What Is the AAFP's Political Action Committee Fighting For?

• Decision Making
• Family Physicians
• Firearms
• Health Insurance
• Politics
• Violence

For American family physicians and their patients, critical issues hung in the balance of the 2018 midterm election, ranging from the sustainability of health insurance expansions, the global reputation of the US vis-à-vis human and refugee rights, and the possibility of federal responses to quell firearm violence. As family physicians, we entrust the American Academy of Family Physicians (AAFP) to represent our common beliefs and interests in the political process. The AAFP has a history of supporting universal health care coverage and the Patient Protection and Affordable Care Act (ACA) of 2010,¹ has spoken forcefully against the separation of children from parents at the US southern border,² and has voiced strong support for legislation to address gun safety, including strengthened background checks and greater funding for firearm injury prevention research.³ The AAFP has also highlighted the health implications of environmental degradation. When the Environmental Protection Agency recently announced plans to repeal the Clean Power Plan, the AAFP's Board Chair, Dr John Meigs, called out that the repeal would worsen health disparities due to the disproportionate impacts of air pollution on poor, nonwhite populations.⁴

Hence, I reacted with disbelief when my brother, an emergency physician, told me that the AAFP had supported the campaign of incumbent Senator Cindy Hyde-Smith (R-MS), who came to national attention when she said she'd be “in the front row” of a “public hanging” if invited by a campaign supporter. Even disregarding this incident, Hyde-Smith's progun, repeal-the-ACA stances should have disqualified her for AAFP support. However, publicly available campaign finance data reveal that indeed the AAFP's Political Action Committee (FamMedPAC) donated $5000 to Hyde-Smith's campaign—the maximum allowable per election under federal law.⁵

It turns out that FamMedPAC supported many candidates for federal office whose platforms or voting records contradict AAFP's core principles and priorities. In the 2018 election cycle, FamMedPAC donated $170,000 to the campaigns of 40 Republican members of Congress who campaigned on the platform of repealing and replacing the ACA and received high grades from the National Rifle Association (NRA), including Senator Bill Cassidy (R-LA) who, during his political career, has received $2.8 million of NRA campaign support⁶ and cosponsored the Graham-Cassidy bill, which would have eliminated ACA cost-sharing subsidies and Medicaid expansions. Many of these candidates have also sown doubts about the science of climate change, and to my knowledge, none have publicly criticized the Trump Administration for its separation of children from parents at the southern border. A recent analysis showed that FamMedPAC also donated large sums to NRA-friendly candidates during the 2016 cycle.⁷

During the 2018 cycle, FamMedPAC donated $531,500 to all candidates for federal office, so the $170,000 donated to these 40 Republican candidates comprised 32% of FamMedPAC donations; the remaining $361,000 was donated to Democratic candidates. Still, one questions by what criteria the Republican candidates were judged to be worthy of support. FamMedPAC publicly issued its 2018 election cycle contribution criteria,⁸ but this document is murky about the methods used to prioritize candidates for donations. At the top of the PAC's list of legislative priorities was “health care coverage for all.” By that criterion, the 40 Republican candidates who ran on a platform of repealing the ACA should have been eliminated. But the document explains, “Although FamMedPAC will want to direct most contributions to candidates… who have shown concrete support for AAFP's priorities, a special relationship with AAFP can be an important factor in considering a contribution request.” FamMedPAC also lists a hodge-podge of other criteria that might influence donations, including committee assignments, leadership positions, relationships with AAFP members, the likelihood of election, residence in states or districts of AAFP or FamMedPAC Board members, and the hope that donations will help “get a foot in the door.” The document does not outline how these various criteria are assessed and weighted during the election cycle and by whom.

As a family physician, I can appreciate that there are other issues of legislative importance to AAFP members, including rural health and graduate medical education reform, and I do not believe that Democratic party affiliation should be a litmus test for FamMedPAC donations. But the 2018 midterm election called for special strategic considerations in light of the urgency of achieving Democratic control of at least one Congressional chamber. Since Donald Trump's election, the Republican party has unified around a platform of “repealing and replacing” the ACA, although the party has never articulated a cogent replacement proposal. Most Republican members of Congress have been silent or complicit as the Trump Administration has pursued other policies that are antithetical to core AAFP principles, including the systematic separation of children from parents at the southern border and the uprooting of domestic and international attempts to address climate change. Due to the influences of the NRA lobbying, opposition to legislation regulating guns has become Republican party orthodoxy. While Republicans and Democrats have historically worked toward compromise for the common good, Congressional Republicans in the current polarized political environment so fear the public repudiation they would receive from President Trump that they will not speak out or cooperate with Democrats. With so much hinging on which party obtained the majority in the 2 chambers after the 2018 cycle, it is unclear why FamMedPAC supported any Republican candidates who were in tight races for re-election, including Senator Hyde-Camp of Mississippi (who won) and Senator Dean Heller of Nevada (who lost).

FamMedPAC's current approach to allocating campaign funding risks losing something essential to our broader influence on the body politic: our patients' trust, which is contingent on the socially just public stances we take as family physicians. If the AAFP chief executive officer signs off on a manifesto to address gun violence,³ then the FamMedPAC cannot support the campaigns of fierce opponents of the very legislative solutions the AAFP chief executive has publicly advocated. The same goes for health care access. What is the public to infer from our support for members of Congress who have promised to dismantle the ACA or its protections for coverage for pre-existing conditions?

FamMedPAC's pattern of donations also threatens to undermine the trust of family physicians for the AAFP. I have been an AAFP member since my residency, and, while I was frustrated by the AAFP's dalliance with the Coca-Cola Company (ended in 2015), I have never seriously considered discontinuing my membership until recently. FamMedPAC's participation and influence in recent election cycle conflicts with my personal values as a family physician and the expressed aspirations of the AAFP. I hope that future FamMedPAC contributions will align consistently with the publicly expressed values and policies of the AAFP.

• Received for publication March 27, 2019.
• Revision received May 31, 2019.
• Accepted for publication June 12, 2019.