​It is difficult if not impossible to square the current Congress’s recent attacks on health care with its responsibility to provide for the general welfare. Not the welfare of the wealthiest 1%, but the general welfare.
 
For a number of reasons, I have felt alienated by my current government. I am a woman, and like many other women across the country, have not taken kindly to the current Congress’s assaults on access to women’s health care – whether through Planned Parenthood or essential health benefits – sometimes without the input of any women. Women comprise 51% of the population, and any efforts to undermine our full inclusion in discussions about the care of our own bodies is as absurd as it is offensive. And my own research has shown the immense public health, and in turn economic impact that Planned Parenthood clinic access has for millions, driving down rates of STDs, teen pregnancy, and HIV. Gutting Planned Parenthood funding doesn’t make America great again, it makes teen pregnancy great again.  
 
I am a rape survivor, and like many survivors of assault was appalled by the Republican Party’s normalizing of then-candidate Trump’s boasting of sexual assault, and am even more appalled by their treatment of sexual assault and domestic violence as declinable preexisting conditions under the American Health Care Act (AHCA).
 
The AHCA, which passed on May 4 with a mere 217 votes, is the most recent, and by all accounts most egregious grievance. And as with issues pertaining to women’s health, I have dual responses – those of a frequent patient, and those of a scholar whose work increasingly addresses health care policy.
 
As a scholar, I trust data, and while the House failed to wait for a CBO report, we know from the prior iteration that at least 24 million will lose coverage, and that many will face higher health costs on account of their being older, poorer, sicker, or (gasp!) born with a vagina. We know that the estimated premium hikes for those with asthma are $4,000, for those with diabetes are $5,500, for pregnancy are $17,000 (ironic given Republicans’ constraints on contraception and abortion), and for cancer are a whopping $140,000.
 
Cancer does not discriminate between Democrats and Republicans. It afflicts the young and the old, the rich and the poor, the liberal and the conservative, and we owe it to ourselves as a nation to care for individuals in need. And from an economic standpoint, we know that contributing to the nation’s economy is hardly as feasible when people are not physically or emotionally well. We know that while people will be grandfathered in to plans, 85% of people stop working when they receive cancer treatment, resulting in gaps in coverage that would lead them painfully vulnerable under this plan.
 
Moreover, by undermining essential health benefits and protections for those with preexisting conditions, this includes mental health treatment, which is essential for treating both mental illness and substance abuse amid a rampant opioid epidemic. And we know that mental illness and poverty are all-too-commonly linked, such that the economic impact of restricting access to care in this domain is devastating. Moreover, full-time employees with depression miss nearly twice as many work days each year than do their non-depressed counterparts, a pattern that could potentially have consequences resulting in gaps in coverage and in turn, the effect of changes to preexisting condition provisions.
 
While I have never had cancer, I have struggled with chronic illness from early childhood onward. With chronic kidney infections and ear infections, scarce were the days I wasn’t on an antibiotic. Throughout my teens and early twenties, I struggled with severe anemia with a then-unknown cause (it was later determined to be an autoimmune gastrointestinal condition), which ultimately required iron infusions. My final year of college, I was hospitalized for severe electrolyte abnormalities ultimately diagnosed years later when I was in graduate school (it is a rare parathyroid condition). With several subsequent hospitalizations, as well as ongoing depression and PTSD, I have for now several years had several doctors overseeing my care, with my survival (not to mention thriving) contingent upon taking a job that has good medical benefits in close proximity to high-quality research hospitals.
 
It is both dismaying and offensive that Representative Mo Brooks views those with preexisting conditions as being at fault for their conditions, for not leading good lives. With multiple autoimmune conditions, and extensive childhood illness, there is little question that I would have been in the 27% well before I could be blamed for what I eat or drink. And even if it were lung cancer, don’t patients deserve some measure of compassion? Are we so soulless that we are unwilling to help people to heal?
 
If we measure a country not by how it treats its wealthiest 1%, but rather by how it treats its most vulnerable, the Republican Party has a lot of explaining to do.

President Bannon wants to tear it all down and deconstruct the administrative state. Neil Gorsuch may be the man for the job.
 
