ACA repeal prompts medical student advocacy
Just past noon on Jan. 30, over 100 Yale medical students, hospital residents and faculty members congregated before the Sterling Hall of Medicine. At the top of the steps, six students stood shoulder to shoulder, wearing white lab coats over their winter clothes as they rallied the crowd with chants and neon signs.
This gathering at the heart of the Yale School of Medicine was one of nearly 50 demonstrations that took place at medical schools across the country that day. Protesting the potential repeal of the Affordable Care Act, the rallies called on members of Congress to put patients before politics and “do no harm.”
“It is important to remember that we have a special obligation when it comes to health care,” Matt Meizlish ’11 GRD ’20 MED ’20 told the crowd. “When we put on our white coats, we represent our patients. When we walk into a legislator’s office in our white coats, they know what you stand for, they know why you’re there. Let’s lend our voices everywhere they’re needed, but let’s lead when it comes to health care.”
Since it was signed into law in 2010, the ACA, also known as Obamacare, has faced strong opposition from the Republican Party, including multiple attempts at repeal. However, with President Donald Trump in the White House and Republican majorities in both houses of Congress, repeal stares the nation in the face as never before.
Priscilla Wang MED '17
'When you strip away all these political layers, everyone cares about health care and everyone cares for their family.'
Since the Nov. 8 presidential election, the threat of repeal has led to an upwelling of grassroots support for the act. One advocacy group born from these efforts is #ProtectOurPatients, a national campaign led by future health care providers dedicated to the ACA’s preservation and improvement. At the heart of this student movement is the Yale Healthcare Coalition, a group of medical students who have played an instrumental role in building #POP and mobilizing their peers — at Yale and nationwide.
Over the last six months, as Republicans have advanced a repeal plan that has been seven years in the making, the YHC has responded by writing op-eds, circulating petitions, leading phone banking efforts, sharing patient stories with Senate staffers and rallying in New Haven, Hartford and Washington, D.C.
In March, Republicans unveiled the American Health Care Act — an alternative health plan that would involve ACA repeal and replacement — but withdrew the bill later that month, citing disagreement within the party. The YHC joined advocacy groups around the country in celebrating this as a victory for grassroots activism.
Last week, however, Republicans revived the AHCA with a new amendment that may attract the necessary support to clear the House of Representatives, presenting a new challenge to the YHC and student health care activists nationwide. But given their limited reach, how influential can the coalition be in today’s politically charged, bitterly divided health care landscape? What is the role of medical students in this debate, and what can grassroots activism hope to achieve in the face of powerful obstacles?
CULTIVATING A STUDENT VOICE
The presidential election sent shockwaves through the country, and Yale was no exception. The week after Nov. 8, students and faculty from across campus convened at the Yale Law School to discuss the issues now at stake.
Matthew Meizlish '11 MED '20 GRD '20
'We see ourselves as apolitical, but that doesn't mean we sit on the sidelines. We think advocacy is an important part of taking care of our patients — it defines our generation of medical students.'
It was at this event, during a health care breakout session, that the Yale Healthcare Coalition was born. Karri Weisenthal ’09 MED ’18, a YHC leader, said she was motivated by the urgency of the moment, coupled with her firsthand observations of Obamacare’s benefits.
“All of us care about a lot of different issues that will be affected by this administration,” said Meizlish, another leader of the YHC. “We all need to offer energy and resistance where we’re best positioned to do it. We’re positioned well to have our voices heard in health care and to defend this particular group of vulnerable people — the people who will lose health insurance if the ACA is repealed.”
Following a series of informal meetings, the coalition developed from a core group of nine students, comprising Meizlish, Weisenthal, Juliana Berk-Krauss MED ’18, Eamon Duffy MED ’18 SOM ’18, Samara Fox ’09 MED ’19, Erik Levinsohn MED ’18, Talía Robledo-Gil MED ’18, Andi Shahu MED ’18 and Priscilla Wang MED ’17.
