At a Crossroads: Medicaid and Health Policy in the U.S.

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Hannah Giunta, DO, PhD, MPH

Recently, U.S. states were granted federal permission to pilot a variety of initiatives that will require able-bodied, adult Medicaid recipients to attend school, work, volunteer, or participate in rehabilitation to receive benefits. Earlier this month, Kentucky became the first state to successfully apply for a waiver allowing them to trial work requirements. While the majority of Medicaid recipients—including children, enrollees with disabilities, and full-time caregivers—are exempt from these changes, the initiation of a work requirement represents a dramatic shift in health policy unprecedented in our nation’s history. While I am not opposed to work requirements for cash assistance, access to health care is a fundamentally different matter. Even if the work requirement could be implemented without negative downstream effects, it still values people’s lives according to what they contribute.

When Medicaid was first signed into law as part of the 1965 Social Security Act by President Johnson, it represented the culmination of a larger social debate about poverty and health. A general consensus emerged that no American should be left without access to needed medical care whether due to age, disability, or disadvantage. Against the backdrop of Johnson’s “War on Poverty” and “Great Society” initiatives, access to health care was rightly seen as a crucial factor in economic empowerment and development. Johnson stated unequivocally in his January 1964 State of the Union address to Congress:

This budget, and this year’s legislative program, are designed to help each and every American citizen fulfill his basic hopes—his hopes for a fair chance to make good; his hopes for fair play from the law; his hopes for a full-time job on full-time pay; his hopes for a decent home for his family in a decent community; his hopes for a good school for his children with good teachers; and his hopes for security when faced with sickness or unemployment or old age. (Peters and Woolley, The American Presidency Project)

But, there was also a sense that America could do right by the poor and disadvantaged. Later in the same State of the Union address, Johnson stated:

This administration today, here and now, declares unconditional war on poverty in America. I urge this Congress and all Americans to join with me in that effort. It will not be a short or easy struggle, no single weapon or strategy will suffice, but we shall not rest until that war is won. The richest Nation on earth can afford to win it. We cannot afford to lose it. (Peters and Woolley, The American Presidency Project)

1200px-Lyndon_Johnson_signing_Medicare_bill,_with_Harry_Truman,_July_30,_1965

Image description:  President Lyndon B. Johnson signing the Medicare amendment at the Harry S. Truman Library in Independence, Missouri on July 30, 1965. Former president Harry S. Truman is seated at the table with President Johnson. Image source: Wikimedia Commons.

Thus, from the very beginning, the Medicaid program was justified based on the importance of economic empowerment and also on the basis of the compassion and decency a rich nation ought to show its citizens. In its present forms, the work requirement will go a long way toward undermining both of these justifications.

From the perspective of economic empowerment, one of the major arguments made in favor of the work requirement emphasizes personal empowerment through work. As Seema Verma, head of the Centers for Medicare and Medicaid Services, reiterated in her public comments, community involvement through work can be a source of empowerment and possibly help recipients transition to jobs with health benefits. Yet, while Americans certainly want good jobs with benefits, current work requirement proposals do little to help Medicaid recipients climb the economic ladder. There is no additional funding for education, workforce placement services, or incentives for companies to hire these workers at a living wage. It is unclear how simply requiring people to find jobs improves the situation. Of course, some might argue that people should take any 20-hour per week job they can find if they want benefits. While you can make an argument in favor of this proposition, you cannot simultaneously herald work requirements as a force for economic empowerment. Workers are likely to end up in the same dead-end jobs available before the work requirement. Additionally, with no upgrade of their skills or qualifications, I imagine the likelihood of them obtaining a job with decent health insurance coverage is the same as it is right now. The only difference is that now workers who lose a job and cannot find new employment lose their health insurance too. If they volunteer, we as a society might benefit from these workers’ efforts. But, though volunteering is laudable, it is unlikely to result in a major step up on the economic ladder and places further burdens on individuals who are already on the margins.

pill bottle and money

Image description: a prescription pill bottle is on its side with capsules still inside and spilling out onto a surface of U.S. $20 bills. Image source: Images Money/Flickr Creative Commons.

Not to mention, the work requirement may paradoxically exacerbate the health inequities Medicaid was designed to address in the first place. For instance, children, pregnant women, and full-time caregivers make up a large number of Medicaid recipients. They are currently exempt from the work requirements, but their family members are not. Imagine how much more hardship a family will face if a partner or parent loses coverage. Adult caregivers and children may be forced into a losing battle between their own needs and the needs of the newly uninsured family member.

