Amid public polls suggesting that only 34% of the country supports the Defense of Marriage Act (DOMA) -- the law that codifies non-recognition of same-sex marriage for all federal purposes -- one wonders why it is actually still law. Maybe the problem is that those fighting to preserve it simply don't recognize its adverse reach. Their arguments, tethered to a view of the intangible institution of marriage, seem to miss the law's tangible consequences. Consider, for example, DOMA's impact to our healthcare system.
By all accounts, the United States has been experiencing a primary care crisis over the past 50 years. Primary care physicians are the general practitioners in either family medicine, internal medicine, or general pediatrics who serve on the front lines of our healthcare system. In a sense, the robustness of a nation's health care system could be judged by those in primary care who are not mere gatekeepers to specialists but who instead have the unique perspective of the patient in her entirety -- not a mere vessel of disease or organ dysfunction. It is thus quite discouraging to learn of the decades-long decline in graduating medical students' choosing primary care as their profession.
"There are financial, lifestyle and health care systems issues that have led to this problem," says Dr. Rosanne M. Leipzig who is Professor and Vice Chair for Education of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine. In her view, "Primary care physicians have lower income prospects by far than those of other medical disciplines, and start their careers seven to ten years later than their peers and $100-200,000 more in debt. There is pressure to increase patient volume to pay for one's practice, particularly with decreasing reimbursements from major payers like Medicare and Medicaid. Lifestyle considerations include responsibility to patients that extends far beyond a nine to five day especially for complex or seriously ill patients. In those cases, the doctor-patient relationship is particularly important to understand the 'whole' of the patient's illness, and is not easily replaced by a covering doctor." It is difficult to imagine any major reform of our health care system that does not address this looming primary care crisis.
Meet two outstanding general practitioners, Dr. Scott Hadland, in pediatrics, and Dr. Jason Vassy, in internal medicine, who embody what we need in primary care physicians in this country. They are the kind of physician you'd want as your or your child's primary care doctor and are intensely interested in staying in primary care for their respective careers. Their resumes read like the New York Times wedding announcements parodied in the opening chapter of David Brooks' Bobos in Paradise. The couple met and started dating when Scott was interviewing for a scholarship (that he later received) that Jason had already received at Washington University in St. Louis School of Medicine. When Scott matriculated as a medical student, their romance blossomed over a discussion of the importance of being openly gay physicians. Jason, from Spartanburg, South Carolina, is a fellow in general medicine and primary care at Harvard Medical School, and Scott, from White Rock, British Columbia, is finishing up his pediatrics residency at Boston Medical Center of Boston University and Children's Hospital Boston of Harvard Medical School. Jason has a research interest in the genetic risk factors of chronic disease and genetic testing in the primary care setting and earned a Masters of Public Health from The Johns Hopkins University in addition to his medical degree. He completed his internal medicine residency at the University of Pennsylvania. Once Scott completes his residency, he will pursue fellowship training in adolescent medicine and be a chief resident in pediatrics. He plans to continue his research on homeless and runaway youth that has led to ten peer-reviewed publications.
The couple married on September 4, 2010 just outside of Vancouver, Canada and currently lives in Massachusetts, one of six states plus Washington, D.C. where same sex marriage is legal. With the backing of Senator John Kerry, the couple applied for Scott to receive a green card as he is only legally allowed to stay in the United States for another four years, at which point his post-graduate medical education will be complete. On March 27, 2012, six months after submission of his green card application, Scott was denied his green card due to DOMA. If Scott had been married to a woman, his green card application would have been approved.
So here is my question: during our primary care crisis, should the U.S. government be using valuable resources and limited funds to deport Harvard-trained primary-care physicians who want to serve patients in our country and also remain in the same country as their spouses? According to DOMA, our government should.
DOMA was signed into federal law on September 21, 1996 by President Bill Clinton to define marriage as the legal union of one man and one woman. Section 3 of the law codifies the non-recognition of same-sex marriage (even in states that legally allow them) for all federal purposes, including joint tax filings, social security survivors' benefits, insurance benefits for government employees and, in the case of Scott and Jason, green card applications. In February of 2011, the Obama administration declared that Section 3 was unconstitutional and that the federal government would no longer defend it in court though it would continue to enforce the law. This unprecedented position led the Republican-led House of Representatives to appoint lawyers to defend the law in place of the Department of Justice. Earlier this month, the United States Court of Appeals for the First District in Boston heard arguments in the first of several cases against DOMA to reach the appeals level. This case has been closely followed by my fellow Huffington Post blogger, Adam Bink.
The consequences of this discriminatory law reach farther than one immediately imagines. Scott and Jason's story is about the burdens that DOMA imposes personally on gay couples; burdens from which many Americans perhaps feel disconnected. But their story is also about DOMA's far-reaching externalities -- the burdens it places on so many aspects of public and private life, including the medical care you and I have access to -- and underscores why everyone should be resisting this law.
To hear from Scott and Jason directly, I've embedded a video that they recently made to depict their story and dilemma to President Obama prior to receiving the news about Scott's green card.
The views expressed in this blog are my own and do not reflect the views of The Mount Sinai Medical Center.
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