Indeed, in his concurring opinion in Gutierrez-Brizuela v. Lynch (2016), Judge Gorsuch wrote, “We managed to live with the administrative state before Chevron. We could do it again.”
 
To be sure, at a basic level, Judge Gorsuch is not incorrect. America’s modern administrative state could reasonably be characterized to have emerged in 1887 with the Interstate Commerce Act, 97 years prior to the Chevron holding. Policy implementation by way of rulemaking would not cease in the event of its reversal.
 
Yet the aversion to Chevron deference to agency expertise is emblematic of a broader view about regulatory capacity and the proper role of the federal government versus states and private enterprise. Indeed, in that same opinion he held that Chevron and Brand X “permit executive bureaucracies to swallow huge amounts of federal power” in excess of that envisioned by the framers. 
 
Judge Gorsuch’s mother, Anne Gorsuch, is notable for a deregulatory stance while serving as Administrator of the Environmental Protection Agency from 1981 to 1983, and Judge Gorsuch seems to share her view about the proper role of executive branch agencies as vehicles of policy change. Indeed, the notion of having an agenda characterized by “regulatory relief” is far from unusual in a Republican administration.
 
What is less usual is President Trump’s Executive Order calling for the rescission of two rules for every new rule promulgated. Such a move could reasonably be characterized as working toward Bannon’s stated goal of “deconstructing the administrative state.” Setting aside the logistical challenges that would emerge in the implementation of the EO – namely, that some rulemaking is mandatory not discretionary, and that notice and comment processes apply to rule rescission as well – it reflects a hostility to a regulatory state across a range of policy domains.   
 
The proper scope of the regulatory state is not crystal clear, though many would hold that complexities of contemporary politics and policymaking require a significant measure of deference to agency interpretations of regulatory authority. Members of Congress, whether junior or senior, are not experts in the safe levels of benzene in water. They are not experts in the the design features ensuring safety of particular classes of vehicles. They are not experts in ergonomic design for diverse ranges of workplaces.
 
Agencies, on the other hand, are comprised of experts and have the technical knowledge as well as the resources to render such reasoned judgments, and are able to draw also on an extensive body of information gleaned through the notice and comment process. And while this presents reasonable questions of democratic theory – that is, members of Congress are directly accountable to the voters, whereas bureaucrats are not – it presents practical, efficiency advantages. By all accounts, drawing on this scientific and otherwise technical expertise is imperative. In its absence, Congress is left to construct these technical details absent the adequate training and resources to do so.
 
Judge Gorsuch’s confirmation hearing was – true to form with respect to any Supreme Court nomination proceeding – characterized by a vigilant defense of stare decisis, or respect for judicial precedent. That is, he articulated a commitment to upholding existing case law, to enforcing laws passed by Congress and respecting prior decisions rendered by the Court. Such a view is commonly articulated in nomination hearings, and will (if true) give comfort both to liberals concerned about the endurance of Roe v. Wade and to conservatives concerned about judicial activism.
 
This makes Gorsuch’s stated views on Chevron all the more interesting, given its status as a widely-cited and heavily influential administrative law precedent from 1984. Indeed, it is the third most-cited administrative law case. While publicly characterizing such holdings as Roe and Obergefell as being “the law of the land,” he openly criticized in Gutierrez the view of the regulatory state embraced by Chevron deference to agency interpretations of the laws that Congress passes.
 
It is unclear that Congress will indeed succeed with its legislation to reshape the deference afforded. Yet there is a striking inconsistency on the part of Judge Gorsuch, accepting on principle one precedent as the law of the land while stating we could (perhaps should) do without another precedent. Thus, it is distinct from mere disagreement from the holding, in that he advocated in his concurrence a world without Chevron.
 
And while Judge Gorsuch was not actually advocating in his hearing for its overturning, and indeed acknowledged the value of scientific expertise, if we rely on his written words as he called upon the committee to do, there is ample reason for concern about the scope of the regulatory state under the Trump Administration and beyond if and when Judge Gorsuch is confirmed to the Supreme Court. Scaling back on the Court’s reliance on Chevron may prove to have only a modest impact, though it has the capacity to impact the multitude of cases that rely on it, with potentially drastic impact on environmental regulation. Indeed, the EO and Judge Gorsuch could potentially be the perfect convergence of circumstances for the Trump Administration in its effort to deconstruct the administrative state.
 
