​While the National Rifle Association claims that gun control is an infringement on their Second Amendment rights, they demonstrate little understanding of constitutional law in reaching their conclusions. Indeed, the NRA has virtually rewritten the Second Amendment to the point of declaring gun rights unfettered, leading former Chief Justice Warren Burger – a Nixon appointee – to characterize in 1990 this reinterpretation of the Second Amendment as a “fraud on the American public.”
 
More recently, the Supreme Court in DC v. Heller (2008) – a case in which the Supreme Court upheld gun rights – also held that while the Second Amendment did protect one’s right to possess a firearm outside the context of service in a militia, “Like most rights, the Second Amendment right is not unlimited. It is not a right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose: For example, concealed weapons prohibitions have been upheld under the Amendment or state analogues. The Court’s opinion should not be taken to cast doubt on longstanding prohibitions on the possession of firearms by felons and the mentally ill, or laws forbidding the carrying of firearms in sensitive places such as schools and government buildings, or laws imposing conditions and qualifications on the commercial sale of arms.”
 
Thus, the Court held that while a total ban on handguns was in violation of the Second Amendment, less expansive limits would be within reason. And while the Court famously struck down the Guns-Free School Zones Act in US v. Lopez on the grounds that its relationship to interstate commerce was too attenuated, it would be within Congress’s right under the Spending Clause to condition federal funding on compliance with guns-free school zones, especially with respect to assault weapons. Nor would a nation-wide assault weapons ban, background checks, and prohibitions of domestic abusers from having guns be out of accord with the Second Amendment or with the Heller holding.  
 
Such a reading is wholly consistent with our treatment of other constitutional amendments. We do not have blanket protections for freedom of speech, which is why in Miller v. California, the Supreme Court established that obscenity is not a class of communication that is deserving of First Amendment protection. It is why in Brandenburg v. Ohio, the Supreme Court established that while speech can enjoy First Amendment protection while advocating for illegal activities, it is not protected if it is “directed at inciting or producing imminent lawless action” and is likely to produce that illegal action. And it is why in Chaplinsky v. New Hampshire, the Supreme Court held that certain fighting words can fall outside the scope of speech that is protected under the First Amendment.
 
Some conservatives have sought limits on the scope of the Establishment Clause by encouraging the availability of school vouchers that may be used in a religious school. The first clause of the First Amendment, “Congress shall make no law respecting an establishment of religion” would seem at first blush to preclude federal dollars to going toward a religious institution. The Supreme Court has, over the years, worked to decipher what constitutes an “establishment” of religion – that is, whether it simply means the preclusion of preferential treatment toward particular religions, or a wall of separation between church and state. And the Court has wrestled with the scope of its protections of free exercise protection, viewing the First Amendment not with absolutism, but rather balancing the individual’s interests in free exercise of religion against, for example, a state’s interest in educating students (Wisconsin v. Yoder) or ensuring compliance with anti-drugs laws (Employment Division v. Smith).
 
Limiting the scope of the Second Amendment is also consistent with limits on the scope of the Fourth Amendment, which is why in New Jersey vs. T.L.O., the Court held that public schools did not require probable cause to search a student, but rather only “reasonable suspicion,” because “striking the balance between schoolchildren's legitimate expectations of privacy and the school's equally legitimate need to maintain an environment in which learning can take place requires some easing of the restrictions to which searches by public authorities are ordinarily subject.” The flexibility with which the Court has interpreted the Fourth Amendment in times of national security also provides precedent here, with electronic surveillance capacity vastly expanded under the PATRIOT Act even with respect to those about whom there was not probably cause that illegal activity might occur. Rather, there was a balancing of liberty and security, which at times can be in tension with one another.
 
So is the case with gun violence.
 
There are some who attribute the gun violence epidemic to mental illness. Yet mental illnesses pervade many countries around the world, while the United States leads the world in mass shootings. Moreover, too often the legislators who dismiss mass shootings as problems of mental illness are legislators who themselves voted for legislation that reduces funding for Medicaid and destabilize for Affordable Care Act markets, both of which deliver vital coverage for mental health and substance abuse treatment. And while mental health background checks are sensible to be sure, the information one can glean from them is limited given their focus on involuntary commitment, thus leaving out those who have either not sought treatment at all or who have done so on a voluntary basis.
 
