Tag: Affordable Care

Blog Posts (6)

March 9, 2017

The End Of The Affordable Care Act and Its Critics’ Hollow Moral Rhetoric

From the 1940’s to the present, it’s hard to think of a major topic on the American political agenda that has been subjected to more tortured language and ideological extremism than healthcare. By no means am I saying that healthcare proposals to expand access to healthcare over the years should not have been subjected to rational scrutiny and disagreement. But it seems, by and large, disagreement over healthcare policy proposals have always been about the opponents of progressive options to expand insurance coverage tapping into a certain segment of voters’ deepest fears and biases to predispose them against any alternative for change.

All progressive leaders who have attempted reform in healthcare, like Earl Warren (Governor of California from 1943-53) and President Harry Truman (mid-late 1040’s), to President John Kennedy and Lyndon Johnson in the 1960’s, to the Clintons in the 1990’s, to Barack Obama in 2009, have been met with fierce opposition from lobbying groups representing big business, including insurance and pharmaceutical companies, and often physicians through the American Medical Association. The essential line of attack has been that government would become overly involved in medical decision-making and overshadow the influence and judgment of physicians in the care of patients. But to win this argument decisively, the hired consultants devised plans to associate expanded healthcare coverage or universal healthcare with “socialized medicine” and even the “red scare”—clear demeaning associations with undemocratic countries, unlike the United States, that quickly appeal to irrational sentiments and undermine any consensus for reform. These basic underhand, scare tactics continued to be effective against the failed Clinton proposal in 1993 and, later, President Obama’s signature achievement—the Affordable Care Act—which currently in the process of being repealed and radically scaled down in terms of benefits.

It is noteworthy that a trend developed during the Reagan administration in the 1980’s that added ideological vitality to arguments against expanded access to healthcare: not only was any move toward expanded healthcare a move toward socialism, something assumed to be inherently repugnant, but also, that government, compared to free market mechanisms, was particularly inept to bring about any desire change—as Reagan stated in his 1981 inaugural speech. Just as it is not unreasonable to question the viability of various healthcare proposals, it is not unreasonable to question the legitimate and reasonable extent government should be involved in providing public goods and services. But from the outset, Reagan’s critique of government was simultaneously an outcry of how government was providing benefits to undeserving people, like the infamous “welfare queen” who was abusing the system. It’s hard not to discern from his message clear racial overtones that were meant to appeal to crass biases and prejudices of White working people. It became easy to see government services and benefits as “free stuff” that undeserving people received because those who worked were being coerced to support with their tax dollars.

By the 1990’s government was under attack by the political right and when the Clinton healthcare reform effort began to crack in 1993, the opponents pounced. Healthcare reform was not on the public agenda during the Bush administration and many of thought it was a dead issue for at least another generation. However, the election of President Obama revived interest in healthcare reform, which resulted in the passage of the Patient Protection and Affordable Care Act (ACA). In spite of the fact that this bill was developed by Heritage Foundation, a conservative, pro-free market think tank, and implemented rather successfully in Massachusetts by a Republican governor and future Presidential candidate, the political right attacked it from the outset. The passage of the ACA gave right wing media handlers all the talking points they needed to incite public outrage on the part of many White, working Americans, most in need of healthcare coverage, not less.

The ACA was adopted and pushed through by our country’s first African American president, whose success his opponents wanted to subvert, even if they agreed with him. The ACA was predicated on the use of mandates and expanded a Medicaid program, and provided healthcare coverage for many millions of more Americans. Though it used the private insurance market, the ACA was viewed by its strongest opponents, viz. Republicans in the House of Representatives, as a new government, welfare program that provided more free stuff to non-working people on Medicaid; was paid for by those who chose to work; and interfered in the physician-patient relationship, as critic Dr. Tom Price, the new Secretary of Health and Human Services, was wont to say. There were many ways that reasonable people could have made their critiques, but for the Republican Congressional Representatives, the ACA became a bizarre obsession, attempting to repeal without success 60 times. That is, until the unexpected outcome of the 2016 presidential election. Since then, they have been somewhat like the proverbial dog who finally caught the car he had been chasing.

Now the Republicans are in control of the White House and both houses of Congress, and are unwinding of the ACA. Many on the extreme right are eager to see its full repeal in spite of the lack of any clear consensus on the plan for what will replace it and the consequences that will ensue. All along, we have heard promises that the replacement will provide healthcare that is cheaper and better quality care – but so far those promises seem to ring hollow.

