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06/22/2017

Two Random Thoughts about Health Care Policy and Justice

I haven’t yet read the Senate Republicans’ draft health care bill, just out today.  Until I do I’m not going to comment about it directly.

The matter is a bioethics concern solely from the perspective of justice, really.  What is the wisest, most just policy?  And here one is forced, I think, into a fairly utilitarian assessment of what approach provides the best outcome for the country overall?  In that, we can allow for a “priority concern” for pool or relatively poor folks, allowing a weighting of factors in their favor.  In fact, I’m all for that.

But two thoughts.  First, I and others tend to argue that we should reform Medicare and Medicaid and not just leave them as they are, because to do so is to ratify their demise into bankruptcy or unaffordability.  That argument is open to two charges: that it assumes that forecasts of rapid demise are reliable, and that preserving the programs, in a sustainable form, favors future generations at the expense of the current ones.  On the latter, to wit:  Most people would agree that “my” (i.e., someone’s in general) duty to people close to them (like spouse, children) is greater than to a stranger.  But can we not say the same thing about generations?  Isn’t our duty to people already among us greater than, say, our envisioned duty to our grandchildren and great-grandchildren, even if they are ours and not someone else’s?  I suppose that one might argue that.  Then my longer-term argument would lose force.

Second, we hear so much about people who will be harmed if the Affordable Care Act is significantly touched, much less repealed.  (I don’t think any minimally serious observer of the political scene would suggest that true “repeal” of the ACA is even a remote possibility.)  But ANY change is called disastrous, mean, evil—pick your pejorative.  On the other side of the leger are working-class or middle-class people who can’t afford insurance and don’t qualify for subsidies now.  An accurate calculation of the two groups and what they stand to lose seems impossible.  Which group to favor?

Then again, maybe single-payer would conquer all.  As I have written 2 weeks ago and in the past, I’m not so sure.

In the meantime, I am at the annual meeting of the Multidisciplinary Association for Supportive Care in Cancer (MASCC) this week.  Discussions today centered on “financial toxicity”—the negative effects of high drug prices—and on the coming changes in how doctors are paid.  Bottom line: it all has to cost less.  The outcome may not be that public health will be worse—I’m not at all sure it will—or that rich doctors or industry executives will make less money (they will, but they’ll be OK).  But we don’t have a purchase on how many people of more modest current income will be out of work as a result—e.g., the chemists, regulatory folks, administrative assistants in industry.  I have no idea what that effect will be.  Maybe significant, maybe not so much.

But we are about to “conduct the experiment.”  One way or another, we have to.

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