Within a month, the YHC found allies in like-minded medical students across the nation, and together they began building the #ProtectOurPatients movement. By the end of December, the YHC had also written a “Do No Harm” petition, which has since garnered signatures from over 5,000 future health care professionals calling on Congress to prioritize patients over party loyalty.
Juliana Berk-Krauss MED '18
'It’s important for those politicians and others across the country in power to hear not only from us, but also people at the bottom who will be most directly affected.'
As 2017 began, the YHC shifted more of its energy outward to influence swing state legislators to oppose ACA repeal. In a Jan. 12 op-ed in the Huffington Post, the group urged Republican lawmakers to put their constituents before party rhetoric. In an effort to oppose the nomination of then Rep. Tom Price, R-Ga., for secretary of health and human services, the group launched a phone banking campaign.
The students also met with Dean of the School of Medicine Robert Alpern and Yale New Haven Health System President and CEO Marna Borgstrom SPH ’79, where they encouraged the administrators to take a public stand on the issue of the ACA.
To the students’ disappointment, Alpern and Borgstrom ultimately did not release a public statement on the ACA. In an interview with the News, Alpern reaffirmed his support for the students’ intentions but said that academic institutions retained a “social responsibility” to nonpartisanship, no matter the political climate.
However, Alpern underscored the difference between speaking as a representative of the medical school and as an individual. In an April 6 interview, he noted that although he and Borgstrom had canceled a planned op-ed following the March 24 AHCA defeat, they would write and publish the piece “if the bill should come alive again.”
Andi Shahu MED '18
'While it would be ideal to practice medicine in a vacuum, the reality is that’s not possible because the legislation being approved, the executive orders being signed — they all change and affect the way we practice.'
Among other changes, the AHCA proposes a system of tax credits which would more heavily subsidize high-income recipients. In addition, it would eliminate the ACA’s individual mandate, which requires people who can afford health insurance to purchase it, punishable by tax penalties.
But according to Wang, the most troubling component of the replacement bill is its restructuring of Medicaid. The AHCA would end Medicaid expansion, which Wang said threatens some of the country’s most vulnerable populations — low-income, disabled and elderly patients.
Duffy stressed the influence of the ACA on his medical career, noting that the act has defined medical education for his generation. He added that many medical students perceive health care as a universal human right.
“For the first time, you have medical students across the country who have been taught that because of the ACA, health care and health insurance should be accessible to everyone,” Duffy said. “I think that’s why you saw such a strong reaction by medical students. It would be as if someone came in and tried to rewrite all the rules of the human body.”
SHOULD MEDICINE BE ABOVE POLITICS?
But institutions of higher learning aside, in the current political climate, individual physicians must decide whether to silently serve as objective providers or take a stand on health care.
Over a dozen interviews with current and former Yale medical school administrators, faculty members and health law experts revealed unanimous support for public physician advocacy.
Yale School of Medicine Associate Dean of Student Affairs Nancy Angoff SPH ’81 MED ’90 said that while physicians should not advertise their political beliefs at patients’ bedsides, they do have a duty to fight for access to affordable, appropriate health care.
She recognized, however, that institutions may be worried that speaking out will cost them a seat at the political table. A response to this concern, she said, is to emphasize physicians’ right to say “we care about the wellbeing of our patients,” which is not a political statement.
Talía Robledo-Gil MED '18
'As medical students, we are often juggling many tasks at once. We’re used to this resetting and refocusing mentality.'
Former Dean of the School of Medicine David Kessler offered a similar perspective.
“What good is it if you spend your life working on developing a new medicine, but then people can’t afford it?” said Kessler, who served as dean from 1997 to 2003. “It’s a sad reflection on our times when taking care of patients and advocating health care for all is viewed as partisan. It’s not — it’s in the public interest.”
Former Dean Leon Rosenberg, who led the Med School from 1984 to 1991, applauded the YHC for its efforts. But like Angoff, he acknowledged the difficulty of striking a balance between speaking up for individual beliefs and protecting an institution’s reputation, noting that medicine’s oldest adage — “do no harm” — is not restricted to just the hospital room.
