​My earliest political memory was November 3, 1992, watching my mom watch the election returns. This was followed soon by my rushing around my elementary school “informing” every teacher and student I saw that Bill Clinton had won the presidency the night before.
 
The reaction was, in hindsight, predictable. The students didn’t care. The teachers politely indulged in my admittedly harmless delusion that I was the official purveyor of political news.
 
“Did you know that Clinton won???”
“Wow, I hadn’t heard that! Pretty great…” they say, nodding along and smiling.
 
I didn’t know Bill Clinton’s economic platform. I had a vague recollection of watching him sexily play the saxophone. But watching my mom watching the results at the end of what had been a really difficult year for us, I could tell that things were feeling possible again. And to paraphrase his theme song, at that moment we began thinking about tomorrow.
 
Like many, though amused by the late-night humor that emerged from the 2000 election cycle, I stood aghast as I watched the 2000 election night and the resolution of the Florida recount, which I sometimes have the misfortune of reliving when I teach Bush v. Gore in my Constitutional Law classes.
 
537 votes.
 
537 votes in a state that at the time had a population of just over 16 million.
 
Though I have not lived much of my life in key states or districts, I have (for better and worse) always been in love with political participation, whether that meant pestering high school teachers to vote on key ballot measures when I was not yet 18, informing (okay, maybe “informing”) high school teachers about key issues on the legislative agenda about which they should call Senators Feinstein and Boxer, “informing” Iowa voters of the importance of caucus participation, or knocking on doors and phone banking for the 2004 presidential election cycle (I was 24 days too young to vote in the 2004 election – not that I was counting – and I was skeptical that I’d successfully petition for my voting rights on the grounds that I would have been eligible to vote if I’d been born on time).
 
I remember the night of November 2nd/early morning November 3rd, a night on which I had at that point never before cried so inconsolably, and counted down the days until I could register to vote on my 18th birthday. And as the conflict in Iraq intensified and as I watched people I knew go off to Baghdad, I wondered how many more Democratic voters in Ohio could have made the difference.  
 
But the truth is, voting is not just about calculating the extent to which our vote will be pivotal. It is about civic duty. And it’s about joining the chorus of the millions standing up injustice that we see in our communities and the nation as a whole. And it’s about supporting candidates and policy agendas that we think will help us to build a better tomorrow.
 
This has never resonated with me more than one a civil rights trip that I took through the Deep South when I was 18. It began with meeting civil rights icon and Congressman John Lewis, with whom I talked about how not to get disillusioned in the face of electoral defeat or the murder of movement leaders. We walked across the Edmund Pettus Bridge, the site of Bloody Sunday, during which Congressman Lewis’s skull was fractured amid the beatings of white supremacist police forces. And we went to grave of James Chaney, one of the slain civil rights workers in Freedom Summer.  
 
And when graduating high school and receiving the social studies award from my favorite teacher, in roasting me he said that being my teacher meant that the day started with a list of important things that were going on in the news, lunch involved getting a couple of op-eds to read, and the school day ended getting a list of senators to call about issues on the legislative agenda. And he said I was the only student he had had who cried watching documentaries about voting rights.
 
To be honest, I haven’t changed much in the last 13 years.
 
And while I try to limit the extent to which my partisan preferences show in class, I am unabashed in my effort to instill in my students the importance of voting, a right for which people have died or been beaten in our parents’ lifetimes. Indeed, when teaching Constitutional Law and going over voting rights, I give my students the notorious Louisiana literacy test as an in-class activity without telling them beforehand what it is. Their responses are consistently some combination of being befuddled and aghast. And I remind them of how recently these were administered. (When I give them the Alabama literacy test, which had absurdly detailed questions about American government –  e.g., “Of the original 13 states, the one with the largest representation in the first Congress was ____”, “If a state is a party to a case, the Constitution provides that original jurisdiction shall be in ____”, and “If it were proposed to join Alabama and Mississippi to form one state, what group would have to vote approval in order for this to be done?” – my students generally mistake it for a citizenship test.)
 
