Tag: Distributive Justice

Blog Posts (8)

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and, later, President Obama’s signature achievement—the Affordable Care Act—which currently in the process of being repealed and radically scaled down in terms of benefits.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 10, 2015

Will America Ever Come To Terms With Its Past?

<p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">In my <a href="/BioethicsBlog/post.cfm/some-reflections-on-summer-vacation-reading">last blog</a> I wrote, what was in effect, a review of three books from my summer reading I did while on vacation. The first book covered the life of George Washington from the time of his resignation as General in the Continental Army, through his leadership in the Constitutional Convention in 1788, until his inauguration ceremony on 1789. The second book was a narrative history of the Great Migration of African Americans from the Jim Crow south to Northern and Western cities, and the hardships they endured throughout. And finally the third book was a contemporary description of what it is like to live in a black body today in the United States. I have been continuing my thoughts on the fate of blacks in America.</span></p> <p style="font-size: 11.2px; line-height: 19.04px;"><span style="font-size: 11.2px; line-height: 19.04px;">From the era of George Washington, we see the American political and social power structure becoming embedded into a political system filled, from the first moment with enormous hope but with equal, deeply troubling contradictions. There was eloquent language of the “many” no longer having to remain subservient to the “few” that seemed to reflect through reason the rights of human kind. Yet it was equally clear that Washington’s America was created to protect the financial interests of privileged white males as many human beings were excluded from participation in the new, fledgling nation, including women, native Americans who would be driven from the lands and basically exterminated, and African Americans, a few of whom were free but most enslaved as the property of white slave owners. </span></p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">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>
September 16, 2014

Is It Possible To Do Bioethics In Contemporary America?

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Ok, I realize I am being somewhat provocative. But there is a real and very serious issue, which I am groping to address in a more precise manner.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">In my last blog I described the contemporary moral setting from a philosophical perspective as one in which no single substantive normative moral perspective can resolve moral questions, such as the boundaries of human life and the scope of individual rights, with final moral authority. This is just to say, more simply and obviously when we reflect upon it, that in democratic, secular America, ethics, both philosophically and practically, becomes inextricably linked to public discourse in politics and public policy.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">When bioethicists ask questions and make arguments about abortion, physician assisted suicide, stem cell research and cloning, and many other similar issues that pertain to questions about the value of human life in relation to both individual rights and societal goals, we have no privileged moral authority from which to draw. As bioethicists we engage in procedural, persuasive discourse, based on conventional moral principles that most often conflict, which is why there is moral dilemma or problem requiring analysis and prioritization. Our purpose in defending a particular moral position is to win assent from others. In short, for a bioethicist to promote a moral position, it is implicitly an attempt to build a consensus among readers and listeners that will hopefully impact public opinion about a particular moral problem or question. Moreover, to the extent these questions have public policy ramifications, and practically all do, it means that moral discourse is also oriented to effect change and function as a medium in which bioethicists often speak as advocates about how moral options should be framed as public policy positions in a democratic society.</span><span style="line-height: 19.0400009155273px;"> </span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><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="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;"> </span></p>
September 9, 2014

Drug Innovation and Government-Operated Health Systems

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">On August 30, 2014, cardiovascular drug researchers managing the PARADIGM-HF Study and its Committees announced that they were terminating their Phase III trial of LCZ696 because of observed “<a href="http://www.dailymail.co.uk/health/article-2738993/Remarkable-new-heart-drug-cut-deaths-fifth-available-early-year.html">overwhelming benefit</a>.” As reported in The Daily Mail: “Thousands of lives could be saved by a new drug for heart failure that researchers claim outperforms the current best treatments. … Research on more than 8,000 patients found that it saved 20 per cent more lives than the current ‘gold standard’ treatment – the ACE inhibitor enalapril.” The <a href="http://www.reuters.com/article/2014/08/30/us-health-heart-novartis-idUSKBN0GU0CQ20140830">findings were announced</a> at the annual meeting of the European Society of Cardiology and published the same day in the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1409077">The New England Journal of Medicine</a>. In a news release, the Switzerland-based Novartis International AG – the drug manufacturer sponsor – said that it would submit an FDA application to market the drug in the US by the end of 2014. Novartis anticipates <a href="http://www.novartis.com/newsroom/media-releases/en/2014/1852531.shtml">submitting a similar application</a> to the European Union by early 2015.</span></p> <p style="line-height: 19.0400009155273px;">Analysts say “that [the new drug] might <a href="http://www.nytimes.com/2014/08/31/business/new-novartis-drug-shows-striking-efficacy-in-treating-heart-failure.html">cost $7 a day in the United States</a>, or about $2,500 a year. Existing [standard] drugs are generic, costing as little as [$48 a year] … .”</p> <p style="line-height: 19.0400009155273px;"><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="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
August 3, 2014