He added that the medical profession — both institutions and private practitioners — do not tend to be politically active.
“The idea that medicine is pure, that it doesn’t want to dirty itself with the rough and tumble of partisan politics — I think that’s old-fashioned and outdated,” Rosenberg said. “[Doctors] have an enormous stake in what happens across the broad panorama of health care, so I believe it is not only OK for medical professionals to become involved, but it is necessary that they speak from what they know best.”
Abbe Gluck ’96 LAW ’00, who encouraged the YHC to write their Jan. 12 Huffington Post op-ed and directs the Yale Law School Solomon Center for Health Law and Policy, noted that in the past, doctors have been one of health care reform’s biggest opponents, pointing to medical groups that opposed reform efforts in the 1960s. Gluck said that it is refreshing to see Yale students take the lead on shifting the narrative toward social justice and equality.
For medical professor Naftali Kaminski, who participated in some of the YHC’s rallies, the students are part of an especially important movement that has given the medical profession a strong moral and ethical foundation. Kaminski received his medical training in Israel, where health care is offered to all citizens and participation in a medical insurance plan is mandatory.
Samara Fox '09 MED '19
'Activism is about changing the rules of the game and changing the messaging. In some ways it’s more fun because you get to make your own rules, but on the other hand the impact can be less immediate and measurable than with direct services work, even though it’s just as important.'
He said that, from an outsider’s perspective, he has been frustrated that American physicians do not have a strong, collective position on the need for health care reform. He added that, in general, the desire to ensure access to care for all is not present in discussions about career choice, which he finds surprising.
Among the crowd rallying on Jan. 30 was Director of the Internal Medicine Traditional Residency Program Mark Siegel, who deemed efforts toward effective health care access a “professional responsibility.” He said that while doctors may hold contrasting opinions regarding the best method of health care delivery, they should unite against harmful health care legislation.
“I think it’s very appropriate for doctors to be involved in these conversations,” said Ben Howell, chief resident for advocacy and community health at the Department of Internal Medicine’s primary care program. “People worry about losing some of the objectivity when you start to make political statements, but I think that if you have power, you have to risk it sometimes to speak for people who don’t.”
A HOTBED OF ACTIVITY AT YALE
Although the YHC members had not previously engaged in activism on this scale, many have used previous experiences to build a foundation for their current political activity.
In 2013, for example, Meizlish and Wang helped cofound Students for a Better Healthcare System, a movement that later evolved into a national campaign aimed at educating community members about the ACA.
Eamon Duffy MED '18 SOM '18
'They tell you on your first day of (Yale) med school, if you ever have the choice between hitting the books and focusing on a community group, choose the community every time.'
At the time, Wang said, there was “a lot of misinformation” surrounding the ACA, with some patients even unaware that the ACA and Obamacare were the same. She added that through SBHS, she helped raise nonpartisan awareness about the act and assist patients in signing up for coverage.
“When you strip away all these political layers, everyone cares about health care and everyone cares for their family,” Wang said. “The majority of people in our audience were surprisingly supportive of the ACA, once it was removed from a political context. This underscored to me that as doctors, our responsibility is to provide our patients with the facts about matters that impact health — and this includes legislation and policies.”
Beyond the YHC, faculty members agree that the Yale School of Medicine has a rich history of activism, although student efforts have not always played out on the national stage. Rosenberg said that during his tenure, he did not recall medical students being noticeably vocal in national politics. Students were most invested in issues involving internal change, such as modifications to the Yale System of Medical Education, he said.
Alpern, who became dean in 2004, said there has been an uptick in student activism only in the last few years. Similarly, professor Robert Gifford, who has taught at Yale since 1966 and served as dean of education at the medical school from 1985 to 2000, agreed that in the last two decades, Yale students have generally been less active on the national scale, compared with Vietnam War and civil rights-related activism from the 1960s. However, he noted that in recent years, student activism has been directed more towards New Haven public health issues.
