanded coverage to 20 million more Americans. I do not believe that it protects patients to strip away requirements that marketplace and most insurance and small group plans provide mental health benefits. I do not believe it protects patients to roll back the Medicaid expansion that delivered expanded access to preventive as well as live-saving care for millions of low-income Americans. I do not believe that it protects patients to allow insurers to charge them exorbitant rates as punishment for having medical histories.

Could you look your former patients in the eye and tell them that you believe that these outcomes are the path to healthcare’s greatness?

Thank you for listening.
​
Best,
Miranda Yaver

​Among the more powerful ads run by Secretary Clinton in the presidential election campaign was that run by Khizir Khan, the gold star father whom Mr. Trump famously verbally attacked in the aftermath of the Democratic National Convention. Looking at a picture of his deceased son, Khan asked in the ad, “Would my son have a place in your America?”

​Those words were especially chilling to those who are Muslim or immigrants, both groups against whom Mr. Trump has lodged especially virulent attacks. But in the aftermath of Mr. Trump’s election upset, there are many reasons to ask who indeed does have a place in Trump’s America.

Among those seemingly left behind in Trump’s America are the many millions who struggle with mental illness.

This is far from a small problem. Indeed, approximately one in five American adults (48.5 million) experience mental illness in a given year, with one in 25 American adults (10 million) experiencing a severe mental disorder that substantially interferes with their life activities. An additional 21.4% of American teens experience mental illness. Such conditions can have the capacity to exacerbate physical conditions — whether from anxiety exacerbating high blood pressure or leading to less vigilant maintenance of chronic conditions — and can impede ability to maintain full productivity in work, thus leading to further vulnerabilities with respect to financial security and potentially needing to go on disability. Indeed, serious mental illness alone costs Americans $193.2 billion in lost earnings per year. The most serious consequence of untreated mental illness is suicide.
There are, to be sure, some cases of severe mental illness for which this will not be avoided, or easily avoided due to the need for considerably more intensive treatment. But for many, these adverse outcomes can be moderated with increasing access to quality and affordable treatment options.

Both for reasons of sigma and lack of access (both regarding a shortage of clinicians and a difficulty affording care), only 41% of American adults who have a diagnosed mental illness receive treatment, with only 62.9% of those with serious mental illness receiving treatment and only 50.6% of children with mental illness receiving treatment. And unsurprisingly, white Americans receive those services at much higher rates than do minorities.

Among other aspects of the Affordable Care Act, which delivered health insurance to an additional 20 million Americans and brought the insured rate to a historic low, the Act delivered a massive expansion of mental health benefits. The Act required that most individual and and small employer group health plans, and all plans offered through the Health Insurance Marketplace, offer insurance coverage for mental health and substance use disorder treatment services. Thus, not only were non-marketplace plan benefits expanded to ensure better treatment for these sets of conditions, but the millions who obtained coverage through the ACA marketplace obtained new behavioral health benefits of which they were not previously recipients.

While Mr. Trump had initially expressed an interest in salvaging some more favorable aspects of the Affordable Care Act — namely, protecting people against insurance denials due to preexisting conditions and allowing people to stay on their parents’ health insurance plans until the age of 26, not only is the former goal virtually infeasible absent the insurance mandate so as to broaden the risk pool of insured patients, but Mr. Trump’s nominee for the Secretary of Health and Human Services, Tom Price, is one of the most virulent opponents of the ACA.

While it is not entirely clear with what, if anything, the Affordable Care Act will be replaced as the GOP meanders from “repeal and replace” to “repeal and delay,” what is clear is that neither Speaker Ryan nor Representative Price’s plans would guard against insurers charging markedly higher premiums for those with preexisting conditions, which depression and anxiety would both constitute. Whether or not they officially allow insurers to deny due to preexisting conditions or simply allow for insurance rates to vary as a consequence of those conditions, given the economic realities faced by many Americans — and in particular those Americans struggling with mental illness — they may ultimately prove to be observationally equivalent.

Moreover, with Price’s refundable tax credits allocated based on age group rather than income, no effort will be made to aid those who are lower income (though potentially not so low-income as to qualify for Medicaid (the future of which is also in question) and young or middle-aged and in need of aid to afford their coverage for their physical and behavioral healthcare. The justification is that premiums are determined on the basis of age, with older patients expected to have higher healthcare costs, though to be sure a more fitting allocation would incorporate both age and income into the tax credit schedule. Yet studies evaluating mood, anxiety, psychotic, and substance use disorders found that the average age of onset was typically in teens and twenties, the age groups receiving the least in the way of tax credit aid under Price’s plan.