At this point the Republican proposal repeals the individual and employer mandates as well as the subsidies based on a sliding scale according to income; the replacement would distribute subsidies based on age, not income, which in effect greatly benefits those in higher income brackets and harms those in lower brackets.

States would allow to cover Medicaid patients using block grants, which would give states broad discretion over how care is provided and greater emphasis would be placed on health savings accounts (which presupposes people have money to save and would only affect the fairly well-off) The new proposal would continue to guarantee that patients with preexisting conditions will not be denied access to healthcare coverage and that children can remain on their parents’ healthcare insurance until age 26.

This proposal will cause many millions of people—ironically many poor people in states that supported the current president like Kentucky and West Virginia—to lose their healthcare coverage. Moreover, with the demise of the ACA there is the real risk that millions of Americans will not only be without healthcare, many more will die unnecessarily.

Let me say again, I fully realize that rational people could disagree about the wisdom of the ACA and which healthcare policy makes the most sense. But attack on the ACA and the insistence on its repeal have been irrational. It is only in the context of a tradition of distorted information, hype, and ideological zealotry that Speaker Paul Ryan could make statements like he did on Twitter on February 21:

Freedom is the ability to buy what you want to fit what you need. Obamacare is Washington telling you what to buy regardless of your needs.”

 It is a moral tragedy that such statements about an essential human service, like healthcare, is even taken seriously by anyone who knows anything about healthcare. All human beings are vulnerable to illness and accidents and when their bodies, or the bodies of those we are caring for, fail acutely, we seek and expect help in hospital emergency rooms.  This expectation will continue and the result will be greatly increased healthcare costs and human suffering, since more people will lose access to primary care and be forced to enter the healthcare system at the acute stage with no insurance, rather than earlier on with medical problems can be more easily managed.

But Ryan’s words also offer a distorted, truncated view of freedom that likely only appeals to the well off with blinkered moral concerns about their fellow human travelers. Freedom for him and his ilk is like saying, “I got mine, let those without fend for themselves; after all, they are free.”  This is a hollow, simplistic view of freedom and our society is paying the price for decades of distorted information about healthcare policy.

We can only hope the fight for universal healthcare continues and eventually a consensus emerges to do the right thing.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

 

September 16, 2016

Outside the Comfort Zone

I always feel a little nervous for the folks who sign up to be contestants on “Dancing with the Stars” because despite any prior fame or achievements they are spectacularly and uniquely vulnerable on the dance floor. Stepping outside their comfort zone is perhaps what we admire about these celebrities – they are suddenly vulnerable to a different and unfamiliar scrutiny. Mastering new skills alongside an assigned partner we hope for the best as the dancers put their best effort on display. There are criteria to be satisfied (need to show enough Viennese Waltz and Foxtrot moves), and judges to score how well they met these standards. While there is no small amount of entertainment value to the evaluation of the contestants, what is interesting is that the public votes too. This may be a reach, but as healthcare faces new standards measuring quality under the ACA, we see some interesting parallels.

Like our intrepid celebrity dancers, healthcare institutions need to adapt to an evolving set of quality measurements under the ACA. As healthcare institutions brace for the uncertain impact of the ACA regulations on the day to day operations and finances, those responsible for assuring the delivery of care are focusing on not only the cost per patient, but also on improving how patient experience care, and how the health of the community at large can be improved. Like the dancers finding their footing, the ACA challenges the healthcare industry to serve patients with agile and efficient practices in order to not be left behind. An increased the number of patients who now have access to health insurance coverage in states with expanded Medicaid; there is good reason to anticipate a continued increase in the demand for healthcare services. At the same time, the ACA reimbursement requires added accountability for healthcare outcomes, packaged as a blend of incentives and penalties.  An article published in the Annals of Internal Medicine in 2014 (Ryan AM and Mushlin AI. The Affordable Care Act’s Payment Reforms and the Future of Hospitals, Ann Intern Med: 2014; 160(10): 729-730) reminds us that the US healthcare system has navigated change before, and will likely be able to do so again, though the initial phases may require tolerating uncertainty and fiscal caution. We will have to step outside the comfort zone, hope for skilled partners in healthcare leadership, and giving our best effort.