There are some who attribute the gun violence epidemic to exposure to violent video games. Yet many countries with access to such video games do not find that it spurs gun violence in their countries, and a ten-country comparison did not demonstrate a correlation between video game consumption and gun violence. Moreover, the countries that have the most deaths from gun violence do not tend to spend the most on video games.
 
Blaming gun violence on mental illness and video games is easy. What is necessary is recognizing the problem of the ease with which people acquire dangerous, high-capacity weapons under the guise of embracing the Second Amendment.
 
Constitutional questions are challenging, with multiple competing interests at play. But if gun rights advocates want to be taken seriously in opposing on Second Amendment grounds such basic policies as assault weapons bans, stronger background checks, and raising the age limits, they would do well to acknowledge (for better or worse) the malleability with which we have precedent in treating other constitutional rights in times of danger.
 
As Judge Richard Posner wrote, “Concretely, the scope of these rights has been determined, through an interaction of constitutional text and subsequent judicial interpretation, by a weighing of competing interests… The safer the nation feels, the more weight judges will be willing to give to the liberty interest. The greater the threat that an activity poses to the nation's safety, the stronger will the grounds seem for seeking to repress that activity, even at some cost to liberty. This fluid approach is only common sense.”
 
We can certainly debate the virtues of setting a precedent for relaxing First and Fourth Amendment protections, but to act as though any act of gun control is impermissible because of the existence of the Second Amendment is as ill-informed as it is dangerous. And quite rightly, lower courts have held that assault weapons bans are not inconsistent with the preservation of the Second Amendment and the central holding of Heller, with the 4th Circuit holding in Kolbe v. Hogan (2017) that the gun prohibition advanced an important state interest of protecting public safety. The reality is that we do not have a precedent of treating all rights in the Constitution in a dichotomous, all-or-nothing fashion, and to pretend otherwise limits our capacity to have serious and thoughtful discussions about the balancing of Second Amendment rights and the public safety measures on which lives literally depend.
 
The United States has more guns per capita than the rest of the world, and its epidemic of gun violence poses profound challenges of public safety and public health. With people dying every day from gun violence – both from suicide and from homicide – and with students left every day to wonder whether their school will be the next Sandy Hook Elementary School or the next Marjory Stone Douglas High School, we owe it to our students and to our communities to be better, and to do better. 

​After Jimmy Kimmel’s touching monologue about the heart problems and surgeries that his newborn son underwent, and the need for more to get the care that his son did, Senator Bill Cassidy (R-LA) told Kimmel in May that he believed that Republicans’ Obamacare replacement legislation should not deny care to a child faced with serious medical problems like Kimmel’s young son is. That is, would such a child subsequently be denied coverage due to preexisting conditions? Would he face maximum benefits over the years?  

To the surprise of few Democrats, Cassidy has now gone on to co-sponsor with Lindsey Graham (R-SC) the Cassidy-Graham bill, which by all accounts is the harshest Republican repeal effort yet, resulting in 32 million fewer being uninsured and flagrantly failing the “Kimmel test.” Kimmel fought back, and has become a powerful advocate for patients who would be imperiled by this legislation.
 
But the truth is, the Republicans have never believed in the Kimmel test.
 
If Republicans supported the Kimmel test, House Republicans wouldn’t have voted for legislation that decimates Medicaid when 1 in 5 Americans receive their health coverage through Medicaid or CHIP. If Republicans supported the Kimmel test, they wouldn’t be considering letting CHIP expire in their latest heartlessness toward poor children. If Republicans cared about the Kimmel test, they wouldn’t be manufacturing and disseminating lies about the Obamacare markets – on which many families rely – to help render markets unstable and score a political point with the base while patients face higher premiums amid market uncertainty. And if Republicans supported the Kimmel test, they would demand a CBO score and thorough hearings to evaluate the impact of this legislation, rather than endangering millions because of a stubborn adherence to an arbitrary deadline after which they will be forced to work with Democrats when reorganizing a sixth of the American economy.  
 