Most crucially, the issue at stake in this debate is truly whether health care is a human right or a commodity provided or traded to those who contribute something in return. Of course, supporters of the work requirement will point out that they merely want those enrollees who can work to contribute something in exchange for free benefits. It is human nature to count the cost of our generosity. However, in a society as rich as our own, should anyone go without needed care? Is the life and health of an individual who has not held a job in years worth less than the life of someone who works 20 hours each week? According to the work requirements, it seems like the answer is a resounding “yes.” Of course, the person could seek care at the emergency room—a place of last resort for many people without resources. But, can’t we do better than that? The question really becomes: can the United States care for its own, or has the most powerful nation in history lost its way? We can decide to declare defeat or we can develop new battle strategies to win the war on poverty once and for all. How we answer this challenge will undoubtedly determine how future historians look back on this time.

hannah-giunta-2017-cropHannah Giunta, DO, PhD, MPH, is a first year pediatric resident at Mayo Clinic and proud alumnus of Michigan State University. She completed her PhD in spring 2016 under the direction of Dr. Tom Tomlinson and her medical degree in May 2017.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Tuesday, February 13, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Ethics in Surgical Research and Publication

Marleen Eijkholt photoCenter Assistant Professor Dr. Marleen Eijkholt co-authored the chapter “Ethics in Surgical Research and Publication” in Ethical Issues in Surgical Care, a fall 2017 publication from the American College of Surgeons Division of Education. Dr. Eijkholt’s co-authors are Lance K. Stell, MA, PhD, FACFE, and Richard B. Reiling, MD, FACS.

Chapter summary: Surgical research is the foundation of evidence-based surgical practice. The question “what makes research ethical?” entails particular challenges for surgical research. For example, uncertainty and controversy exist in areas of research methodology, given the unique circumstances of each surgical intervention. Placebo control groups and randomization practices, too, raise major methodological issues in surgical research. This chapter discusses controversies in surgical research and publication thereof. The chapter follows the submission of a hypothetical research study through the institutional review board, to highlight areas of ethical controversy, and describe such issues too for the publication of such studies.

For more information on Ethical Issues in Surgical Care, please visit the American College of Surgeons website.

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February webinar to address Michigan’s vaccine waiver education policy

bbag-blog-image-logoWhat’s the point of Michigan’s vaccine waiver education requirement?

Event Flyer

Since 2015, Michigan parents have had to attend education sessions at public health offices if they want their unvaccinated or under-vaccinated children to attend school or daycare. This policy seems to have succeeded: the state’s nonmedical exemption rate declined by 35% from 2014 to 2015. But what explains this apparent success? Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions? Also, does vaccine education promote additional public health goals, i.e. other than short-term vaccination compliance? This presentation will attempt to answer these questions by drawing on immunization records, interviews with public health staff, and surveys of health department leaders, with the goal of informing arguments about the value of Michigan’s vaccine waiver education policy.

Feb 15 date iconJoin us for Dr. Navin’s lecture on Wednesday, February 14, 2018 from noon till 1 pm in person or online.

Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University. His recent work is primarily in bioethics and public health ethics. His book, Values and Vaccine Refusal, was published by Routledge in 2015.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

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Announcing the Spring 2018 Bioethics Brownbag & Webinar Series

green brownbag and webinar iconThis year’s Bioethics Brownbag & Webinar Series resumes in February. You are invited to join us in person or watch live online from anywhere in the world. Information about the spring series is listed below. Please visit our website for more details, including the full description and speaker bio for each event.

Spring 2018 Series Flyer

Feb 15 date iconWhat’s the point of Michigan’s vaccine waiver education requirement?
Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions?
Wednesday, February 14, 2018
Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University.

March 14 calendar iconPain But No Gain: Pain as a Problematic and Useless Concept?
Do references to pain help us with anything, or should we perhaps abandon pain as a “useless concept?”
Wednesday, March 14, 2018
Marleen Eijkholt, JD, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine, and Clinical Ethics Consultant at Spectrum Health System.

April 11 calendar iconEthical Issues Related to Fundraising from Grateful Patients
How should the process of philanthropic development be structured in order to demonstrate respect for all persons involved?
Wednesday, April 11, 2018
Reshma Jagsi, MD, DPhil, is Professor and Deputy Chair in the Department of Radiation Oncology, and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan Medical School.

In person: These lectures will take place in C102 (Patenge Room) East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

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Episode 5: Public Perception of Psychiatric Interventions

No Easy Answers in Bioethics logoEpisode 5 of No Easy Answers in Bioethics is now available! This episode features guests Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, Dr. Robyn Bluhm, Associate Professor in the Philosophy Department and Lyman Briggs College, and undergraduate research assistant Rachel McKenzie. Together at Michigan State University they have collaborated on research regarding psychiatric interventions, including pharmacological interventions as well as neurosurgery, like deep brain stimulation. In this episode they share some highlights from their internally-funded Science and Society at State project, which focused on the public perceptions of such psychiatric interventions.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Three Cheers for the DNR Tattoo

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Tom Tomlinson, PhD

A Letter to the Editor published at the end of November in The New England Journal of Medicine excited a lot of comment and mass media coverage. The letter by Holt and colleagues, “An Unconscious Patient with a DNR Tattoo,” made the news throughout the U.S., and internationally.