A Cure So Expensive No One Can Afford It

<p>In December 2013, the FDA approved <a href="http://www.sovaldi.com">Sovaldi</a>® (sofosbuvir, Gilead Sciences, Inc.) for treatment of hepatitis C. A truly wonderful <a href="http://www.hcvguidelines.org/full-report/introduction">medical breakthrough</a>, the oral drug effectively <a href="https://www.ncbi.nlm.nih.gov/pubmed/23281974">cures 90% of patients</a> who take it correctly. The online physician resource Web site <a href="http://www.medscape.com/viewarticle/817371">Medscape</a> has referred to this drug as a “game changer.” Clearly it will change the health care delivery game in any number of ways.</p> <p>But the miracle comes with a catch: the cost is prohibitive. The full treatment course is <a href="http://www.newsweek.com/insurers-worry-84000-hepatitis-c-drug-sovaldi-could-break-bank-252539">so expensive</a> that very few can afford it even with good health insurance. Each pill costs about $1000; patients will need to take the medicine once a day for about 12 weeks for a full course. The total cost will be about <a href="http://www.nytimes.com/2014/03/16/opinion/sunday/how-much-should-hepatitis-c-treatment-cost.html">$90-120,000 per patient</a>. Many are asking how is it possible to justify the cost? <a href="http://jama.jamanetwork.com/article.aspx?articleid=1890401">Is this fair?</a></p> <p>Of course, the principal difficulty at first glace is that the costs will strain the system to a degree never before seen with the introduction of a new drug. The strain may break the bank. Recently Reuters has reported that one Florida health insurer – WellCare Health Plans – has sustained <a href="http://www.reuters.com/article/2014/07/25/wellcare-health-stocks-idUSL4N0Q047L20140725">significant corporate losses</a> attributable to the fact that Florida requires insurers to prove sofosbuvir to Medicaid patients. It has been reported that 47 state Medicaid programs are covering the drug, and about half have some form of preauthorization. Illinois Medicaid has recently changed its preauthorization criteria to provide the drug only to those patients with advanced liver disease, and to those who can tolerate interferon as an adjunctive treatment, and to <a href="http://www.chicagobusiness.com/article/20140729/NEWS03/140729819/ill…estricts-who-can-get-game-changing-hepatitis-drug">exclude individuals</a> with a history of alcohol or drug abuse. It has been projected that drug availability to California residents alone will add $18 billion to health care costs in one year.</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>
June 6, 2014

To Properly Care for Veterans, Do We Really Need a VA Health System?