I am hardly an unbiased party in these debates. I was born with a kidney disorder that resulted in chronic kidney infections from early childhood until my late teens. In my teens, I was diagnosed with anemia severe enough to require iron infusions, though the cause was then unknown. At 22, I was hospitalized for severe hypocalcemia and other electrolyte imbalances and at 24 was formally given the diagnosis of a very rare parathyroid disorder that had already rendered me osteopeneic. At 25 (and 27), I was raped and while the physical wounds healed within a few days, I fell into a deep depression requiring extensive treatment for depression and PTSD. Soon thereafter, I was diagnosed with a rare GI disorder that accounted for my chronic symptoms, as well as a less rare autoimmune condition that accounted for my iron deficiency and B-12 anemias. I was in and out of the emergency room the last couple of years, primarily due to electrolyte imbalances. And in my current (hopefully very short-term) state of unemployment, I am for the first time reliant on Medicaid, thanks to Connecticut's Medicaid expansion through the ACA.
 
Suffice it to say, absent employer-provided insurance and the preservation of Obamacare and the associated Medicaid expansion, I’m screwed or dead. I never felt that more potently than as I watched President Trump's inauguration from my hospital room at New York Presbyterian Hospital at Columbia, fearful about the fate of my health care. 
 
We have cynically – and I think rather dangerously – become accustomed to politicians lying to us. By all accounts, it’s our president’s main talent. And to be sure, politicians are no strangers to reliance on “cheap talk,” and so has been the case for decades.
 
But health care is different. While there is persistent health inequality, in many cases, disease does not discriminate between Democrats and Republicans, between the rich and the poor. The expansion of health coverage should not be a Democrat versus Republican issue, but rather a human issue to which we should all be committed.
 
Health care is also different in that it’s harder to fool patients than it is to fool voters on a number of other issues.
 
People can unfortunately be goaded into thinking that voter fraud is an issue about which we should be concerned, despite voter suppression being the issue with which vastly more Americans struggle. People can be manipulated into thinking that immigrants are taking their jobs more than automation and outsourcing are. But people cannot be manipulated into thinking that they can pay for both groceries and a doctor’s visit when their health coverage is taken away and they’ve got fifty dollars left in their checking account. And no politicians’ framing will erase the bankruptcy someone might face pursuing expensive cancer treatment under the Graham-Cassidy bill.
 
Those who care more about tax cuts for the wealthy than about a child with cancer or heart problems not hitting a lifetime limit by the age of 15 shouldn’t be in the business of drafting and voting on health care legislation. Those who embrace the new “choice” between bankruptcy and untreated illness shouldn’t be in politics, let alone have the audacity to call themselves “pro-life.” Believing in the “Kimmel test” isn’t about partisanship, it’s about demonstrating a conscience and basic human decency. It’s as simple as that.
 
And those up for reelection in 2018 and 2020 would do well to remember that while Americans may not properly attribute credit for some policies like the Medicaid expansion that accompanied Obamacare in many states, you can be sure that we will know it was Republicans who took their health care away.

​One of the things by which I’m most struck in the Trump era – and which may have helped cause the Trump era – is a remarkably abhorrent culture of selfishness. I’d happily blame Ayn Rand, but I’m guessing that many contemporary students’ version of reading The Fountainhead involves reading Wikipedia and SparkNotes. (That said, we all know Paul Ryan has been masturbating to Ayn Rand since his teens. Apologies for the unpleasant image.) But whatever the cause, it’s dismaying at both a personal and a societal level.
 
​Senator Kirsten Gillibrand said recently, “If we’ are not helping people, we should go the fuck home.” She was right. Indeed, the operative word in public service is service. Sadly, this sentiment isn’t shared by enough of her colleagues.

Watching Senator John McCain – who is fighting cancer and receiving taxpayer-subsidized health care – fly to Washington D.C. to proceed with Republican efforts to dismantle the Affordable Care Act is a perfect example: “I got mine, so I don’t care about you.” We see white men in Congress crowded around a table agreeing to undermine insurers’ coverage of women’s health. (Okay, if I’d been in abstinence-only education and had as little sex as they look like they’ve had, I might think a stork dropped me off too). We see doctors in the Senate who have taken the Hippocratic Oath to “do no harm” working to advance legislation knowing that it will result in tens of millions fewer with insurance, but with so much “freedom” to go without care because of prohibitively high costs. We see wealthy senators without a care in the world voting to strip care from the nation’s most vulnerable populations, while claiming to embrace Jesus Christ, who, like, TOTALLY was all about just helping the rich and the healthy.
 