This was treated as an unusual oddity, but DNR tattoos are a lot more common than one might think. Try searching for images of them. The first I heard of them was a news report in the late ’80s of an ICU nurse who had one done, to guard against a fate that had befallen too many of her patients.

DNR tattoos in Google image search results

Image description: a screen shot of Google image search results for “DNR OR “do not resuscitate” “tattoo”” captured January 9, 2018.

Acting on the advice of their ethics consultants, the University of Miami physicians decided to honor the tattoo and wrote a DNR order for the patient, but in the article they studiously avoided taking any position for or against DNR tattoos.

I think they were right to honor the tattoo, but maybe more timid than they needed to be on the general question. I’ll put up three cheers for DNR tattoos.

First, once I’ve got that tattoo, my advance directive goes wherever I go, always there when I need it. Unlike written directives, which are virtually never found in the ER, too seldom presented on admission, and often devilishly hard to get into the medical record for those patients who purportedly have one.

Second, unlike state-authorized advance directives, the DNR tattoo does not require anyone to witness my signature as evidence that the wishes expressed therein were indeed mine. Unless you imagine I was somehow unconscious or blind drunk when I got my tattoo, the wishes expressed thereupon are undoubtedly mine. And getting a witness for a state-authorized advance directive can be more difficult than it sounds, with all the people prohibited from serving under many statutes. Still, for the legally scrupulous among you with high pain tolerance, it may still be possible to have your DNR tattoo witnessed.

Third, “do-not-resuscitate” on the chest is no more ambiguous a directive than “do-not-resuscitate” in a written document. Neither of them provides a clue regarding the motivation for that instruction. What circumstances did the person have in mind at the time? What fate did they hope to avoid? Is the medical situation they are now in similar enough to what they had in mind? These may have been the “uncertainties” the University of Miami team had in mind when they initially decided not to honor the tattoo, deferring to “the principle of not choosing an irreversible path when faced with uncertainty.”

As I’ve just pointed out, these are not uncertainties unique to tattooed advance directives. Just as importantly, these are uncertainties that can be resolved by two factors that can tip the balance in favor of honoring the tattoo. First is knowledge of the circumstances in which the patient got the tattoo. Was it sometime during the course of a progressive, worsening illness? Then it is entirely reasonable to infer that the patient did not want to be resuscitated from the cardiac arrest waiting at the end of that decline. Second (and related) is prognosis. Given the severity of the patient’s condition, what are the chances of a successful resuscitation that at least might return them to their pre-admission baseline? If the chances are small, then consideration of their best interest does not carry enough weight to justify acting against the literal meaning of their tattoo. A little reading between the lines suggests that this combination of considerations is what persuaded the team at the University of Miami to honor their patient’s tattoo, just as it would have had the same directive been documented on paper.

Of course, there are some advantages to the paper version, and it would be irresponsible for me not to mention them.

First, unless I’m willing to tattoo a lot of skin, the paper version gives me the space I might use to elaborate on my preferences, not only about specific interventions, but more importantly about my goals, especially those outcomes I want to avoid.

Second, since the tattoo probably won’t meet the requirements as to form set under state statutes, it is an advance directive that won’t offer the liability immunities such statutes provide. Not an ethical objection, I note, but a powerful motivator for risk management departments to be more skittish than they need to be in most circumstances, making it less likely that my wishes will be honored.

Finally, a not inconsiderable factor favoring the paper version is the significantly lower risk of getting a nasty infection.

Looks like a virtual tie on paper, but on balance, I’m not about to toss out my paper advance directive for a tattoo. If I see one as an ethics consultant, however, I will give it very serious consideration.

Tom Tomlinson photoTom Tomlinson, PhD, is Director and Professor in the Center for Ethics and Humanities in the Life Sciences and Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Tuesday, January 23, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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Dr. Fleck co-authors ICU article in new ‘Cambridge Quarterly of Healthcare Ethics’

Leonard Fleck photoCenter Professor Dr. Leonard Fleck has a new article in the January 2018 issue of Cambridge Quarterly of Healthcare Ethics. The article, “First Come, First Served in the Intensive Care Unit: Always?,” was written by Dr. Fleck and Timothy F. Murphy.

Abstract: Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes.

The full text is available online through Cambridge University Press (MSU Library or other institutional access may be required to view this article).

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