“That is such a tremendous difference from when I went to medical school — there was very little interest in the surrounding community. That’s not true here,” Gifford said. “It’s been a hotbed of activity for whatever the major cause might be. That’s one thing that really strikes me over the years.”
Gifford pointed to the early and mid-1990s, when a rise in student recognition of New Haven poverty led to the annual Hunger and Homelessness Auction at the medical school, which now regularly raises over $20,000 every year. The AIDS epidemic also fostered awareness among medical students of people without health insurance, particularly undocumented immigrants, Gifford said, which eventually led to the establishment of the HAVEN Free Clinic in 2005.
He added that the medical school incorporates a course titled “professional responsibility,” which teaches students about medical ethics, the pharmaceutical industry and health care policy. The class begins in the first week of the first year, which acquaints students with “all of the ethical and financial issues facing medicine right from the start,” Gifford said.
According to Angoff, medical students today also receive an education that places a much more pronounced emphasis on the social determinants of health care. Rather than simply studying disease processes, students are now more aware of the ways in which access to food, housing and education affect patient health.
However, Yale student activism in the health arena is not restricted to the medical school. In 2000, first-year law student Amy Kapczynski LAW ’03 spearheaded efforts to make more widely available an important anti-AIDS drug, for which Yale held a patent that was licensed to pharmaceutical firm Bristol-Myers Squibb.
Kapczynski, now a professor at Yale Law School and co-director of the Global Health Justice Partnership, praised medical student activism, noting that it allowed students to find their place in a critical national debate.
Many members of the YHC credit the Yale System for providing them an opportunity to get involved with student advocacy. The Yale System is a philosophy unique among medical schools that de-emphasizes grades and competition and encourages students to cultivate interests outside of the direct practice of medicine.
Meizlish said that founding SBHS would have been difficult at other medical schools, noting that he and his peers sometimes worked up to 40 hours a week on community health care education.
However, Fox noted that even with Yale’s flexibility, it is still hard to persuade peers that advocacy is worth their time. As the only second-year student in the YHC core group, Fox said that it has been especially hard to mobilize her class, although she has not found this surprising, given that the second-year students have just started their clinical rotations.
“They tell you on your first day of [Yale] med school, if you ever have the choice between hitting the books and focusing on a community group, choose the community every time,” Duffy said.
THE POWER OF THE SHORT WHITE COAT
Just as they had used the power of the short white coat — the traditional garb of a medical student — to teach the New Haven community about the ACA, the YHC is once again in a unique position to bridge the gap between patients and physicians, this time on the national scene.
On Jan. 9, Berk-Krauss, Levinsohn, Meizlish and Wang joined dozens of their peers in Washington, D.C. for one of several Days of Action organized by #POP.
In addition to delivering the “Do No Harm” petition to the offices of all 100 senators and sharing patient stories on a Facebook live video alongside Senate Democrats, the YHC representatives also met with staff members of Republican senators who had expressed concerns about ACA repeal. Meizlish said that they were taken very seriously by Republican staffers, who appeared genuinely open to their views.
As they walked through the halls of a Senate building, Wang recalled being approached by people who asked, “why are the doctors here? There must be something going on.”
“That spoke to me about the power of our position and the responsibility we have to speak out,” Wang told the News. “The message we often get in medical school is a sense of delayed gratification — someday you’ll be able to effectively take care of patients. It was empowering to hear that people cared about what medical students had to say, that trainees can make a difference right now.”
Alpern and Gifford both noted that part of being a student is defending the higher good, which happens less as people get further along in their medical training. Howell added that unlike residents, who are spread out across different specialty programs, medical students generally have more opportunities to make connections with like-minded peers.
“Let’s face it — youth do things that older people somehow are a little more hesitant to do,” Gifford said. “It’s a little embarrassing, to tell you the truth, that students are out in front on this issue. They’re standing up for what needs to be said.”