Judge Gorsuch at his hearing set up a false dichotomy between being thoughtful versus being political, the latter of which Gorsuch decried given his status as a federal judge. Ultimately, a reality of being in the government – even in the judicial branch – is that politics and policy are often (some might say too often) intertwined. This is ever truer at this time when President Trump’s policies defy historical precedent with respect to both domestic and foreign policy. Whether he likes it or not, the implications of Judge Gorsuch’s views about Chevron and its proper ongoing role in American administrative law are important to our law, politics, and policy.
 
America’s greatness is not achieved by looking “backward, not forward.”
 

Before proclaiming oneself to be “pro-life,” it is incumbent upon the person to answer the following question: For whose life?
 
I support the lives of women around the nation and their entitlement to bodily autonomy, because I know that we thrive and our families thrive when we can properly care for ourselves and our families.
 
I support the lives of survivors of sexual assault, for whom we should provide compassionate care rather than sentencing to motherhood on account of punitive legislation that values a 25-day old (or even two day-old) cluster of cells more so than we do a twenty-five year-old woman, especially when the pregnancy is the result of a violent crime.
 
I am for the lives of women who want to become mothers but whose health precludes a safe and healthy pregnancy and delivery, and thus who cannot carry their pregnancies to term.
 
I am for the lives of pregnant women seeking to obtain quality and affordable prenatal care, and who should not be denied access to health insurance because of the “preexisting condition” of having been pregnant.  And I am for the soon-to-be babies who will benefit from their mothers having received that medical care, and will suffer in that absence.
 
I am for the lives of the millions of women served by Planned Parenthood, which apart from abortion services delivers access to invaluable contraceptive care, STD testing, and cancer screenings, because early detection is imperative. Moreover, with over half of Planned Parenthood patients relying on Medicaid and still many others being low-income, few alternatives exist for receiving quality women’s health services.
 
I am for the lives of the millions of women around the globe who will suffer as a consequence of the Trump Administration’s reinstatement of the global gag rule and its adverse consequences for a range of health services extending well beyond the domain of abortion.
 
I am for the lives of the millions all across this country who depend on quality, affordable health care, whether for preventive care or for the treatment of preexisting conditions, which 27% of Americans have and thus would be denied health care coverage in the absence of the Affordable Care Act. I am for the lives of those who have been able to access essential care through Medicaid, without which they would be unable to receive treatment, potentially dying as a consequence.
 
I am for the lives of the refugees fleeing war-torn countries in hope of a better life, in a nation where they can thrive away from the devastation and violence of their native land. As a nation of immigrants who preach about the American dream, I believe that while we can be a land of opportunity, such opportunities are rarely obtained through Horatio Alger stories, but rather through a collective commitment to our remembering our nation’s history, and an investment in helping people to rise up and contribute to our society.
 
I am for the lives of those who have committed crimes and for whom many other first-world nations would deem a life sentence to be a worthy punishment, rather than the death penalty. And I am for the lives of those who could have been better protected with tighter regulations on the sales and distribution of guns. 
 
I am for the lives of all who drink the water and breathe the air on which we depend, and for which we require an Environmental Protection Agency to responsibly regulate rather than subject populations to dangerous and life-threatening toxins as we have seen in Flint, Michigan and beyond.
 
I am for life. But I am not simply for life until birth.
 
We could claim that the anti-abortion movement is motivated by hostility to abortion, but were that simply the case, they would support Planned Parenthood’s provision of contraception, which significantly obviates the need for the abortions that they abhor. Indeed, in 2010 alone, publicly funded family planning services helped women to prevent more than 2 million unintended pregnancies. We can claim that they are for the life of the unborn, but were that the case, they would invest in prenatal care to enable a safe and healthy pregnancy and delivery (services also, incidentally, offered at Planned Parenthood).
 