Despite some Americans’ fantasies that race-based discrimination is a thing of the past – hey, Chief Justice John Roberts seems to think so! – the reality is that these atrocities were within my parents’ lifetime. What’s more, subtler tactics have persisted, even exacerbated with Kris Kobach, Brian Kemp, and others’ efforts at voter suppression and the fueling of voter fraud conspiracies to justify restrictive measures. And while courts have struck down some of the egregious voting maps and voter suppression tactics, some remain intact and others may be discouraged that the election may already be rigged.
 
In Shelby County v. Holder, the Supreme Court invalidated the formula according to which states with histories of discriminatory voting practices had to first petition the federal government for approval (that is, this preclearance mechanism helped to stop discriminatory practices before they went into effect), and southern states have taken notice. Indeed, Kemp’s efforts to secure the governorship (while administering the election as Georgia’s Secretary of States) look like Jim Crow by another name.
 
We have read about the civil rights movement in history and political science textbooks. And many of us have wondered what we ourselves would have done if living in that time.
 
Now is the time to find out.
 
I have waited in long lines to vote, and I have never missed an election, even the seemingly endless special elections and ballot propositions when I was voting absentee in California. When I lived in St. Louis I cast my ballot for Hillary Clinton in the Missouri primary while I was still in the intensive care unit. I had just regained consciousness, realized it was Election Day, and pleaded with the hospital staff to help me to vote. (Incidentally, that did turn out to be an extraordinarily close election.)
 
At the end of the day, my votes have not been conditional upon my expectation that my vote would make the difference in the election of Barack Obama versus John McCain or Mitt Romney, Jerry Brown versus Meg Whitman, Hillary Clinton versus Donald Trump, Ned Lamont versus Bob Stefanowski.  
 
It has been because of a sense of civic duty to use this voice that I have to support the candidacies of those I support, and who will help to move America forward and knock down barriers to our most sacred right in our democracy. And it is because of my memory of walking across the Edmund Pettus Bridge and the exchange that Congressman Lewis had with a fellow civil rights activist. “Can you swim?” Hosea Williams asked Lewis as they saw the state troopers ahead of them. Lewis didn’t know how to swim, and he pressed on in the march, to be bloodied and beaten in defense of the right to vote.  
 
These fights cannot have been in vain.
 
Vote. Vote like our democracy depends on it, because it does. 

​The evening of January 19, 2017, I marched down Central Park West outside of Trump Tower, in protest of the inauguration while holding a sign that read, “GOP Health Plan: Grab ‘Em by the Premium.” Then I got a text message from my doctor, who told me that based on my recent test results, I needed to go to the emergency room, where I would surely be admitted rather than going to DC for the women’s march.
 
Health policy is an issue to which I have long been invested, both as a scholar and as a patient. And while I have long advocated expanding health coverage, this month is the first time I have ever been on government-provided insurance.
 
This is not to say that I haven’t been immensely concerned amid the Republicans’ ongoing efforts to repeal the Affordable Care Act. From an early age, I have struggled with a number of health problems, whether chronic ear infections to chronic kidney inflections stemming from a kidney disorder that almost required surgery. While in college, my anemia worsened and required iron infusions, but the underlying cause of the anemia wouldn’t be discovered for a few years. While I was in graduate school, in addition to being diagnosed with a couple of stomach conditions, I was diagnosed with a rare parathyroid disorder that caused electrolyte imbalances requiring several hospitalizations. In 2012, I experienced a violent assault, after which I required extensive treatment for depression and PTSD. As a postdoctoral fellow, my electrolyte abnormalities began to cause what were thankfully only minor cardiac complications.
 
Long story short, while I was able to thrive in graduate school and beyond, I have a lot of preexisting conditions, which prior to Obamacare’s passage would have led me imperiled had I not been on my mother’s insurance through college.  
 
