On April 26, 2023, the U.S. House of Representatives passed a debt ceiling bill that includes several health-care-related provisions, one of which is adding work requirements to the Medicaid program. We know that work requirements will mean loss of coverage for millions of people, even people who are working and therefore meet the requirements or are exempt for reasons such as disability, because of the burdensome administrative hurdles these requirements impose.
It is clear, by tying Medicaid changes to the debt ceiling bill in this way—where the pure and simple goal is about restricting enrollment in order to reduce costs, not improving health—that the intention behind this bill is to harm the Medicaid program, not help it fulfill its mission. And since Medicaid is one of the primary sources of health coverage in the United States, especially for low-income people, people with disabilities, and people of color, restrictions on accessing this program will harm these individuals, families, and communities as well.
Whatever happened to “first, do no harm” as a fundamental health care principle? Recent attacks on the U.S. health care system seem to have abandoned this principle in favor of a discriminatory, non-health-promoting agenda that goes far beyond the debt ceiling bill. Rather than centering ways that the health care system and providers can help people get the care and coverage they need, with dignity and respect, this harmful agenda currently is driving many legislative, regulatory, and judicial efforts to make it harder for people to have a fair and just opportunity for health; or, in other words, make it harder to advance health equity. These harmful efforts will prevent millions of Americans from getting the health care they need, pitting providers’ concerns about their own safety and security against patient needs.
Abortion bans are harmful for patients and providers.
No realm of health care has been more weaponized than that of reproductive health and abortion care, where abortion bans have removed people’s rights to bodily autonomy in many states. The result is that, rather than the health care system being a place of healing and trust, it has been turned into a battlefield, where physicians not only are unable to provide care that patients need, but also may be implicated by law to turn against their patients. Ten states have proposed legislation that actually criminalizes abortion for women and providers, and many providers in states with strict abortion bans have been forced to make extremely difficult choices between providing the best care for their patients and mitigating threats to themselves and their license to practice medicine in the future.
Bans against gender-affirming care are damaging to health.
Another area being weaponized is gender affirming care, with an increasing number of state governments banning access to this safe care for transgender youth that enables people to be their authentic selves. These proposed laws and the environment of fear that they create lead to major physical and mental stress for patients and their families. Again, just as with abortion care, states are interfering in the patient–provider relationship in a way that is impossible to imagine for other forms of health care, such as for treating cancer or cardiac issues. Many providers are rallying against these bans as a threat to care for patients.
Making the health care system a tool of immigration policy provokes fear rather than safety.
Yet another example of the health care system being weaponized as part of a non-health-promoting agenda, and inciting fear rather than healing, is in immigration policy. A proposed bill in Florida will require all hospitals in the state receiving Medicaid funding to collect information about patients’ immigration status as part of admission. This process will have a chilling effect among many immigrant families, causing them to delay or avoid necessary care altogether. Many provider groups have asked that they not be part of a process as it will disincentivize patient care, interfering in their ability to do their jobs.
Weaponizing the health care system adds in yet another layer of discrimination, with current and future implications.
In addition to transforming the health care system from one of healing into a tool of fear, harm, and disrespect for people’s needs, these attacks on the health care system add yet another layer of discriminatory policies into a system that is already saddled with inequities, especially for certain populations. Birthing people of color currently face disproportionately high rates of morbidity and mortality. Lawfully present and undocumented immigrants already are more likely to forego needed health care. And LGBTQ plus populations face significant challenges to getting the care they need.
The implications of health care weaponization are real—not just acutely for the individual patients who are unable to address specific immediate health care needs, but also for the effectiveness and viability of the health care system overall, as experiencing dignity, trust and respect in the health care system matters for broader patient outcomes. Health care weaponization also has a significant impact on providers, who increasingly suffer from burnout and stress from a variety of factors, including politicization of health care. Recent data also suggest that medical students are making different choices about where and how to practice, which could exacerbate care deserts that already exist, making it even harder for patients to access care in the future.
Federal and state policymakers should reject harmful, discriminatory policies and instead advance equity.
As policymakers across the country consider legislation that impacts the health care system, they should reject efforts to weaponize it against the patients it is supposed to serve. Health care policies should make it easier, not harder, for people to access health care coverage and care, smoothing a path to good health rather than putting up discriminatory barriers. Laws should make it easier, not harder, to get Medicaid coverage, access abortion, and receive reproductive and gender-affirming health care, and they should help everyone—especially people who have been most marginalized—to feel safe, respected and trusted in the health care system. Health care providers should be supported as they seek the best possible care for their patients, not tasked with subverting that patient care in service of a political agenda. Only then can the health care system truly follow the principle of “first, do no harm.”