We could claim that the anti-abortion movement is about protecting women’s health in the conducting of this procedure. Were that the case, they would not push TRAP laws that serve to ultimately restrict access to one of the safest medical procedures when it is done early and legally. Importantly, restricting abortion access does more to restrict access to medically safe abortions than it does to restrict access to the procedure more generally.
 
We could claim that attacks on Planned Parenthood and the Affordable Care Act (“Obamacare”) are grounded in simply different visions of how best to deliver quality and affordable healthcare to the broadest swath of the American public. Were that true, Republicans in Congress would not have voted in favor of stripping away health insurance absent a viable replacement plan that does not reduce the amount of coverage or the number of individuals covered.
 
Conservatives have opposed health care access for women and for mothers-to-be, thus severely compromising any credibility that they might have in making such claims as to the motivations underlying their attacks on women’s bodies, and on health care access more generally.
 
It is not an attack on abortion. It is an attack on women, and an attack on the poor or otherwise vulnerable.
 
With many counties relying heavily– or in some cases, exclusively – on Planned Parenthood as the safety-net health center providing contraceptive care and other basic services, and with many such individuals having incomes unable to support more expensive care (or the resources to travel farther for those services), by restricting support for this organization we relegate women (especially poor women) to second-class citizenship even in this nation that so often preaches language of equality.
 
With 20 million gaining health insurance under the Affordable Care Act and many benefitting from Medicaid expansion, by stripping away the Act we – while purportedly being pro-life – deny millions the ability to obtain reasonably priced and quality medical care that they gained under President Obama – medical care that could be life saving.
 
Those insisting on the rights of a fertilized egg while failing to protect the health or life of millions of women and children, preaching of “regulatory relief” and “personal responsibility,” and insisting on the necessity of reducing health care access are not pro-life. They are only pro-birth.
 
We cannot simply be a nation that fights for the right to simply be born, but rather must fight for the right to thrive once we are brought into the world. As a nation of immigrants and one that purportedly champions equality and opportunity, it is time that we practice what we preach and halt the rollback care that saves lives and enhances quality of life.
 
If it is true that we measure a society by how it treats its most vulnerable members, those pushing for this legislation have a lot to which they must answer in advance of the 2018 and 2020 elections.

​Mr. Trump is not the first president to have a so-called “enemies list,” though the first such presidency did not end well.

Mr. Trump’s enemies list is long. Mexicans. Muslims. Vanity Fair. The New York Times. The Washington Post. Polls (when unfavorable). Fact-checkers. Democrats. The media broadly construed. Judge Curiel. John Lewis. Meryl Streep. Saturday Night Live. Those requesting his tax returns (not just journalists?).

He has now added an entire branch of government, this branch of course being the judicial branch.

If you think that this is not dangerous, guess again.

The judicial branch was famously characterized by Alexander Hamilton in Federalist 78 as the “least dangerous” branch, controlling neither the sword nor the purse, having “neither force nor will; only judgment.” While scholars have debated the extent influence of the judiciary in the separation-of-powers system — whether calling attention to the courts as vehicles for protection of rights, or calling attention to Title VI of the Civil Rights Act of 1964 as being a stronger impetus for desegregation of the American South than was Brown v. Board of Education — it is undeniable that the Supreme Court has served a crucial role in the enforcement of constitutional rights over the decades.

This is enabled in no small part by the fact that the American political system provides for judicial independence — with lifetime appointments and the inability to be removed based on its decisionmaking — thus enabling justices to avoid political pressures that might influence their rulings. It is also enabled by our institutional norm of judicial legitimacy, according to which the branches respect the right of the judicial branch to render the decisions that it does, with respect for the decisionmaking process if not the substance of the outcomes themselves.

To be sure, presidents have spoken out about their views as to the substance of decisions, with President Obama saying publicly that he disagreed with the outcome of Citizens United. But he did not attack the Court or the justices who sit on it. He attacked the particular outcome.
Enter Donald Trump.