Those who have reaped the mental health benefits under the Affordable Care Act’s mental healthcare expansion will thus be penalized upon the Act’s repeal and ill-equipped to afford alternatives absent nearly adequate government-provided assistance. (This is of course true of all physical health conditions, on which I am not focusing in this piece). And given the association between mental illness and income — with those diagnosed with Axis I and Axis II mental disorders typically lower income — those affected will have fewer options for obtaining treatment absent insurance coverage (which was already in need of expansion not rescission).

Intelligent and well-meaning people disagree over the proper scope of government intervention in delivering programs, as opposed to relying on market-based alternatives. It is a given — one might even say, a virtue — of living in a pluralistic society. Yet in these literal life and death scenarios — when one is unable to obtain needed care for crippling and potentially life-threatening depression or addiction (not to mention the associated physical problems that result), blind ideology must be tempered in favor of rationality.

Despite his own medical expertise — and in a setting in which he saw first-hand the access to care that those on Medicare and Medicaid were able obtain when they would not otherwise — Mr. Price’s strident partisanship is sure to undermine the quality and access to physical and mental health care on which millions of Americans rely for their safety and wellbeing.

After an election dominated by rhetoric and anti-establishment sentiment more so than policy specifics, the upset of November 8th left open many policy questions as to the course on which President-Elect Trump would steer the nation. More questions still were raised when it was suggested that some aspects of the Affordable Care Act might, indeed, be salvaged. Such hopes have recently been dashed.

Among President-Elect Donald Trump’s recent cabinet announcements is that of Health and Human Services, for which he has chosen staunch ACA and reproductive choice opponent Representative Tom Price. While qualified for the position as a long-time orthopedic surgeon and member of Congress, much of his political record are deeply troubling in looking to the future of the American healthcare system.

To a long-time observer of American politics, it comes as little surprise that there is ample politics in policy. Yet one domain in which this can be troubling is that of healthcare. After all, cancer, heart disease, and diabetes do not discriminate among Democrats and Republicans. Physicians treat patients of different ideologies and socioeconomic status, and following the Hippocratic Oath they look after the safety and wellbeing of those who are in their care.

To be sure, physicians have their own policy and partisan preferences, though typically they are not (or should not be) on display in an exam room. Indeed, there are are matters of healthcare that may well be in contest with one’s own partisan politics, such as the virtues of Medicaid expansion under the ACA or access to women’s health clinics that, among many other services such as cancer screenings and family planning services, do provide abortions. While scaling back the ACA and restricting access to clinics such as Planned Parenthood is a popular talking point for members of the Republican Party, many physicians see the benefit that their patients reap from obtaining insurance regardless of preexisting conditions and from obtaining affordable contraception.

Yet Mr. Price, placing his partisan politics above medical judgments in many prominent respects, does not recognize these benefits. Rather, he has been among the fiercest opponents.

Indeed, in 2015 he co-sponsored HR 3134, the Defund Planned Parenthood Act of 2015. He has additionally voted against Infant Mortality Pilot Programs (2010), Funding to Combat AIDS, Malaria, and Tuberculosis (2008); Children’s Health Insurance Reauthorization Act of 2007, and he has voted in favor of repeals of provisions of the ACA.

As an orthopedic surgeon whose residency was completed at Emory University and after which directed an orthopedic division of a large hospital in Atlanta, Mr. Price likely saw patients of a range of ages, from younger athletes to more elderly patients whose injuries associated with older age required treatment. And having provided these medical services at major hospitals accepting both Medicare and Medicaid, rather than serving wealthy private-pay clients who would seek medical attention without regard to insurance status, Mr. Price doubtless saw the benefits that his patients reaped from having access through these government programs to the care that aided their healing and mobility. These programs accepted by the hospitals at which he provided care, and from which his patients benefited, are the very programs that he seeks to privatize, thus stripping federal protection of these core medical benefits for seniors and the poor.

Mr. Price may have pledged to do no harm as a practicing physician, but as a legislator and presumptive Secretary of Health and Human Services, it is difficult to see as anything but deeply harmful his assault on programs that care for the physical and mental well-being of some of the most vulnerable subsets of the population.

While Mr. Price and his family currently live a life of much privilege, as a father no doubt Mr. Price understands the fear that a parent would have should their child fall ill when medical treatment is difficult to come by. And as a resident and then attending at major hospitals, no doubt Mr. Price treated families experiencing just those concerns, which the Children’s Health Insurance Program (CHIP) works to address by providing health care coverage to over 8 million low-income children. And yet despite knowing — and as a physician, seeing up close — the importance of delivering quality, affordable healthcare to children so that they may go on to thrive in their adulthood, Mr. Price voted against its reauthorization.

