"Am I then more of an American than those who drew their first breath on American ground?"
-- Alexander Hamilton, 1795
Each year on July 4, the United States celebrates independence won by those whose ancestors did not draw their first breath on American ground. Nearly 89 years after the Declaration of Independence was signed, a day of delayed emancipation was celebrated on June 19, 1865, (Juneteenth) for those whose ancestors drew their first breath on the African continent.
This year on July 4, I celebrated the holiday by watching the much-anticipated streaming of Hamilton. The Broadway hit, inspired by Ron Chernow's 2004 biography of Alexander Hamilton, is a musical adaptation of the life of a Caribbean immigrant who survived all odds to become a hero of the American Revolution. Prior to the meteoric success of the play, Hamilton's legacy remained largely unsung for more than 200 years after his untimely death in a duel with Aaron Burr. With the exception of his portrait on the $10 bill, Hamilton's dramatic life story had been less celebrated than those of some of our nation's other founding fathers.
When Lin-Manuel Miranda conceived the idea of composing a hip-hop album about the life of Alexander Hamilton in 2008, his friends thought it was a drunken joke. But a year later, his ensemble received a standing ovation from those assembled in the East Room of the White House after performing excerpts from the developing musical that would debut on Broadway in 2015.
Among the many brilliantly crafted songs were four that ignited my desire to write this post.
On Nov. 2, 2015, President Barack Obama walked onto the stage of the Richard Rodgers Theater in New York to give his remarks after having seen the completed production of Hamilton.
"One measure of America's health is how warmly it embraces the diverse souls who live here," he said.
The musical he had witnessed was a story of an American Revolution as told by a racially diverse cast of characters. As I watched this particular portion of the play, the lyrics, "I’m just like my country. I'm young, scrappy and hungry. And, I'm not throwing away my shot,” reverberated in my consciousness.
In 1776, the Second Continental Congress issued a statement citing 27 grievances against King George III. This Declaration of Independence was an urgent message regarding "the causes which impel[led] them to the separation" from the status quo of British tyranny. But my thoughts were met with the present-day reality of the up to 26 million protesters (the largest movement in U.S. history) who had risen up to express their collective frustration that the unalienable rights of all Americans had not yet been realized after 244 years of waiting. Too many of our citizens are still awaiting their shot to be warmly embraced by unfettered opportunities.
The AAFP, along with hundreds of other government and private-sector organizations, issued a statement in late May declaring racism a public health crisis. Unlike the colonists' declaration, our statement is not a contemporary political message, and it is not an attempt to cast blame on any individual or group for the inequities HHS continues to objectively confirm each decade in its Healthy People publications -- the latest being Healthy People 2020.
We are all to blame if we fail to assist in exorcising the implicit and explicit biases insidiously hardwired into all of our social systems. Failure to do so provides additional fuel to feed the fire of diminished opportunities for any human being. Silence is not an option. The AAFP could not throw away its shot of advocating for the Americans we so faithfully serve.
During a pivotable point in the play, General George Washington captures a teachable moment with Hamilton to share the story of his disastrous first command. He tells a restless young Alexander, "I know that greatness lies in you." But he admonishes him to always remember that "history has its eyes on you."
In 2019, the AAFP celebrated family medicine's 50 years as a medical specialty. We entered this new decade with the bold intention of leading our nation forward toward improved health care outcomes for all Americans by using the intellectual principles of primary care as the stable foundation to build national health care reforms.
Historical decisions that impact our members' abilities to provide medical services to all populations were made this summer when the U.S. Supreme Court ruled to preserve Deferred Action for Childhood Arrivals and to uphold the right of trained physicians to provide legal reproductive and maternity health services without unnecessary interference. The AAFP welcomed both rulings.
We also supported preserving and strengthening protections provided by the Patient Protection and Affordable Care Act, including those for patients with limited English proficiency, those who are transgender and those with disabilities.
The Academy has a proud history of striving to fulfill our vision statement to: "Transform health care to achieve optimal health for everyone."
In the second act of Hamilton, Aaron Burr questions how this "immigrant" had dinner with Thomas Jefferson and James Madison one evening and emerged with the nation's financial power situated in New York (Hamilton's home state). Allegedly, while confined in the room, the three men also hatched a secret agreement to build our nation's capital in Virginia. Burr laments the fact that no one but Hamilton, Jefferson and Madison had any say in the matter because he had not been in the room where the deals were made.
Family physicians provide our nation with 192 million office visits each year. We are truly in the rooms where essential health care is being delivered.
Not unlike the cast members of Hamilton, who can sing, dance, act and rap, our members are multiskilled. During the COVID-19 pandemic, many of our members have been enlisted to expand their professional services to cover hospital emergency rooms, intensive care units, nurseries, extended care facilities and more. These services are being provided by family physicians in addition to -- or to the exclusion of -- their ambulatory care practice duties.
The AAFP has not paused during this era of social distancing. To the contrary, we have made a conscious effort to use innovative technologies to virtually move closer to our members. During this unprecedented time, the Academy has continued to equip members with resources and advocate on their behalf.
For years, AAFP members have been a chorus of powerful voices advocating in numerous social media outlets and in the rooms where influential decisions are made about our nation's health care systems. CMS has heard our voices and recognized the foundational relevance of primary care to our nation's health. Earlier this year, CMS took decisive action by recommending an update to evaluation and management coding that will yield our members a 12% increase in reimbursement for primary care services -- effective Jan. 1.
The final song of the musical ends with each character briefly appearing in the spotlight to sing a verse that tells the unique story of how their individual lives were woven together to create the tapestry of a nation's history.
In the final analysis, the value family medicine has contributed to our nation and our respective communities -- both before and during the COVID-19 pandemic -- is our story to tell. This is our once-in-a-generation opportunity to not just tell our story, but to demonstrate in real time how we are providing guidance to a health care system in desperate need of a torchbearer.
By working together, we will tell generations to come how we took a world turned upside down by a pandemic and turned it right side up again to support the health care needs of an entire population. The year is not over, but the historical events we have witnessed thus far have left us breathless with anticipation of the stories yet to be written about those who lived, those who died and those who will tell the story of this new American health care revolution.
Gary LeRoy, M.D., is the president of the AAFP.