(Photo by Ellen Kan.)
At once trainees and trusted care providers, medical students occupy a unique position between community and medicine. Shahu acknowledged that some people could argue that students have less of an impact than licensed medical providers, because they lack the title that can earn a seat at the table.
But although medical students do not have as much experience as fully trained doctors, they also do not carry the baggage that comes with the profession, Berk-Krauss said. Fox added that it is not the role of medical students to make complex policy arguments, however tempting this may be. Rather, she said, the real impact of medical student activism lies in its ability to paint portraits of the real people impacted by policy, because students, alongside nurses, usually spend the most time talking to patients.
(Courtesy of #ProtectOurPatients.)
“In graduate school, you can feel very small and inconsequential,” Duffy said. “But when you call a Senate staffer and they say, ‘wow, this is awesome, we want to hear your perspective on health care,’ you make the next call.”
Psychiatry Clerkship Director Kirsten Wilkins said that the YHC regularly informs faculty members of their plans for advocacy. She pointed to the YHC’s April 18 op-ed in the well-known Academic Medicine journal as a compelling argument that has inspired her personally to become a more politically active physician.
Similarly, Ben Doolittle ’91 DIV ’94 MED ’97, who directs the Combined Internal Medicine-Pediatrics Residency Program, said that medical students create a much-needed model of engagement with health care policy, adding that he wasn’t sure demonstrations such as the Jan. 30 rally would happen without the students.
(Courtesy of Priscilla Wang.)
“I think we all agree that things like science should not be politicized,” Shahu said. “The problem is when you have an administration that is threatening to do things like remove funding for essential research or gut something like the ACA that provides care for millions of people. While it would be ideal to practice medicine in a vacuum, the reality is that’s not possible because the legislation being approved, the executive orders being signed — they all change and affect the way we practice.”
Medical education is shifting toward a system that emphasizes value of health care over volume, said Howard Forman, a Yale professor of radiology, economics and public health. Forman said that while it may be too hard to change how current physicians practice, the up-and-coming generation of doctors will be better prepared to deliver cheaper, higher-quality and more accessible health care.
Kaminski said that he hopes to see physicians take on more leadership roles in health care and politics, which will ultimately make the medical profession a more positive force in society.
“If people just have opinions, nothing changes,” Kaminski said. “That’s why student activism — going outside on a cold day, standing in your white coat, meeting with politicians, challenging administration — is so important. You’re defining yourself based on your actions.”
(Graphic by David Hurtado.)
SUSTAINING GRASSROOTS ADVOCACY IN THE LONG TERM
Although the YHC has garnered widespread support from the medical school’s faculty and administration, a broader challenge lies in making their voices heard beyond the Elm City.
Confronted with forces far more complex than those covered in the medical curriculum, their challenge is twofold: building momentum for a national movement while sustaining this activism in the long term.
“There was a lot of alarm all over the country and a lot of motivated groups,” Wang said of the aftermath of the Nov. 8 election. “It seemed like efforts were flying out of the woodwork, which is great, but we were also worried that they would get fragmented. How do we harness that energy and combine all of our voices?”
The first step was embracing what was demanded by the circumstances — the grassroots nature of the movement with both its uncertainties and excitement, according to YHC member Robledo-Gil.
“As medical students, we are often juggling many tasks at once. We’re used to this resetting and refocusing mentality,” Robledo-Gil said. “We were trying to figure out what to do while simultaneously learning how the political system works, to best identify ways to harness the passion and motivation of such a dynamic group of people.”
Meizlish said he believes that the “Do No Harm” petition was a key catalyst for uniting student activists across the nation and amplified their collective voice.
However, even with the extra flexibility afforded by the Yale System, organizing around so many different schedules was difficult, especially for core members pursuing research outside of New Haven or applying to residency programs. But Robledo-Gil said that due to the grassroots nature of the YHC and lack of previously defined organizational leadership structure, the students were able to choose tasks that not only worked well with their weekly schedules, but also showcased their individual strengths.