Up until recently, I had been lucky on the insurance front. As a doctoral student at Columbia University, I had outstanding insurance to cover treatment by some of the best doctors in the country. I had to make some unfortunate changes to my career path on account of limited health care options in certain regions of the country, but otherwise have always made it work.
 
But amid academia’s shift toward hiring visiting or adjunct faculty, and with a laundry list of preexisting conditions, I have known that should Obamacare be repealed and my position not be renewed, I would be unable to obtain health insurance due to either outright denial (as happened to me in the past between college and graduate school) or by insurance companies making coverage prohibitively expensive. Indeed, I watched President Trump’s inauguration from my hospital room at New York Presbyterian Hospital at Columbia University, tears rolling down my cheeks as I considered the fate of the nation and more selfishly, my health care. Up until recently, this concern was merely hypothetical.
 
With my lecturer position not renewed, my health insurance expired on May 31st. Low-deductible marketplace plans in Connecticut were prohibitively expensive while I was job hunting, and COBRA insurance even more so. I decided to take my chances being uninsured, in hopes that it would be a short-lived state of affairs. Each time I noticed more symptoms from my chronic conditions, I felt the anxiety of wondering whether I was getting sick again. Each time I went for a run, I thought about what would happen if I got injured.
 
After 7 weeks of being uninsured, I called the Access Health CT number to see if there was any subsidy assistance available in light of my unemployment. Ten minutes later, thanks to Connecticut’s Medicaid expansion and the helpful woman with whom I spoke, I was able to enroll in Medicaid for the first time in my life. And I cried with relief. This was certainly not a benefit that would have been available to me had I been living in one of the 18 states that has not opted to expand Medicaid through the Affordable Care Act. 
 
Though I have long been well-acquainted with the immense benefits that Medicaid offers millions – with 1 in 5 Americans on Medicaid or CHIP and with Medicaid patients vastly more likely than the uninsured to have a usual source of medical care  – I had never expected that I would be a recipient of that aid. I had aided people in getting connected with social services. I had championed its expansion and called my legislators to thank them for voting in favor of programs I was not on. Today, my Medicaid card came in the mail.
 
The reality is that health, as well as the employment through which many rely on health coverage, can be tenuous. While some are born into fortunate circumstances or have unusually high degrees of job and financial security, a $500 surprise (e.g., an unexpected medical bill) would for the majority of Americans require going into debt. And it goes without saying that absent insurance, medical expenses often aggregate to thousands, if not tens of thousands or more.
 
While I have long advocated Medicaid’s expansion and continued support, I had never envisioned myself as a recipient of its great benefits. Despite a moment of shame at my current state of seeking employment, I’m filled with gratitude to not be without insurance given my medical history. And the reality is that there’s a hubris to assuming that misfortune will never befall us, and the majority of Americans believe that the government has a responsible for ensuring health coverage for all Americans, regardless of our level of good fortune at a given point of time.
 
This has never been a battle over personal responsibility. People cannot accept the responsibility of full-time employment when they are faced with the “choice” of bankruptcy versus untreated illness. And those whose own health care is subsidized by the taxpayers whose care they undermine have no business voting – without so much as a congressional hearing – to decimate care for millions under the guise of “public service.”
 
Deepening health and economic inequality is no path to American greatness. America can and should do better. 

​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.  

​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.
​​

















​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.
​
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.

​

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

​As a scholar of bureaucratic policymaking, watching the Trump cabinet take shape – or rather, the announcement of the prospective nominees whose confirmation ultimately rests with the Senate – has been at once interesting and alarming.
 
First, the nature of his characterization of the search process, with his tweeting on November 15 (amid reports of disarray), “Very organized process taking place as I decide on Cabinet and many other positions. I am the only one who knows who the finalists are!” It is, at times, as though, he is on a new addition to The Apprentice, moving from The Candidate, but not so much transitioning from presidential but rather the television version. All prestige, no responsibility, but sadly, many many repercussions.
 
