Back in 2005, Dr. Ezekiel Emanuel co-wrote an article with Dr. Victor Fuchs entitled “Getting Covered”, where the authors described three factors necessary for major healthcare reform: the problem attracts political attention; major players agree upon a refined and feasible solution; and a transforming political event occurs. Their criteria were met with the election of Barack Obama and a Democrat-controlled Congress in 2008, resulting in Obamacare. Their criteria have been met again with the election of Donald Trump and what will be a Republican-controlled Congress (and perhaps future right-leaning Supreme Court). The result is yet to be determined.
Dr. Emanuel has lately been making the rounds on the various networks performing what some might consider the Sisyphean task of defending large portions of Obamacare against the Republican future. In doing so, he points out that several facets of Obamacare are popular with the public and therefore difficult to repeal. The most interesting is the elimination of pre-existing conditions as a pretext for denying insurance coverage, a necessary requirement for universal coverage. Interestingly, Mr. Trump has stated that he wants to keep the Obamacare pre-existing condition reforms.
Pre-existing conditions are the anathema of insurance risk pools. Including individuals with pre-existing conditions in any risk pool necessarily increases the medical costs in that pool. Increasing the size of the pool(s) by encouraging other healthy, low-risk people to join the risk pool relatively reduces the costs by distributing medical costs more broadly. Obamacare included a mandate/tax/fine for those that would not heed the encouragement. Despite this, most people have seen their insurance costs increase significantly. Mr. Trump claims he does not like the mandate and can eliminate it and still reduce costs by making the insurance market more competitive (such as allowing insurers to compete across state borders). Others argue for a consumption tax to increase revenue (see the Emanuel article above). The success of such plans in mitigating costs are yet to be determined.
The other major way to reduce the medical expenditures of a riskier pool is to begin to reduce the services and conditions that will be covered in that pool; that is, to ration care. This is an emotional topic as many of us have already had personal experience with being denied a service we expected to be covered. But it is a necessary topic to examine given finite financial resources, what Dr. Emanuel described in his article as a Rawlsian sense of justice, as “health care is not the only vital service”. A person with a Christian worldview may come to a different conclusion of justice from Professor Rawls. Deciding the appropriate ethical calculus to use to make these decisions is a topic for many other blog entries.
Politically, on both sides of the aisle, we seem resigned to answering the ethical question of whether healthcare should be a right by answering in the affirmative. The hard work is now determining what medical care obligations we are willing to require to actually meet that right. The ethics of those decisions are yet to be determined.