All health policy is political, as it must be

ACP members unhappy about the College's stance on, say, gun violence or climate change will sometimes assert that the organization should stop taking “political” stances.

I usually respond by pointing out that ACP's positions come from its membership, through a well-regarded and structured policy development process that considers the range of member opinions, as well as evidence on the effectiveness of different policy options, before a consensus is reached on which issues we will address and the positions we will take on them. (You can learn more about the College's policy development process online.)

Also, ACP doesn't take on an issue or make a policy recommendation because it favors one political party, candidate, or public official over another for partisan reasons. Instead, it's because we have determined, through our policy development process, that a public policy issue affects the well-being of our members, the health of patients, or both.

This doesn't mean that every ACP member will agree with our selection of the issues or what we recommend; this simply would not be possible for an organization of 154,000 members who have a diverse range of opinions, partisan leanings, demographics, practice types, and places of locale. Yet the College strives to ensure that this membership diversity is considered as it develops policy and then advocates based on it.

As much as I and others in ACP try to explain our policy process to members, though, some still insist we should “stay out of politics.”

This has led me to reflect on how we might distinguish between “political” and “nonpolitical” issues, if we were inclined to only advocate on nonpolitical ones. My conclusion is that we can't, because all health policy is political in nature.

Merriam-Webster defines “political” as “of or relating to government, a government, or the conduct of government,” while the Oxford English Dictionary defines it as “relating to the government or public affairs of a country.” Accordingly, all health policy is political, because it relates to government, the conduct of government, and the public affairs of a country, in this case the United States.

Moreover, all public policy affecting internists and their patients is derived through a political process, “the formulation and administration of public policy usually by interaction between social groups and political institutions or between political leadership and public opinion,” as Merriam-Webster states. This describes ACP advocacy to a T: ACP, as a social organization, influences public policy by expressing the opinions of its members through interactions with the U.S. Congress, the President, agency officials, state governors and lawmakers, and other political leaders and institutions.

Issues like climate change and gun violence prevention are “political” in that they relate to government and are formulated through a political process, in which ACP participates. Yet this is also true of ACP's advocacy to reduce administrative tasks (our Patients Before Paperwork initiative)—because the preauthorization and documentation requirements that drive physicians up a wall in most cases were authorized by legislation enacted by a U.S. Congress and signed into law by a U.S. president, current or past, and implemented via regulation by whichever federal agency is currently in charge of administering the laws on the books.

In other cases, such requirements are formulated and administered by a state's lawmakers, its governors, and its agencies. Even administrative tasks imposed by private insurers are subject to regulation by the state in which they are located, or by the federal government for insurance products subject to federal oversight, like the Affordable Care Act's Marketplace plans or Medicare Advantage.

What about advocacy to improve payments for internists' services? Also political, because payments under most public and private insurance programs are based on the resource-based relative value scale, authorized through legislation passed by Congress in 1989 and implemented to this very day by agency officials appointed by President Trump. Don't like the performance measures that are linked to Medicare payments? These too are authorized by legislation passed by Congress in 2015 and administered today by the current administration. We can't change any of these for the better without engaging in politics and the political process.

Think about it. Is there any public policy issue that isn't political, and that wasn't formulated through a political process? I can't think of one.

For ACP to remove itself from politics, we would have to remove ourselves from advocating on anything. We couldn't interact with members of Congress or state lawmakers. We couldn't submit comments on proposed regulations, or meet with agency officials. We couldn't participate in coalitions that interact with political institutions.

Since ACP can't change anything without participating in politics and the political process, the real question, then, is what kind of organization do ACP members want ACP to be? Should ACP advocate only on issues that directly affect the professional well-being and satisfaction of its members, like reimbursement and paperwork, and stay away from issues that affect the health of the public, like gun violence, immigration, and climate change? Should we stay away from issues that are viewed as being controversial and “political” by some members? That is, should we become more like a trade association or union, created mainly to protect the interests of its members? Or will ACP continue to view its mission as advocating for both the interests of its members and the health and well-being of patients and the public?

I believe that most ACP members want us to engage on both fronts, even as some continue to raise questions about whether we've struck the right balance between the two. What's at stake, though, is much more than a semantic debate over the meaning of being “political.” It's the very nature of ACP advocacy.