The relationship between the Trump Administration and the judiciary has already been one marked by tension, with Kellyanne Conway initially holding that the district court restraining order “really doesn’t affect” the Trump Administration’s implementation of the notorious executive order of prohibiting travel from seven predominantly Muslim nations. While we do not always agree with the outcome of judicial rulings, the rule of law necessitates compliance with them, and appeals procedures are in place in order to challenge adverse actions. This does not, however, obviate the need to comply in the meantime, a norm that initially was not followed.

Following Judge Robart’s determination that there should be a nationwide restraining order with respect to this EO, Mr. Trump in true Trump fashion lashed out on Twitter at the “so-called judge.” While party affiliation would have no bearing on Robart’s legitimacy as a judge, it is worth noting that he was a George W. Bush appointee who was confirmed unanimously. He soon thereafter held (again via Twitter) that in the event of a national security problem, the American people should blame Judge Robart and the court system. Thus, we saw for the first time in modern American history, the President of the United States attacking the judiciary’s legitimacy and scapegoating it in the event of a hypothetical attack, likely setting it up to restrict its independence under conditions of such heightened national security risk. Absent such judicial independence, judges are not free of political pressures in their decisionmaking and thus may operate as inadequate checks on the other branches and intrusions of rights.

So, rather than accepting the outcome and following the appeals process, he filed the appeal and engaged in a Twitter tirade the compromised the very legitimacy of the branch of government dedicated to the safeguarding of rights that are left in question by the EO and its implementation’s depriving of due process and equal protection under the law. He went on to question what our country is coming to when a judge is able to halt a Homeland Security ban. He further has tweeted insidiously that we are at risk for terror attacks — an effort that like his constant falsehoods about crime rates is with the aim of instilling fear and thus willingness to forego some civil liberties — and thus that courts must act fast.

This shows a fundamental lack of understanding of, and appreciation for, the important role that courts play in our political process. The business of courts is not to act quickly, but rather to be a slower-moving political authority that is not acting out of political expediency, but rather in defense of the constitutional principles that are dangerously under attack currently between the EO and Mr. Trump’s frequent attacks on the media.

When appealing Judge Robart’s order, the Trump Administration further went on to hold, “A reviewing court would not be well-equipped to ascertain the quantum of risk, or what is a reasonable margin of error in assessing risk… Judicial second-guessing of the President’s national security determination in itself imposes substantial harm on the federal government and the nation at large.”

Liberty and security could conceivably be in tension with one another at times, which is why times of national security crisis typically coincide with stronger presidential powers and some degree of constraint on liberties (e.g., the Patriot Act). The Supreme Court’s role is largely the guardian of liberty and it is worth emphasizing also that the ban is not targeting countries from which Americans have suffered particularly, thus raising important questions as to any validity of a national security exception to the claims that his administration makes.

What is perhaps most striking about the Administration’s statement is the notion that judicial second-guessing of the president’s national security determinations is harmful.

“Judicial second-guessing” of the other branches is the job description of judges and justices, and has been since Justice John Marshall famously declared in 1803 in Marbury v. Madison that “it is emphatically the province and the duty of the judicial department to say what the law is.” Indeed, this check on presidential (and legislative) powers is an essential protection of the separation of powers, guarding citizens’ rights against government encroachments of which the Framers were concerned.

Perhaps before Mr. Trump seeks to “make America great again,” he should make Marbury great again.

Those defending Mr. Trump have similarly mischaracterized the critical role that the judicial branch serves in American politics. Mike Huckabee said on Fox that the executive branch historically “has emasculated itself by surrendering constantly to the idea that once the court says something, that’s it. It’s the law of the land… The court can’t make law. They cannot legislate.”

While it is true that legislation is pursued through Congress, the elected branch, and it is true that the judiciary relies on the other branches for the implementation of its decisions, judicial holdings create binding precedent, laws contrary to the Constitution are deemed invalid, and the American political system has a norm of compliance with such holdings, lest we compromise the very fabric of the rule of law governing our society.