At the same time, prioritizing the grassroots nature of the YHC and #POP reflects a genuine investment in the community’s best interests, Wang said. She pointed out that when the ACA was first signed into law, some people viewed its top-down implementation in a negative light, which is part of why the act lacked substantial public support from the very beginning.
Berk-Krauss added that a broad base of community support for #POP was also important because it created a stark contrast with the dynamics in Washington, where there were only a few politicians responsible for a bill with such wide-reaching ramifications.
“Repealing [the ACA] would impact millions of people who largely didn’t have a voice,” Berk-Krauss said. “It’s important for those politicians and others across the country in power to hear not only from us, but also people at the bottom who will be most directly affected.”
The Republicans’ March 6 release of the AHCA was a sudden turn of events that forced the YHC to abandon many of their long-term tactics, such as a carefully planned op-ed campaign, and assume an “all hands on deck” response to the situation, Wang said.
Along with their peers across the country, the YHC spent their days monitoring the news and inundating Congressional offices with phone calls and tweets.
Sen. Richard Blumenthal.
Sens. Richard Blumenthal LAW ’73, D-Conn., and Chris Murphy, D-Conn., both told the News that grassroots advocates were the most important players in the AHCA’s defeat on March 24.
“Grassroots advocacy changed the entire political dynamic because it literally brought to the fore a kind of common sense and real-world understanding of what the consequences would be for average people, about these draconian cuts in coverage that would happen under ‘Trumpcare,’” Blumenthal said.
Blumenthal also described the medical community as a force that has “tethered the political debate to science and reality and insisted that policy be fact-based.”
In an interview with the News, Murphy noted that while a lot of attention was paid to the right-wing Freedom Caucus as the main cause of the AHCA’s defeat, there were far more Republicans from swing districts who were ready to vote against the bill.
Sen. Chris Murphy.
“Republicans ultimately knew they were going to lose their seats in Congress if they voted for a bill that stripped health care from 24 million Americans and raised prices by 20 percent,” Murphy said.
The impact of the grassroots student movement is two-sided. In terms of legislative advocacy, #POP students collectively made over 3,000 calls to Congress, authored over a dozen op-eds and visited their representatives at district offices, town halls and Capitol Hill, said #POP cofounder Sidra Bonner, a fourth-year medical student at the University of California, San Francisco.
However, #POP has also made a significant impact within the medical community itself by providing students with a platform to join forces with peers and learn more about specific health policy topics. Bonner added that the YHC has been a major contributor to all stages of the #POP planning process, from developing phone banking scripts to coordinating nationwide Days of Action.
“There is inherent power in the medical community to create change in the national healthcare debate, given the generally positive public perception of health care professionals,” Bonner said. “I think that the voices of providers have been strengthening over the past several months, but [there] is still a need for continuing collaboration and coalition building across organizations and grassroots movements.”
Although House Republicans are still divided over the amended AHCA, the possibility of ACA repeal remains a stark reality, with the House voting on the AHCA as early as next week. The YHC and #POP are returning to their grassroots advocacy — phone banking and social media — to call on Congress to put patients before politics.
The silver lining, members of the YHC agree, is that Trump’s election has galvanized support for the ACA and universal health care at both the medical school and nationwide. No matter what happens to the ACA, what remains to be seen is how this new generation of physicians will carve out a role for themselves in both their medical specialties and an ever-changing political landscape.
“It’ll be fun to see how this ripples throughout everyone’s careers when we’re all attendings and physicians,” Duffy said. “When a young medical student approaches us and asks us if we want to participate in a health care rally they’re organizing, we’ll be ready.”
Correction, May 4: An earlier version of this story mistakenly suggested that Abbe Gluck ’96 LAW ’00 said doctors had opposed health care reform efforts in the past due to interests in personal gain. In fact, she stated that doctors had opposed past reform efforts due to other reasons.