Trump's HHS Pick Divides Physicians, Organized Medicine

December 07, 2016

President-elect Donald Trump's choice of Rep. Tom Price, MD (R-GA), to head the US Department of Health and Human Services (HHS) has polarized the medical profession just as the real estate mogul's ascendancy to the White House has polarized the nation.

Some physicians hail Dr Price, chair of the powerful House Budget Committee, as a guardian of the physician-patient relationship and an opponent of burdensome government regulations. Others fear, however, that the orthopedic surgeon will reduce access to healthcare by helping his party repeal the Affordable Care Act (ACA). They also fear that he will restrict abortion rights and turn his back on the needs of the lesbian, gay, bisexual, and transgender (LGBT) community.

These cracks in the House of Medicine are on display in the American Medical Association (AMA), which announced that it "strongly supports" Dr Price — one of its members — as HHS secretary only to see almost 5000 clinicians sign an online petition in a matter of days stating, "The AMA Does Not Speak for Us." Some of those signing physicians are troubled by Dr Price's membership in a splinter medical society described as ultraconservative and antiscientific.

"We do not think this HHS nominee and his policies align with our values," said Jane Zhu, MD, MPP, one of the petition-drive organizers. Dr Zhu, an internist in Philadelphia, added that the protest has nothing to do with the presidential election.

"This is not a left-versus-right issue," she told Medscape Medical News. "It's a patient issue. If this were a Democratic nominee with similar policies, I would be just as concerned."

Dr Zhu's concerns appear to be widely shared by her colleagues. In an online survey of almost 1100 physicians conducted by the recruiting firm Merritt Hawkins, 46% generally feel positive about Dr Price while 42% lean negative, with another 12% on neutral ground. Although this support of Dr Price slightly outweighs opposition, 47% of physicians said that, if confirmed, he would detract from the ability of patients to obtain access to quality care compared with 42% who believe the opposite. Physician well-being is a different story. Forty-six percent said medical-practice conditions would improve with Dr Price at the helm of HHS, while 34% said they would grow worse.

Reaction: From "Extremely Pleased" to "Deeply Concerned"

Dr Price, who declined to be interviewed for this story, has represented Georgia's 6th Congressional district since 2004. As a member of the GOP Doctors Caucus, he has railed against what he calls a government takeover of healthcare. Besides voting repeatedly to repeal the ACA, Dr Price has opposed expansion of the Children's Health Insurance Program, which now provides coverage for some 8 million children.

A bill he sponsored called the Empowering Patients First Act could give Trump and Congressional Republicans a replacement for the healthcare reform law they want to ax. The measure would let individuals opt out of Medicare, Medicaid, TRICARE, and Veterans Affairs benefits and purchase a private health plan using refundable tax credits, a privatization plan similar to what House Speaker Paul Ryan (R-WI) envisions for Medicare. Dr Price's bill would expand the use of health savings accounts, provide states with grants for high-risk insurance pools, allow insurers to sell policies across state lines, and enact tort reforms such as shielding physicians from liability if they adhered to clinical guidelines.

Trump's announcement that he would nominate Dr Price to lead HHS triggered amens from most quarters of organized medicine, amens that ranged from exuberant to tepid. "Extremely pleased," said the Texas Medical Association in a news release. "Excellent choice," said the American Academy of Ophthalmology. The American College of Surgeons said it "applauds" the nomination. It called attention to Dr Price's leadership in repealing the sustainable growth rate formula for setting Medicare pay for physicians.

The word "support," however, was missing from a congratulatory statement issued by the American Academy of Family Physicians (AAFP), which went out on a limb 6 year ago to support the ACA. As a former practicing physician, Dr Price "will provide a much needed medical perspective to US health policy," said AAFP President John Meigs Jr, MD.

Some major medical societies have remained mum about Dr Price. The American College of Physicians (ACP) "does not have a statement and does not plan to comment on nominees," a spokesman told Medscape Medical News. Likewise, the American College of Obstetricians and Gynecologists (ACOG), which supports the availability of abortion as much as Dr Price opposes it, "has no comment on the nomination at this time," a spokesperson said.

Other groups, with far smaller memberships than the AAFP's and ACOG's, have objected to Trump's choice of Dr Price. The Gay and Lesbian Medical Association said it was "deeply concerned," noting that Dr Price's voting record on LGBT equality earned him a zero rating from the Human Rights Campaign. Among other things, Dr Price has opposed a bill called the Employment Non-Discrimination Act, which would prohibit refusing to hire someone based on sexual orientation or gender identity.

The American Medical Student Association (AMSA), which includes residents, adopted a more strident tone. "We denounce Rep. Price's track record," AMSA said in a new release. "Rep. Price's political history illustrates how much he will be a detriment to our patients in the future."

The Committee of Interns and Residents (CIR), a union with roughly 14,000 members, also said it opposed Dr Price's nomination. With his choice for HHS, CIR said in a news release, Trump "has tuned out the voices of America's working families, many of whom are counting on Medicaid, Medicare, or the Affordable Care Act for their healthcare." Yet another opponent, the 10,000-strong National Physicians Alliance, said it was "dismayed that other large physician organizations have endorsed Dr Price without consideration of the harm his policies would inflict on our collective patients."