March 12, 2015

The Unique Challenge of Healthcare Reform in the US, and Why it Might All Fall Apart

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Those of us who aspire to eventually having an affordable, quality, accessible healthcare system for all citizens, or even for most citizens, must first face an obvious but under-discussed challenge that uniquely American: The major players in the US healthcare system—including private insurance companies, pharmaceutical companies, medical device and equipment makers, medical specialties and sub-specialties, healthcare organizations and their executives and shareholders, and all of their lobbyists—are motivated by their own economic self-interests first and foremost. Which means our aspirations must be viewed as a long-term struggle.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Healthcare in American is simply unfettered capitalism at work. Let me hasten to add, this is not to say that all of these entities don’t do some remarkable work—I owe my life to the U.S. healthcare system as do millions more. But the fact remains that much of the extravagantly high costs of medical care in the U.S. healthcare system has nothing to do with improving or adding quality care for patients and producing good outcomes. Rather it’s a reflection of how these key players pursue their own entrenched financial interests, while creating narratives to the public that the services they provide is essential for quality healthcare. Interestingly, over time, this bloated, inefficient system has been generally accepted by the public and therefore gained a façade of legitimacy that makes it virtually intractable to reform.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;"> </span></p>
December 14, 2014

Patients Abandoned—Who is to blame?

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">The vast majority of developed nations in the world provide universal healthcare coverage for its citizens. The only developed nations that do not are “…<a href="http://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/">a few still-troubled Balkan states, the Soviet-style autocracy of Belarus, and the U.S. of A., the richest nation in the world</a>.” </span></p> <p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Yet the United States (US) has the most expensive healthcare system in the world, by far—there really isn’t a close second—spending just under 18% of GPD and around $8,500.00 per person on healthcare. One might assume that given that type of expense, we would be getting a lot more than other countries in return for our investment. According to the research provided by <a href="http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror">Mirror, Mirror</a>, from the Commonwealth Fund, the US sadly underperforms and often fails relative to other developed countries on major measures of performance. </span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
July 1, 2014

Health Care and Crowdsourcing: A CrowdCry For Help.

<p class="MsoNormal">Crowdsourcing seems this month’s health care buzzword. It is everywhere. I’ve seen it used in three different health care contexts over the last months: 1) as a means to raise money for treatment, 2) as a means to gain access to treatments, and 3) as a means to help medical diagnoses.  In thinking about these contexts I found myself asking: Would I use it, or would I not? I am curious to hear if you would use the tool of crowdsourcing, after I give my ideas. Please feel free to comment at the end of my post.</p> <p class="MsoNormal"><strong>What is crowdsourcing?</strong></p> <p class="MsoNormal">The dictionary defines crowdsourcing as: <a href="http://www.merriam-webster.com/dictionary/crowdsourcing">“the practice of obtaining needed services, ideas, or content by soliciting contributions from a large group of people and especially from the online community rather than from traditional employees or suppliers”</a><span class="ssens">. </span>In my own terms, crowdsourcing is an appeal to the online crowd/public to assist in a specific endeavor, like the above. Crowdsourcing is about ‘power in numbers’.  It could be an appeal to the public to raise money, signatures, or to gather information/expertise. </p> <p class="MsoNormal"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
May 11, 2014

A New State Law That Will Harm Women: Why do lawmakers ignore facts and expertise?

<p>Recently, the Governor of Tennessee signed into law a bill, <a href="http://www.capitol.tn.gov/Bills/108/Bill/SB1391.pdf">SB 1391</a>, which criminalizes a woman who has had a baby with drug-related complications.  As a result babies born with addictions due to drug use by the mother during pregnancy will be grounds for the mother being charged with aggravated assault, which could result in sentence of up to 15 years in prison for the mother. The concerns of the state legislators who promoted and passed this bill were over a condition in newborns called neonatal abstinence syndrome (NAS).  This condition results from exposure to addictive drugs while in the mother’s womb. In 2013 the Tennessee state Health Department reported 921 babies born with NAS and 278 cases so far in the past four months. The stated goal of the law was to reduce the number of babies born with this condition. But is criminalizing drug use during pregnancy, in this first of its kind state law, the most effective way of accomplishing this goal?</p> <p>It is important to note that the bill was <a href="http://www.nytimes.com/2014/04/15/us/politics/specialists-join-call-for-veto-of-drug-bill.html?emc=edit_tnt_20140414&amp;nlid=58349537&amp;tntemail0=y&amp;_r=2">passed against the strong objections</a> of women’s rights groups as well as health care and addiction specialty groups. First of all these experts agree that cause more harm to babies as pregnant women will be afraid to seek medical care.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>