There have been all too many moments of the Trump transition and early days of the presidency in which Mr. Trump and his advisors showed a frightening lack of understanding of the role of the president (a fact to which even John Yoo recently called attention) and the powers of administrative agencies in the separation of powers system. While one might find reasons to characterize their statements about the judiciary as being reflections of ignorance, it appears instead to be more deeply pernicious than that. (It is all the more egregious to millions that the man who is this ignorant about, and hostile to, the courts has been given the capacity to fill the seat left vacant by the passing of Justice Scalia, and kept vacant amid the Senate Republicans’ refusal to so much as grant Judge Merrick Garland a hearing.)

Never before has American government seen such a nefarious hostility to the institutions protecting these rights. While President Roosevelt provides a salient example of executive-judicial conflict, it is worth noting that President Roosevelt sought to expand protections of rights amid the New Deal, whereas the Court at that time was striking such protections invalid. As things stand currently, with undemocratic moves being made throughout the executive branch — whether the dissemination of falsehoods, the attacks on the media, the marked corruption, lack of transparency, and imposition of likely unconstitutional executive orders — and an all-too-obsequious and enabling legislative branch of the same party control, the courts stand currently as the sole buffer against further intrusion into fundamental democratic principles.

​It is not hard to imagine why the Trump Administration would be so hostile to them. It is also not difficult to see why it is so dangerous.
​
It is up to us as citizens to be all the more vigilant to guard these ever-more-fragile rights before they are long gone.

​President-Elect Trump’s unprecedentedly anti-media and in many cases undemocratic position-taking has raised for many journalists the question of how to properly cover the Trump Administration. How critical can we be without looking biased? Does objectivity necessitate neutrality? Should we cover his speeches? What is signal versus noise, and how should we treat them differently?
 
While these are all important questions to raise in the media, never before have they been so needed with respect to an American national politician, for whom “controversial” would be a clear understatement. Bloomberg journalist Mark Halperin’s neutral coverage of Mr. Trump led him to be characterized by many on the left as a Trump apologist. Those on the right have characterized CNN and MSNBC and being too far left for expressing criticism of his more controversial positions, such as his attacks on the media and his insistence that it was a rigged system, the outcome of which could not be trusted (unless he won).
 
To be sure, fine journalism requires objectivity and a fierce investigation into the truth, whether or not the truth uncovered is pleasing to one’s political party or the president. But we would be doing ourselves a disservice if we conflate impartiality with a need to to hold back in actively defending a free press against First Amendment threats, with a prominent such threat being Mr. Trump himself and those whom he mobilizes. Impartiality and objectivity are insufficient: we must also actively oppose threats to a free press, even if that carries with it a risk of appearing to have an agenda. After all, while we can certainly criticize journalists should they proselytize over issues of ideology – healthcare, abortion, gay marriage, vouchers – without making clear that it is opinion rather than news reporting, taking a stand for the basic tenets of democracy is not bias but rather patriotism.
 
This is certainly not to say that we should on principle either be neutral or critical of everything that Mr. Trump says, but rather that as citizens and scholars, we should scrutinize the ideas being put forth into the news media and social media, and vigilantly hold him accountable if (when) he spreads falsehoods. After all, only 4% of Mr. Trump’s statements were rated as “true” by PolitiFact, compared to 51% rated as “false” or “pants on fire.”
 
The reality is that it is not a partisan position to hold that while we are entitled to our own opinions, we are NOT entitled to our own facts. That is very bit as true for the president-elect as it is for you or me. 
​
Reiterating falsehoods cannot be tolerated, and to call him out for lies (when they are in fact lies) should be incumbent upon us all. His continued assertion that he would have won the popular vote but for the “millions” who voted illegally left a mark on much of the American electorate, with a recent Economist/You Gov survey indicating that 46% of respondents overall and 52% of Republican respondents viewed it as definitely or probably true that millions of illegal votes were cast in the recent election.
 
There is, of course, the question of whether discussing publicly Trump’s numerous lies gives them life, with many failing to look beyond the headlines to the responsible fact-checking. Yet to fail to ensure that American voters understand that voter fraud is fact a myth, that it was not voter fraud that precluded Mr. Trump from winning the popular vote (by nearly 3 million votes), myths that might be used as fuel for the introduction of more restrictive voting legislation that disproportionately impact poor and minority voters (who, coincidentally, vote overwhelmingly for the Democratic Party).
 
