This is written as a public response to Jonathan Imbody, VP of Government Relations for CMDA, who recently wrote an opinion piece for a CMDA blog titled “Donald Trump got elected and now I don’t know what to think.”  As he introduces:

If that statement describes how you feel, you are a member of a large group of Americans who neither enthusiastically support nor disgustedly oppose the new administration. You land somewhere between “Not My President” and “Make America Great Again.”

The brief suggestions below aim to help you process what’s happened, what’s happening and what you can do about it all.

While I have great respect for the work of CMDA in legislative advocacy to protect physician freedom of conscience (even if I disagree with certain points), and would consider Mr. Imbody and others as part of the Christ community, there are both specific and coded references written in this piece that I have concerns about.  As a former student leader for CMDA and ongoing active member, I am obligated to represent viewpoints of Christian healthcare professionals otherwise excluded in this narrative.  Even if my points here constitute a minority perspective, I hope to demonstrate their validity.  I also hope these words will not be construed as contention or meaningless dissent, as I do support much of the work and perspective of CMDA, but that it represents a plea to not alienate those who share my concerns from within the body of CMDA constituents.

Mr. Imbody writes this piece as an attempt to placate concerns regarding the Trump administration.  He states that detractors are unnecessarily concerned because they have placed disproportionate faith in government to be the “primary vehicle for social change.”  He assuages:

Our founders and Constitution, however, designed government with a small “g.” They designed a limited government that reserves maximum power to the people, a deliberately cumbersome system that makes sweeping change difficult.

That realization should help hyperventilating Trump opponents breathe a significant sigh of relief. Ironically, the small government system that Big Government advocates have been trying to dismantle is actually the very system that will protect them from any tyranny they now fear. (emphasis mine)

However, he minimizes or overlooks issues concerning to both physicians and patients related to the new administration and the public. Here are a few:

TRAVEL BAN

Mr. Imbody cites the federal court “kiboshing” of the executive order on immigration as an example of this natural check and balance system.  Though the ban has now been limited twice by the federal court, it illustrates both the persistence and the scope with which the Trump Administration is seeking such restrictions.  Even with these reversals, the initial implementation of the original ban created sufficient chaos within the legitimate migration of refugees, visa and green card holders, healthcare practitioners, and patients that the response of other medical professional organizations was swift and strong.  These concerns focused primarily on the uncertainty it produced among practicing & research physicians planning to travel abroad, International Medical Graduates (IMG) planning to match, and the care & treatment of immigrant children:

Internists: The ACP issued a comprehensive statement with plain opposition to “denying refugee status from persons in designated countries of origin who otherwise would meet refugee status law requirements in the United States,” interference with legal migration, religious discrimination, and forcible deportation.  The NEJM published a specific perspective piece on the order’s “detrimental effects on medical training and healthcare,” again related to interference of graduate medical education.

Pediatricians: The AAP statement reads: “Children do not decide where they or their parents were born. They do not choose whether or how to travel to the United States. We owe it to these children to protect them. Far from doing so, this Executive Order temporarily bans refugees—including children and families who are fleeing persecution, war, or violence—from entering the United States and appears to open the door for individual states to refuse to resettle them.
The Order also impacts our colleagues in medicine, as international medical school graduates and pediatric researchers will continue to be among the foreign nationals and refugees impacted by the travel ban. Leaving it to the discretion of Customs and Border Protection to decide whether to grant entry on a case-by-case basis will prevent these professionals from traveling or training here. This means that vulnerable children, particularly in rural and underserved areas of the United States, will be unable to access care provided by some of the brightest minds in medicine.”

Family Physicians: The President of the AAFP issued a public letter to the president plainly stating: “We are deeply concerned that steps your Administration has taken will have a chilling effect on our nation’s physician workforce, biomedical research, and global health. It is often America’s physicians who answer the call to assist people around the world when a public health crisis occurs. Imagine a world where physicians fail to answer the call of the needy because they fear they may not be able to return to their home and families in the United States. Many family physicians are international medical graduates, who have completed all or part of their education and training in the United States. They are professionals who dedicate their careers to the service of their patients in communities large and small, urban and rural. In fact, 20 percent of our membership and over 25 percent of family medicine residents are comprised of international medical graduates. The AAFP applauds and supports wholly the contributions of these individual family physicians to their patients and communities and we celebrate their diversity.”