Second, while one might be able to make a case for an outsider bringing a fresh perspective into the government, one must still expect that their hires would pick up the slack when it comes to policy expertise, with the policy outcomes reflecting some measure of compromise between establishment and the new wing of the party. That is, while many view experience normatively desirable, among those for whom it was not a dealbreaker, there was presumably some expectation of Trump surrounding himself with good, bright people.
 
Yet his choices thus far raise a number of serious concerns, not to mention a challenge to a rich political science literature (to which I have contributed) resting on assumptions of bureaucratic competence and expertise. After all, the landmark administrative law case Chevron v. NRDC (1984) lays out the “Chevron Two Step” articulating the conditions under which deference should be accorded to agencies’ interpretation of statutory delegations of authority, and that deference is based on a higher degree of technical expertise upon which to draw to determine important matters of policy implementation for the nation. While a legislature comprised mainly of lawyers may not be well-equipped to determine the threshold of harm for benzene in water, the Environmental Protection Agency’s bureaucrats are.
 
Trump has chosen as his Secretary of Housing and Urban Development Dr. Ben Carson, who said himself that (while he felt qualified to run for President of the United States) he lacked the requisite experience to be a cabinet secretary and who nevertheless was offered this position. There are two problems here. First, he is a medical doctor whose experience would be leveraged much more appropriately as Secretary of Health and Human Services or Surgeon General, given his understanding of (at least some aspects of) healthcare. In contrast, his experience in no way prepares him for work in HUD, the work of which impacts public housing across the nation, among many other things. Indeed, the Hill article discussing the nomination cited that Carson was seen as a resource in addressing “inner cities,” a sore spot given Trump’s conflation of minorities and inner cities. While it is certainly admirable to add to the diversity of one’s cabinet, it should not be targeted based on a misguided association, not to mention should not be entirely at the expense of the expertise on which he might be able to draw (e.g., healthcare as opposed to housing).
 
And second, though relatedly, Carson himself said he was too inexperienced for the cabinet before a particular post was being offered, suggesting a broad-based concession to lacking the credentials to guide policy at the national level. Trump would have done well to heed Carson’s words (something I never thought I’d say…), perhaps keeping Carson as an advisor in the inner circle to weigh in on matters to which he could contribute (such as how to balance their aversion to many parts of the Affordable Care Act without taking health insurance away from millions of Americans who have benefited from the Act’s provisions).
 
Trump has chosen as Ambassador to the UN Nikki Haley of South Carolina, a woman who has in some cases drawn relief from those on the left because of her competence at what she does currently, and the fact that she is not among the “overly obsequious to Trump but combative with others” crowd (I’m looking at you, Giuliani, Christie, and Flynn). These are all qualities that point to her being an appropriate pick for something. Yet he has chosen as his ambassador to the UN someone whose entire repertoire of political experience is domestic rather than foreign. It is a misallocation of brainpower, and a sad reflection of his inattention to the expertise and skill sets of those around him.
 
Moreover, he has been rumored to be considering for a post David Petraeus, who pled guilty to the leaking of classified information. He has already named as National Security Advisor Michael Flynn, who is not only vehemently anti-Muslim but has disseminated fake news via Twitter. The likely appointee as Administrator of the EPA is Myron Ebell, a man who is neither a scientist nor a believer in climate change, instead characterizing climate scientists as “global warming alarmists” who “exaggerate the rate of warming… exaggerate the potential impacts of warming and how soon they may occur… and underestimate wildly the costs of reducing our emissions by the magical amount they have picked.” And as icing on the cake, Jared Kushner reportedly asked about how many current staffers would be saying on, apparently unaware of the vast staffing issues that lay before them in order to run the nation (not into the ground).
 