Of course, if we’re human, we’re fallible, and if we’re fallible, we can fall ill. The good fortune we may have had shouldn’t serve as a license to deprive basic needs from others less fortunate. And it’s almost like the Bible had a lot to say about that… What can I say, the religious right seems to be a lot better on memorization than reading comprehension.
 
Twitter is at times a fun, and at other times a disturbing place, where I have made friends with some and been told by others that my autoimmune conditions are my fault and that I’m a drain on the health care system. (Me, personally? I had no idea I was that powerful!). I’ve seen people freely say that their own ability to get health insurance should mean other people are on their own caring for their needs. And I’ve been left baffled by their transparent disregard for fellow citizens (don’t get me started on many people’s views on non-citizens…).

When did basic kindness and decency come to be viewed as prohibitively costly, as opposed to a moral imperative?
 
I’ve been asked more times than I can count whether I’ve had an abortion since I write a lot on Planned Parenthood (not that it’s anyone’s business, but I haven’t), whether I’m in the LGBT community since I’ve long advocated for LGBT rights (not that it’s anyone’s business, but I’ve explored with women but for all intents and purposes am basically straight, much to my chagrin at times), or whether I’m on Medicaid since I’m fiercely committed to its expansion (up until this month, I’d only ever had private insurance). I’ve been asked if my life is at stake with the repeal efforts and while it most definitely is, my passion for this issue preceded the decline of my health.
 
I care because I’m human and I care about people. But this isn’t me patting myself on the back, though I think I was brought up right. This is me saying that other people should care too. Indeed, it shouldn’t require a majority female Congress to have basic health care protections for women. And while greater LGBT representation in our government would be ideal, that shouldn’t be a necessary condition for opposing infringements on their basic rights, with the most recent attack being the barring of transgender individuals from the United States military.
 
I may be overly idealistic, but I’ve always believed that those who are self-serving rather than believers in loving thy neighbor shouldn’t opt for careers in public service. And for the love of god, if you hate government, don’t work in it. Instead, be businessmen on Wall Street, where they reward being a soulless schmuck if it means improving the business and one’s financial earnings.
 
Senator Ben Sasse recently wrote a book on the “vanishing adult,” viewing young adults as lacking the personal responsibility and independence observed in prior decades, rather existing in a perpetual adolescence. What he fails to truly confront is that this generation was graduating from college amid the greatest economic recession since the Great Depression, and has a Congress working to demolish safety-net programs on which millions rely but on which members of Congress have not themselves depended.
 
The reality is that it’s very difficult, if not impossible, to take personal responsibility when conservatives’ self-serving economic policy plunges the nation into deep recession. It’s difficult to take personal responsibility when white, heterosexual men make it easier to discriminate on the basis of sexual orientation and identity, or to maintain job security and maternity benefits when deciding to have a child. It’s difficult to take personal responsibility when Republican determination to micromanage women’s bodies means that women with unwanted pregnancies in some parts of the country may need to either obtain dangerous, illegal abortions or else have children for whom they cannot properly care and for whom a Republican-led government will not care either. It’s difficult to take personal responsibility when wealthy, healthy men never relying on safety-net programs work to gut Medicaid funding, thus leaving one with the “freedom” to choose between untreated illness and bankruptcy.
 
Selfishness under the label of “personal responsibility” is still selfishness. And while this selfishness under the guise of limited government (government so small it fits in bedrooms and bathrooms!) has been the Republican mantra for quite some time, we see it at full force now with unified Republican government as well as Republican-dominated governorships and state legislatures.
 
When the Republican budget won’t even provide for the bootstraps by which we can pull ourselves up, it is difficult to see their party as doing anything other than engaging in naked partisanship and selfishness to a degree that is now dangerously normalized, if not embraced.
 
Claiming to love America while showing utter disregard for helping tens of millions of Americans is no way to govern, or even to exist in the diverse, pluralistic society that defines America.

​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. 

​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.

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.

​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.