<p><span style="line-height: 22.399999618530273px;">The ongoing VA scandal is indeed unfortunate and sad. In a speech on May 30, 2014, in Washington, DC, <a href="http://www.nytimes.com/2014/05/31/us/politics/va-chief-eric-shinseki.html">Eric K. Shinseki apologized</a> for the “systemic, totally unacceptable lack of integrity” shown by some administrators in managing the Veterans Administration health care system hospitals and clinics. Within hours of the apology, Secretary Shinseki <a href="http://www.nytimes.com/2014/05/31/us/politics/eric-shinseki-resigns-as-veterans-affairs-head.html">resigned</a>.</span></p> <p class="MsoNormal" style="line-height: 22.399999618530273px;">It is clear that the trouble within the VA has been brewing for some time. The fuse that set off this latest explosion may have been <a href="http://www.azcentral.com/longform/news/arizona/investigations/2014/05/31/va-scandal-whistleblower-sam-foote/9830057/">whistleblower claims</a> that managers at the Phoenix VA Medical Center were keeping two sets of books which logged wait times for veterans seeking primary care appointments. There are allegations that some of the delays resulted in veteran deaths. Acting VA Inspector General Richard J. Griffin issued a <a href="http://www.nytimes.com/2014/05/29/us/va-report-confirms-improper-waiting-lists-at-phoenix-center.html">preliminary report</a> confirming that Phoenix VA administrators had manipulated wait times possibly to assure more favorable annual performance reviews and higher bonuses and compensation for staff.  The unethical behavior by those entrusted with the care of our veterans is inexcusable.</p> <p class="MsoNormal" style="line-height: 22.399999618530273px;"><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="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
March 28, 2014

Fairness and a right to health care

<p>Amber is a 70 year old woman. She is doing poorly. She has metastasized cancer, multiple co-morbidities and a pressure ulcer. Apart from her ulcer, she has no acute care needs that condone her to the hospital. Some predict that she is likely to pass over in 3 months. With the right type of medications Amber could go home. However, the pressure ulcer medications that she needs cost about 200 dollars a day and she does not have the right type of insurance to pay for this. As a result, she is confined to a hospital bed. </p> <p>Amber has always contributed diligently to society. She worked from age 17 in a bank and paid her taxes diligently. Amber and her husband, who died 3 years ago, raised 3 children and lived in a town upstate New York. They used to take holidays on the West-Coast, where Amber has a family summer home.  This house belonged to her great grand-mother and has been in her family for 120 years. All of Amber’s family is attached to this house.</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="text-decoration: underline; color: #000099;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
March 7, 2014

GlaxoSmithKline and Conflicts of Interests

<p class="MsoNormal" style="line-height: 22.399999618530273px;">A <em><a href="http://www.nytimes.com/2013/12/17/business/glaxo-says-it-will-stop-paying-doctors-to-promote-drugs.html">New York Times</a></em><a href="http://www.nytimes.com/2013/12/17/business/glaxo-says-it-will-stop-paying-doctors-to-promote-drugs.html"> article</a> by Katie Thomas published on December 16, 2013 led with this sentence: “The British drug maker GlaxoSmithKline will no longer pay doctors to promote its products and will stop tying compensation of sales representatives to the number of prescriptions doctors write, its chief executive said Monday, effectively ending two common industry practices that critics have long assailed as troublesome conflicts of interest.” Might one ask: Are these really conflict of interests problems?</p> <p class="MsoNormal" style="line-height: 22.399999618530273px;">A <em>conflict of interest</em> (so sometimes, <em>conflict of interests</em>) is <a href="http://www.nejm.org/doi/full/10.1056/NEJM199308193290812">often defined as</a>: “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.”  In a short introduction to conflicts of interests, written for a business ethics class at the McCombs School of Business at the University of Texas at Austin, Dr. Lamar Pierce (Associate Professor of Strategy, Olin Business School, Washington University, St. Louis) said:</p> <p class="MsoNormal" style="line-height: 22.399999618530273px; padding-left: 60px;"><span style="color: #434343;">Incentives are pervasive in every aspect of society. People are rewarded for taking certain actions, and not rewarded for taking others. Workers are paid for their effort and productivity, salespeople are paid for their sales, and small business owners are rewarded with profits for successful ventures. So long as these incentives are well-understood by everyone, they work reasonably well. They motivate effort, performance, and social welfare. But sometimes, individuals have incentives that conflict with their professional responsibilities, often in ways that are not transparent to the public or in their own minds. These conflicts of interest produce serious economic and social problems.</span></p> <p class="MsoNormal" style="line-height: 22.399999618530273px;"><span style="color: #434343;"></span><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="/Academic/bioethics/index.cfm">website</a>.</strong></p>