(While competence and expertise are not such problems in the case of Senator Sessions, his hostility to all of the things under the umbrella of the Department of Justice – from his lack of opposition to the KKK, his hostility to school desegregation, history of racial slurs, and his fighting against voting rights – is deeply troubling and should be disqualifying. There were challenges enough around the slogan “Make America Great Again” without reframing Session’s apparent goal to “Make America Jim Crow Again”).
 
This is all to say that the fact that while Trump could conceivably select a cabinet of advisors to compensate for his inexperience, he has failed spectacularly to do so. The functioning of the American government requires that someone responsible be at the wheel, or at least in the passenger seat and able to intervene when needed. While some might have viewed Priebus as that person, his deference to both Steve Bannon (“a force of good”) and Jeff Sessions gives no reason to expect him to provide any push-back on the more extreme aspects of the Trump agenda, let alone question authority on more everyday aspects of governance. Those whom he is selecting for top positions either are inexperienced or are inexperienced in their designated policy domains. (If we took Carson and Hayley and let them do random draws for their new position, they might well wind up in a more sensible department).
 
Campaigns are too often not about the realities of policymaking but rather about rhetoric, which Trump’s core coalition is being reminded of as he backs away from several of his key promises (though those opposing Trump are breathing sighs of relief about some of that backtracking). The reality of governance is that it is hard work, yet Trump often appears to have the mentality of Aziz Ansari’s “Parks and Recreation” character Tom Haverford, who said, “I hate doing work, but I love being flattered.” Politics involves a lot of credit-claiming, but behind the scenes there must be hard-working, competent, expert bureaucrats – from civil servants to partisan appointees – who can draw on their policy knowledge to craft policy that is consistent with the president’s objectives and what they view as the good of the country. Indeed, that they are insulated from electoral pressures enables them to apply their expertise without concern for electoral implications. Members of Congress and first-term presidents do not have that luxury, and so it behooves the president – and in this case the president-elect – to consider the policy and administrative implications of his current staffing decisions, which will shape much of the direction that they choose to take. Indeed, it would be for Trump’s own benefit to maximize his ability to “make America great” by placing his agenda in competent hands (that presumably are larger than his).
 
Whether for the left or for the right, for regulation or deregulation, we want the person behind the wheel to have a license (and preferably no prior record of at-fault collisions). Thus far, Mr. Trump has yet to demonstrate an interest in making such basic protections against collision. And unlike the (many) bankruptcies that he himself has taken, as president his legacy in crashing will have far vaster repercussions. 

​In the aftermath of Mr. Trump’s upset on November 8, there was speculation as to whether the more extreme elements of his campaign positioning was rhetorical flair to appeal to the more extreme segments of the electorate, as opposed to genuine policy preferences. With the hiring of white supremacist and anti-Semite Steve Bannon as senior advisor and the nomination of Jefferson (“Jeff”) Beauregard Sessions for Attorney General, we got the answer loud and clear (and spoiler: many aren’t happy with that answer).
 
The Attorney General, the head of the Department of Justice, is a position whose importance cannot be overstated, adjudicating matters ranging from the criminal justice system to immigration to civil rights and voting rights. The position filling this position must be sympathetic to such matters of justice and equality. After all, the operative word in “Department of Justice” is, you know, justice.
 
For this role, Mr. Trump has nominated Senator Jeff Sessions, a man whose hostility to civil rights and voting rights cannot be overstated.
 
In the aftermath of the Supreme Court decision of Shelby County v. Holder (2013), states whose preclearance requirements with respect to the Voting Rights Act capitalized on the relaxation of voting rights regulations by passing new restrictive legislation on such issues as voter ID and the number of polling places, issues that disproportionately impact minorities and the poor.
 
2016 was the first presidential election that the United States had since the enactment of these new voting constraints, and we saw the egregious impact, with 868 fewer polling places than in previous elections. For example, North Carolina, Texas, Wisconsin, and others enacted new voting restrictions by way of stricter voter ID law. The largest county in Arizona, Maricopa County, reduced the number of polling places by 70% between 2012 and 2016, from just 200 to 60.  The Leadership Council on Civil Rights studied the 381 counties affected by Shelby for which data were available in 2012 or 2014, and found that 43% of them had reduced the number of voting locations.
 