These are neither hypothetical nor minor concerns.  While the multiple publicized examples of physicians temporarily denied entry or re-entry have been reversed, the case of a Houston OB/GYN physician who cancelled his medical team’s trip to perform fetal surgeries, likely resulting in those pregnancy losses, should be distressing to any pro-life advocate.  Additionally, the areas that IMGs from these countries serve are disproportionately in medically underserved areas, and though the second iteration of the travel ban would exempt visa holders, it is entirely plausible that it would continue to have a chilling effect on applicants from those countries as well as an implicit bias by program directors against ranking applicants from those countries if there is any degree of uncertainty of their immigration eligibility in the future.  In fact, even the NRMP issued a statement on the Executive Order:

The consequences of the Executive Order are far reaching for Match applicants, and the upheaval it is causing is extensive. The affected applicants have worked hard for many years to achieve their goal of becoming physicians, and they should not be denied that opportunity because of a blanket policy that does not consider the individual. Similarly, U.S. training programs should be able to select applicants based on their excellent character and qualifications, without regard to nationality. Both applicants and programs benefit from an orderly process for entry into graduate medical education. The Executive Order disrupts that process very considerably.

This does not even begin to address the impact on refugee migration, which represents a particularly vulnerable population of patients.  The revised ban continues to seek a complete and arbitrary suspension of the refugee program for 120 days which threatens the supportive infrastructure of refugee resettlement programs.  In fact World Relief, a Christian non-profit agency that works with refugee resettlement, has closed 5 of 27 offices and laid off over a hundred employees in response.  Robert George, eminent Constitutional scholar and avid Catholic pro-life advocate who has favored the nomination of Neil Gorsuch to the Supreme Court, soundly denounced (in conjunction with Angela Wu Howard) the travel ban in this joint article from First Things:

I myself only learned about the stringency of our refugee vetting procedures as a result of extensive briefing when I was chairing the U.S. Commission on International Religious Freedom (USCIRF). There are many things in our government that are “broken,” but our refugee vetting system isn’t one of them. We needn’t, and therefore we shouldn’t, shut out refugees who are fleeing terrorism in places such as Syria and Iraq, even temporarily. Because it isn’t necessary to do it, it is, in my opinion, necessary not to do it.

When I was chairing USCIRF, I called for an increase in the refugee quota. I continue to favor that. Many of my conservative friends disagree, but I believe that justice as well as compassion requires it. The U.S. is not without responsibility for creating the refugee crisis (or the conditions for it)—though we can debate just which presidents and others bear just what portion of that responsibility. I also favor maintaining the stringency of the vetting system, even if that means we do not reach the quota. That’s because I do believe that national security is preeminently important, and I want to make sure that what has happened in some places in Europe does not happen here. The other thing I advocated, and continue to advocate, is prioritization of refugee acceptance based on vulnerability to the worst forms of abuse: murder, rape, torture, enslavement. This is not because I want to bias the system in favor of Christians, as some of my more ridiculous critics on the Left have claimed. It is because decency requires it. Yes, Christians will benefit, but so will Yazidis, Shabak, Turkmen, minority Muslims, and even majority Muslims who are targeted by terrorists (such as ISIS) for helping U.S. forces or opposing terrorist entities. These are the people targeted by ISIS and other evildoers for the worst forms of abuse.

While a check-and-balance system may limit the long term consequences of an administrative agenda, to overlook the short term consequences of the uncertainty introduced does not provide reassurance because it intentionally understates the power of the President to cause real, actualized harm and therefore further alienates the very group meant to be comforted.  If the physician creed is to “first do no harm”, how can we as healthcare practitioners – especially Christian ones committed to political advocacy – not object to the irresponsible use of force and poor policy?

I know exactly what to think about that.

HARMS TO PATIENT CARE AND LIVELIHOOD

Even more puzzling is the assurance that we should trust the administration because “thousands of good people will run the new government.”