When the Associated Press tweeted on January 1, “President-elect Trump will boldly use Twitter to make major policy announcements, incoming press chief says,” they neglected to scrutinize why Mr. Trump is using this unorthodox medium: the lack of accountability. Mr. Trump has not held a press conference since July, when he actively encouraged Russians to hack Secretary Clinton’s emails. His December press conference meant to address his conflicts of interest was cancelled. He has refused to disclose his tax returns. He as refused to put his assets in a blind trust. He was refused to hold a full press conference in which he could be questioned on these issues and others (such as ties to Russia, his position on the hacking, and issues such as his interest in expanding nuclear capacity in contradiction with long-standing United States policy). Twitter is fast, direct, and does not have immediate fact checking or follow-up questions. It is instant dissemination of ideas that go unfiltered until the media comment, with that commentary garnering far less attention than do the tweets themselves. It is irresponsible for members of the media not to shine a light on this clear motive that Trump has in shifting his policymaking to this dangerously unfiltered and unaccountable medium.
 
There is then the question of how to cover his stranger tweets that could reasonably be characterized as tantrums or otherwise complaints of those who are critical, or else distractions from substantive matters on which he might find the spotlight unfavorable. For example, on November 29th, he tweeted that those who burn the American flag should be punished with loss of citizenship or jail.
 
Is it signal or noise? Answer: Noise, though there are some responsible ways to cover it. For example, does the president-elect know landmark American jurisprudence? Do we have reason to fear more crackdown on First Amendment protections of speech? Likewise, his tweets attacking Saturday Night Live and Vanity Fair, petulant though they are, suggest a willingness to restrict – or at minimum publicly condemn – news and entertainment sources that deign to criticize him.
 
His tweet that China’s capturing of a drone was an “unpresidented” act garnered (justified) mockery for its misspelling of “unprecedented,” but that was not the important implication. The bigger issues were his addressing foreign policy matters in public and 140-character format, and the typo indicated that his tweets on these serious matters were not being vetted by those advising him. The absence of collaborative involvement in shaping the course of American foreign policy, especially given the president-elect’s thin skin and inexperience, is deeply troubling and is grounds for close scrutiny.
 
The Wall Street Journal recently sparked a controversy when its editor determined that the Journal would not call Trump’s lies “lies,” given the implication that lies intend to mislead. Rather, the Journal held that reporters should state the facts and leave to readers their classification as honest or false.

We do ourselves and our nation a disservice when we let the semantics of "lie" versus "falsehood" undermine our commitment to the truth. We cannot always decipher the intent of Mr. Trump's inaccurate statements about such things as crime rates and illegal voting, though we can certainly make our own conjectures especially with respect to things that have been debunked repeatedly. But regardless of intent, a falsehood must be disavowed. It is not bias, it is responsible journalism, and fear about the use of the word "lie" precluding us from responsible fact-checking does us a great harm.

An additional and monumental problem, of course, is that the average reader does not go on PolitiFact or other websites to fact check, but rather depends on vigilant journalists to do the leg work to ferret out the truth. They are not likely accustomed to the degree of lies that we are seeing in the president-elect, and as the Economist/YouGov survey suggests, many have adopted the beliefs that he and those supporting him embrace, whether with respect to illegal voting, Pizzagate (36% believing it to be true), or the notion that President Obama was born in Kenya (36% believing it to be true). In the era of increasing degrees of fake news with instant dissemination and at times difficulty deciphering fact from fiction, journalists and their editors owe it to the American people to be ever more vigorous in their efforts to fact check people on both sides of the political aisle (though the president-elect’s many falsehoods are, to be sure, those most prominent in public discourse).
 
The notion that scrutinizing the president-elect’s statements indicates bias is misleading. His successes should be acknowledged, and his falsehoods corrected. Calling him out for lying – intentionally or not – and actively opposing efforts to undermine a free and independent media (essential to our democracy) is not bias. On the contrary, it is responsible journalism, and it is patriotism. And if we have a pro-democracy bias, well, we should be able to live with that.  

​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.