Indeed, the number of polling place closures fits quite clearly along the lines of the states affected by the holding, with 212 closures in Arizona, 403 closures in Texas, 103 closures in Louisiana, 44 closures in Mississippi, 66 closures in Alabama, 12 closures in South Carolina, and 27 closures in North Carolina. Such closures have the result of producing inordinately long lines in order to vote, with some states providing only two hours of time away from work to vote, and some states not having any such law in place. Even if able to take time away from work (and in many cases the lines vastly exceeded two hours), there are significant opportunity costs to lost time away from work, potentially billable hours.
 
Amid what will soon be a very conservative Supreme Court, and a challenging terrain in which to defend voting rights for all Americans, we deserve – indeed, we require –  an Attorney General who is on the side of voters. Which brings us to Jeff Sessions, whose controversial stances on civil rights include a defense of the KKK but for their use of marijuana (because that’s the real problem with them?), who characterized the NAACP and the ACLU as “Communist-inspired” and “un-American,” and who allegedly told an African American staffer that he should be careful what he said to white people. Indeed, in 1986 his past of racial discrimination disqualified him from the post of being a federal judge, and those who defend civil rights are now left praying that the 115th Congress is not more racist than the 99th Congress was.
 
Within the realm of voting rights, Sessions has been equally antagonistic, characterizing the Voting Rights Act of 1965 as a “piece of intrusive legislation,” this comment about a law that outlawed the racially discriminatory practices that violated the Fifteenth Amendment of the Constitution of the United States. As a United States attorney in Alabama in the 1980s, he sought to prosecute an African American man for alleged voter fraud when registering African American voters (the fraud allegations were not substantiated and Sessions lost the case). Perhaps most surprising is that in the aftermath of Shelby County v. Holder (2013), Sessions denied that Shelby County, Alabama had ever had a history of voter discrimination (this coming from the state where many of the fiercest battles over voting rights were waged, as in Selma, and with civil rights activist and Congressman John Lewis staunchly challenging Sessions’ characterization).
 
The Voting Rights Act previously had stipulated that regions with histories of racial discrimination required prior authorization from the Department of Justice before enacting new voting legislation (ahem, restrictions). While this no longer applies, doubtless voting rights cases will continue to be waged in the DOJ and in courts. Needless to say, viewing Shelby County’s current state, not to mention its prior history, as not being discriminatory toward minorities, it is not difficult to see the damage that he could easily do when tasked with adjudicating which voting restrictions are acceptable given the Voting Rights Act’s provisions (to the extent that they remain intact).   
 
Congressional crafting of law almost always provides for some executive branch enforcement and/or rulemaking, but in some cases also provides a venue for litigants to themselves assert their rights. Indeed, Title VII of the Civil Rights Act of 1964, though originally a compromise with the Republican coalitions, ultimately proved to be a highly potent means through which to challenge discrimination based on race, sex, religion, or national origin. Thus, regardless of administrative decisionmaking, individuals were given a voice through courts.
 
The Voting Rights Act has no such provision for a private right of action. Rather, the power rests in the Attorney General himself or herself to institute proceedings to enforce the guarantees of the Fifteenth Amendment and the VRA’s other statutory provisions. Thus, absent a committed Attorney General, and with a conservative judiciary, progress within this domain can vanish with ease and without recourse by private parties.
 
Essential to democracy is the right of political participation. As over 62 million Americans are reminded, sometimes this yields bad results. However, it is the best system that we have, and preserving the franchise is fundamental to the democracy for which our nation is known (for now). Americans require an Attorney General committed to the Constitution and to enforcing basic rights, not undermining them. Jeff Sessions is not that person. It is incumbent upon the United States Senate to recognize that and to vote against him accordingly.