The Chief Executive determines broad policies, but these people scattered throughout federal agencies make the government run. They flesh out laws through detailed regulations. They write the aims and guidelines for grants that fund the work of non-profit charities and organizations across the country. And they develop the pragmatic policies and programs that help our children learn, ensure that patients receive good healthcare and assist in feeding the poor and housing the homeless.

But Mr. Imbody’s statement remains problematic for many reasons.  I draw direct attention to the gross omission, in his benevolent description of the “thousands of good people”, of Steve Bannon, the Chief Strategist of the White House.  Bannon, who occupies a position not subject to the scrutiny of Congress for approval (one of the checks-and-balances cited earlier), has raised significant controversy for his leadership of Breitbart News and the alt-right movement.  This alone was enough to draw criticism by the Anti-Defamation League for implicit support of white supremacists (though it acknowledges Bannon himself has not explicitly done this).  But Bannon’s agenda, which as Chief Strategist is a reasonable proxy for that of the administration itself, has moreover explicitly been to “deconstruct the administrative state.”

While I appreciate Mr. Imbody’s point that government is not necessarily meant to be the “primary vehicle of social change,” the new administrative agenda stands in direct contradiction to his appeal that we trust in its intent to “develop the pragmatic policies and programs that help our children learn, ensure that patients receive good healthcare and assist in feeding the poor and housing the homeless” in that it has both implicitly and explicitly pledged itself to dismantling those things.  Not restructuring, dismantling.

Though the American Health Care Act (AHCA) eventually failed to pass the House, it is indicative of the agenda of the administration (and the GOP).  On a patient care level, the impact of the AHCA according to CBO estimates would result in worsening coverage loss, premium increases, and Medicaid contraction.  Though multiple other professional organizations have taken stances criticizing the current form of the AHCA (including the AAFP, AAP, AMA, ANA, AHA, and even the AARP and Medicaid CMO), I understand that CMDA may not necessarily agree with these shared perspectives of healthcare policy as its constituents are diverse and not all agree that health insurance is necessary for quality healthcare; as an example, the AHCA pledges to increase funding to Federally Qualified Health Centers (FQHC) which are primarily designed to care for uninsured patients, many of which are operated by explicitly Christian organizations (though doubtful that the proposed augmentation will be proportional to the needs of the newly uninsured).  I also recognize that other elements of the AHCA also directly align with CMDA interests, such as reducing abortion subsidy by decreasing funding for Planned Parenthood.

But, as the Annals of Internal Medicine has cautioned regarding proposed ACA repeal: first, do no harm:

The 2010 health reform law is far from perfect, in either its structure or its execution; in a less dysfunctional political era, the flaws would have been addressed through subsequent changes. Now, amid the drive not to amend the law, but to repeal it—and absent a definitive replacement plan—physicians, as stewards of the nation’s health care, should be up at arms about the potentially dangerous impact.

Additionally, to imply that the new administration will be proactive about developing new programs to “help our children learn… assist in feeding the poor, and housing the homeless” is also directly contradicted by President Trump’s initial budget proposal, which:

– Eliminates US Interagency Council on Homelessness
– Eliminates Community Development Block Grant and Community Services Block Grant
– Eliminates funding for Habitat for Humanity and YouthBuild
– Eliminates the Home Investment Partnership Program
– Eliminates assistance to Community Development Financial Institutions
– Eliminates weatherization assistance program and Low Income Home Energy Assistance Program
– Reduces Legal Services Corp
– Reduces SNAP and WIC assistance
– Reduces Job Corps
– Eliminates the Senior Community Service Employment Program

In summary, this is a reduction of the:

– Department of Health and Human Services by 16.2%
– National Institutes of Health by 20%
– Department of Education by 13.5%
– Department of Housing and Urban Development by 13.2%

While one may make an argument in favor of these cuts in terms of a lack of efficacy by these programs, any claim that these are meant to improve the deficit is offset by the fact that these savings only make up 6% of the simultaneously proposed increase to defense spending by $54 billion.  The proposed increase in defense spending also sends the signal that there is no intent to replace the cut programs but to rather displace their responsibility to states.

To therefore claim that this administration will make these issues a priority is financially, intellectually, and politically disingenuous.

I know exactly what to think about that.