Among the most deeply partisan issues of the recent election cycle was the expansion versus repeal of the ACA which — for all its faults with respect to continued underinsurance of millions — expanded the number of insured Americans by approximately twenty million. As someone who practiced as an orthopedist for over twenty years, Mr. Price should know the impact that insurance coverage has on one’s willingness to pursue treatment for their injuries, and the sometimes dire consequences of going untreated due to lack of insurance. Despite this, he has sought to repeal the Act, challenging the “stifling and oppressive federal government,” with the GOP replacement plans all estimated to reduce the number of insured Americans and the extent to which they are covered. If there were any doubt as to Mr. Trump’s seriousness about dismantling the ACA, those doubts have now been vanquished.

As both a politician engaging in diverse matters of public policy, and as a physician who had many patients with diverse stories, Mr. Price no doubt understands the important role that mental health plays in physical health as well as worker productivity and potential proclivity toward substance use and abuse. Indeed, Mr. Price’s own state of Georgia ranks 47th out of 51 in access to mental health care according to Mental Health America. This carries physical, emotional, and economic consequences, with major depressive disorder costing an estimated $210.5 billion, raising the prevalence of other medical conditions that require treatment (which carries additional expenses and stressors), and in extreme cases, suicide.

The legislation of which Mr. Price has been a fierce critic, the Affordable Care Act, created one of the largest expansions of mental health and substance abuse coverage in a generation. Among its requirements were that all marketplace insurance plans, and most individual and small employer health insurance plans, provide coverage for mental health and substance use treatment services. While some attention has been paid to addressing ways to continue to protect those with pre-existing conditions, Mr. Price and his Republican colleagues have yet to provide answers as to the future of mental health treatment in the absence of the ACA, whose progress has not yet had the chance to be fully realized. Leaving these populations of individuals, already vulnerable, without an affordable means to address mental health or substance use concerns, would be deleterious to their physical health, and well beyond what many physicians would deem permissible.

Moreover, while opposition to abortion access is a position commonly held among those on the right, the Planned Parenthood clinics that Mr. Price has sought to defund provide a range of affordable family planning services that contribute to the physical and economic well-being of the nation. The National Campaign to Prevent Teen and Unplanned Pregnancy estimated that the cost to taxpayers associated with teen childbearing was $9.4 billion in 2010 alone. As Figure 1 illustrates, greater access to Planned Parenthood clinics is associated with marked declines in teen childbearing, with my own research showing additional effects of curbing sexually transmitted diseases and HIV.
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​Similarly, Figure 2 shows that greater access to women’s health clinics is associated with lower rates of sexually transmitted disease diagnoses, the medical treatment of which aggregated to an estimated $16 billion in 2010. These issues will never disappear, but they can be minimized by maximizing access to these medical services that Mr. Price has shown himself committed to eliminate. The Vice President-Elect Mike Pence is himself, though vehemently pro-life, well-acquainted with the pitfalls of aggressively curbing access to Planned Parenthood clinics, with his slashing of funding to the organization in Indiana sparking an HIV outbreak in Scott County, which in the absence of Planned Parenthood no longer had an HIV testing center.

The outcomes of fewer teen births and fewer STD diagnoses are surely beneficial from both medical and economic standpoints, and yet even as a physician this information has yet to sway Mr. Price in his vehemently supporting the organization’s defunding and even going so far as to dispute that any women struggle to afford birth control. He even went so far as to cosponsor in his first year as a congressman HR 552: Right to Life Act, which was legislation to define personhood in the 14th Amendment of the Constitution as beginning at the point of fertilization, without any exceptions listed with regard to rape, incest, or the health of the woman. While an orthopedist and not an obstetrician, as a physician Mr. Price surely had some female patients, and as their physician it was incumbent upon him to provide them with the best care. That care does not include contributing toward their being sentenced to motherhood because they were subjected to a violent crime, nor should it include forcing a woman into a life-changing decision that would carry a high risk of compromising her health and safety.

One cannot expect a cabinet appointee to be devoid of partisan preferences. Indeed, partisan political experience often contributes heavily toward their nominations. And unlike the selection of Senator Sessions for Attorney General, despite his staunch conservatism even relative to his own party (see Figure 3), Mr. Price does not present existential threats to democratic institutions, but rather strident challenges to policy issues that too often are rendered partisan.
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However, the consequences of Mr. Price consistently ignoring the empirical evidence in favor widely-used healthcare programs — even despite his medical expertise — have both vast economic and human consequences that will be all the graver upon his presumptive confirmation as Secretary.

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Note: An abridged version of this piece appeared in The Guardian on November 30, 2016.