AMA's Stance Prompts #NotMyAMA Hashtag

The dismay about organized medicine's support of Dr Price has centered on the AMA, so much so that critics have called the giant medical association to account on Twitter with the hashtag #NotMyAMA.

Some of those same tweeting physicians have signed the online petition against the AMA's stance sponsored by a group called Clinician Action Network (CAN). Its founders are Dr Jane Zhu, Manik Chhabra, MD, and Navin Vij, MD. Dr Chhabra told Medscape Medical News that they formed CAN shortly after Trump's election because "we saw that some of the [Trump] policies on the table were direct threats to our patients." He described CAN as a loosely organized grassroots organization with no membership dues and a mailing list of several hundred physicians.

"A lot of [medical societies] are doing work to defend physicians' interests," said Dr Zhu. "We'd like to distinguish ourselves. We want to support evidence-based policies that put patients first."

After CAN launched its petition drive, the AMA posted a lengthy explanation on its website of why it came out for Dr Price. In it, AMA Board Chairperson Patrice Harris, MD, cited the physician perspective that he would bring to HHS and his demonstrated willingness to listen to the AMA and other medical societies.

"Even so, our support for Dr Price to lead HHS should not be taken as an endorsement of every policy position he has advocated," Dr Harris said, singling out his opposition to the ACA, which the AMA supported.

In an interview with Medscape Medical News, Dr Harris gave her take on the #NotMyAMA Twitter movement.

The AMA "is a big-tent organization," she said. "We value diversity of thought and opinion. In a democracy, you have reasoned discourse and debate. That's all part of the process."

Dr Harris would not elaborate on other disagreements that the AMA has with Dr Price besides the ACA. However, she said her association "has a long-standing commitment to equality and equity and access and the support of those who suffer regarding healthcare disparities. We will vigorously advocate for our policies."

Just last month, the AMA House of Delegates approved several resolutions to improve healthcare for LGBT individuals, targeting insurance companies, for example, that discriminate against beneficiaries on the basis of gender identity or sexual orientation.

"Many of our policies don't focus on physician finances," Dr Harris said.

AAPS: "We Think He Is a Good Man"

Trump's choice of Dr Price for HHS has shone a harsh spotlight not only on the AMA, but also on the Association of American Physicians and Surgeons (AAPS), a tiny medical society that views itself as the anti-AMA. Formed in 1943 and based in Tucson, Arizona, the AAPS claims just 3000 to 5000 dues-paying members, but exercises outsized influence in terms of lobbying for legislation that benefits physicians. AAPS spokesperson Jane Orient, MD, confirms that Dr Price is a current member.

Dr Price's membership in the AAPS was cited by pediatrican Carolyn Sax, MD, in her recent public radio commentary on why she quit the AMA over its support of the congressman. Dr Sax, who practices in Hyde Park, Massachusetts, criticized AAPS for publishing articles "with discredited scientific premises" in its house journal. Some of those articles have linked childhood vaccines to autism, and breast cancer to abortion.

"Just because we have published a controversial article in our journal doesn't mean that we have a position in favor of that," Dr Orient told Medscape Medical News. "We believe in free and open scientific discussion."

There are beliefs, however, that AAPS subscribes to collectively. In 2003, its assembly approved an antiabortion resolution that "supports the right to life of human beings from the moment of conception to natural death." And in its "Principles of Medical Ethics" the group describes Medicare and Medicaid as a form of socialized medicine that lowers the standard of medical care. It calls participation by physicians in these programs "immoral." That position, however, is not a litmus test for membership, Dr Orient said. "Most of our people do take money from Medicare."

AAPS claims to be a nonpartisan organization, but one might not think that reading its news releases during the recent presidential election. "Hillary's Health Concerns Serious, Say Most Doctors Polled by the Association of American Physicians and Surgeons" was the headline of a September news release that circulated widely on the Internet. The news release included a hyperlink to comments from 82 respondents, many of whom were more preoccupied with politics than medicine. "I despise her even if this corrupt, evil anti-American creature were in good health," wrote one.

The fact-checking news operation PolitiFact rated this claim about Hillary Clinton's health as false, pointing out that AAPS had polled its own members, and that diagnosing someone without a physical exam is "folly."

Undeterred by such criticism, AAPS issued a news release in October reporting that "Hillary Has Abnormal Eye Movements, Say Majority of Doctors Surveyed." AAPS said that most of the physicians who spotted abnormal eye movements on a video believed they could stem from a "potentially disabling neurological condition."

In terms of politics, AAPS members lean toward the conservative, libertarian end of the spectrum, opposing an "all-powerful government" that takes away their liberties," Dr Orient said. "A lot of our membership participated in Tea Party rallies."

She said it was unfair to tar Dr Price with his membership in AAPS.

"It's kind of like a black list, isn't it, back in the McCarthy era?" she said. "You belong to this association, therefore you agree with everything they said, and they're evil, and therefore you're evil, and therefore we're going to make a pariah out of you."

Although her group has not taken an official stand on Dr Price becoming HHS secretary, "I think the AAPS is generally favorable to Dr Price," she said.

"We don't agree with him about everything in his policies," Dr Orient said. "I'd imagine he doesn't agree with us on everything. We think he is a good man and that he is very well qualified, and that he is generally with us philosophically."

Follow Robert Lowes on Twitter @LowesRobert

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