A few weeks ago, I participated in a health advocacy day in Sacramento, where those involved in public health issues could meet with state senators and assemblymen. I mostly followed around people who work for Community Health Partnership and some of their patients who had come up to the Capitol to advocate for the community clinics. I went because it was a required activity as part of population health in my practice of medicine course at Stanford. We were given a list of possible activities, and this one struck my fancy. I’ve lived in California since 2005, and I had never been to Sacramento. I was even confused about whether it should be spelled Capitol or capital. Prior to visiting Sacramento, my primary understanding of the legislative process could probably be best summarized by this Schoolhouse Rock video, I’m Just a Bill:
Actually, that’s not entirely true. In high school, I took part in Youth in Government and was one of the justice’s on the mock version of the state’s Supreme Court. Frankly, the judiciary branch has always been more interesting to me, primarily because appellate law involves more logic, puzzles, and problem solving, and legislation seemed more like endless arguing and bargaining.
However, I found being in the state Capitol to be exhilarating. We mostly met with staff members, who listened politely, and only briefly got to talk to Assembly members, but the committee meetings were open to the public, and I go to go hear public testimony on a variety of measures. It was very exciting, but I could see where doing it every day could become tedious, and I’m not sure how much information was actually conveyed, as everyone very briefly summarized key points while trying to appeal to sentiment. It actually felt like things were going very quickly, as measures were brought up, briefly discussed and voted on very quickly. It felt like quite a bit of activity was rapidly occurring. I know that much of that activity represents many days, weeks, months of work on someone’s part drafting a bill and getting it into the committee and probably many “back room” meetings, but the actual discussion was very rapid. The final vote is in the main Assembly, but the committee is an essential part of the process. It had a bit of an arbitrary feel to it in some ways, the legislator can’t be well educated on more than a handful of serious issues (for example people spend lifetimes trying to understand how taxation works), and so their voting is inherently poorly personally informed, relying as it does on executive summaries, despite the great importance of their decisions to the lives of huge numbers of people. It’s how representative democracy works, and somehow it works incredibly well.
The purpose of the course exercise was to learn a little bit about how healthcare providers, in particular physicians, can do healthcare advocacy and be involved in policy making. It is true that physicians have a little bit extra bit of voice particularly on healthcare issues, given their advanced training and having essentially undergone a vetting process through passing boards, although this is of course tempered by individual personality and temperament. However, I’m not sure how strong a voice they actually have, as you can almost always find someone to give a differing expert opinion when it comes to anything even a little bit vague. I’m unsure how much impact a physician can have casually. Large groups of physicians can form trade unions like the AMA, which are able to hire lobbyists at the state and federal level, and certainly seem to have some public clout. As part of the same class, I also interviewed Ann Lindsay, former public health officer for Humboldt County and now on the Stanford faculty. She is certainly someone who has been active in policy making, working directly with legislators, both as part of her official duties and also because of her personal interests and dedication. However, it obviously took a large amount of time and energy on her part. All this leads me to think that a physician, you might have a tiny bit of leverage in trying to get a meeting with someone, particularly if you have a prestigious position or association, but I’m not convinced that having an MD or DO gives you a substantial bit of leverage in political activism. When I read the biographies of state legislators of California, I see that they were mostly regular citizens who started becoming involved in local politics, school boards, planning boards, and the like and just became more and more active in politics. If a given physicians wants to make that level of commitment and involvement, they can certainly do so, but so can most citizens. That’s what makes the system work. Advocacy is open to anyone who wants to try.
Biomedical and public health research may give us many answers, but that is not the same thing as deciding policy. We may know that alcohol and tobacco are the cause of significant amounts of morbidity and mortality. However, smoking and drinking are very popular activities which many people enjoy and feel it is their innate right to continue to enjoy. They are also the source of huge amounts of revenue, particularly for the state in the form of taxes and are represented by huge lobby groups. Attempts at regulation are met with large amounts of resistance. Policy is not necessarily set by science or research. C. Everett Koop was instrumental in governmental policies reducing smoking in the US, but again this was in his capacity as a public servant and as the surgeon general.
It’s certainly possible for medical students and physicians to be highly effective at working in healthcare advocacy and policy change, but like everything worthwhile, it takes hard work and diligence.