THREAT OF INTERPERSONAL VIOLENCE

While not all instances of violence should be attributable to the new administration or its constituents, it cannot be ignored as a primary cause of concern and anxiety among the many who oppose it.  Mr. Imbody’s logic that the opposition’s primary concerns stem from “trust in government” and therefore the protections of the checks-and-balances system above should let “hyperventilating Trump opponents breathe a significant sigh of relief” is incomplete.  Quite frankly, people are afraid of getting hurt.  A Muslim colleague at my institution had a brick thrown through his daughter’s window after the election because she had a Clinton sign in it.  Two Indian men were shot and killed by a white man telling them “get out of my country.”  A Sikh man was shot in his driveway after being told “go back to your country.”  There has been an increase in reported hate crime incidents in the past year (though this number is hopefully declining).  Though President Trump has denounced some of these and the administration has suggested that they are statistically unlikely events, so are terrorist attacks.  Yet the President and administration have used one set of threats against the safety of Americans to justify the Executive Orders for a travel ban while responding to the other set by excluding “white supremacists” from categorization as violent extremists.

This does not even begin to address issues of structural violence such as the mass forcible deportation and incarceration of illegal immigrants or that of mass incarceration in general.  Whatever our political position regarding immigration or social policies may be, as Christian healthcare providers our primary concern should be the health of our patients, whomever they may be and however we come to encounter them.  From this perspective, the administration’s early actions paint an aggressive stance that cannot be brushed aside as mistakes or indelicate handling.

I know exactly what to think.

CONSTITUTIONAL DISDAIN

Mr. Imbody also highlights President Trump’s appointment of Gorsuch as an example of comforting change to the composition of the Supreme Court:

From this list, President Trump has nominated Judge Neil Gorsuch, an originalist in the mold of the late Justice Antonin Scalia, whom Gorsuch would replace. This nomination provides significant reassurance that the Supreme Court will be guided more by the rule of law, which protects everyone equally, than by ideology, which favors only those who support the ideology.

But the President himself, as indicated by his tweets and rhetoric and unprecedented leverage of Executive Orders, expresses disdain or ignorance for Constitutional principles themselves.  He recently hinted, in reference to prior suggestions made during his campaign, that he would like to change libel laws to influence the media.  He has openly challenged the legitimacy of Judge Curiel’s rulings against Trump University solely on the basis of Curiel’s Mexican ethnicity and heritage, a remark that Speaker Paul Ryan openly admitted at the time as being “the textbook definition of a racist comment.”  This does not even begin to probe the concerns regarding conflicts of interest with the Emolument clause.

What does President Trump really think about the Constitution?  Does he intend to govern in a way that respects the rule of law and the courts or does he intend to push their limits in favor of his maximal benefit?  I know exactly what to think about that.

ANTI-BIBLICAL CHARACTER

This is the most egregious omission in a blog post representing an explicitly Christian organization.  That there would not be a single word of criticism or even expression of concern by Mr. Imbody regarding this President – who would be disqualified to become even an overseer in a church much less a self-proclaimed Christian President – is both disturbing and disheartening.

The saying is trustworthy: If anyone aspires to the office of overseer, he desires a noble task. Therefore an overseer must be above reproach, the husband of one wife, sober-minded, self-controlled, respectable, hospitable, able to teach, not a drunkard, not violent but gentle, not quarrelsome, not a lover of money. He must manage his own household well, with all dignity keeping his children submissive, for if someone does not know how to manage his own household, how will he care for God’s church? He must not be a recent convert, or he may become puffed up with conceit and fall into the condemnation of the devil. Moreover, he must be well thought of by outsiders, so that he may not fall into disgrace, into a snare of the devil. – 1 Timothy 3:1-7

CONCLUSION

Mr. Imbody concludes his piece by stating:

As of this writing, the Trump administration is just a month into governing and already has made some strides and some mistakes. The normal course of any administration is a rocky start followed by greater calm and competence. It’s too early to call.

The extent to which the administration advances policies and achieves results that better our own lives and the lives of others around the world does not just depend on one man. It depends upon all of us, advocating for good policies, demanding accountability and supporting our elected leaders with respect for their offices and with prayer.

I agree that it depends on all of us to advocate for good policies, accountability, and respect.  However I strongly disagree that it’s too early to call.

I know exactly what call to make.
I know exactly what to think.