Tag: Affordable Care Act

Incarcerated AND Sick: At Risk for Pain, Injury, and Death

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

By Karen Kelly-Blake, PhD

The U.S. project of mass incarceration reveals that more than 2 million people are jail-involved at any given time. That rate far exceeds that of any other nation in the world. Incarcerated patients are sicker, bearing an increased burden of chronic disease, namely addiction, viral infections, and mental illness. Conditions often exacerbated by solitary confinement. Moreover, those incarcerated are disproportionately from communities of color suffering from historical racial discrimination. Consider the following: Whites (non-Hispanic) comprise 64% of the U.S. population, 39% of the U.S. incarcerated population, and the national incarceration rate (per 100,000) is 450; Hispanics make up 16% of the U.S. population, 19% of incarcerated population, and the national rate is 831; Blacks are 13% of the U.S. population, 40% of the incarcerated population, and the national incarceration rate is 2,306 per 100,000.

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Image description: a black and white photograph showing a person’s hands reaching through from behind metal fencing. Their hands are grasping the fence in the foreground, and the rest of the person’s body is not visible. Image source: Tiago Pinheiro/Flickr Creative Commons

In the 1976 Estelle vs. Gamble ruling the U.S. Supreme Court established that “deliberate indifference to healthcare for inmates constituted cruel and unusual punishment, and was thus prohibited by the U.S. Constitution.” In April of this year, a class action lawsuit was filed in the State of Illinois arguing, “health care inside the Illinois Department of Corrections systematically puts inmates at risk of pain, injury, and death.” In effect, Illinois has been put on notice that the correctional health care it provides (or the lack of provision), violates the 1976 Supreme Court ruling. Of course, Illinois is not the only state faced with this problem. A recent ruling found the Alabama Department of Correction’s mental health care system to be “horrendously inadequate.”

The challenges to delivering health care in correctional institutions are similar to those experienced in delivering care in any under-resourced setting that serves vulnerable patients. Overcrowding and understaffing are oft-cited explanations for the inadequacy of correctional health care delivery. An additional, deeply concerning factor is the privatization of prisons with related underbids, cost overruns, and vast gaps in the actual services provided. With increasing numbers of women cycling in and out of prison, women prisoners have specific health needs related to the increased likelihood of being victims of domestic and sexual violence. There is a pressing need for correctional health care services to address these health issues.

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Image description: a close-up photo of the bars of a prison cell, with the bars in focus in the foreground and an empty green/yellow cell visible in the background. Image source: Dave Nakayama/Flickr Creative Commons

As a matter of justice, incarcerated patients should receive the same level of care that they would receive in a community setting. Unfortunately, this notion is not politically popular. Nevertheless, work is being done to merge correctional health and public health to ensure continuity of care once prisoners are released. Significantly, the Affordable Care Act (ACA) specifically addresses the importance of ensuring that the jail-involved have access to the same benefits as the non-incarcerated. The ACA expansion of Medicaid eligibility supplies a critical opportunity to treat prisoners once released. Untreated substance abuse and mental illness among the jail-involved increases their likelihood of future imprisonment.

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Image description: a close-up photo of part of a large metal door that reads “SOLITARY.” Image source: Shannon O’Toole/Flickr Creative Commons

Health care providers often find themselves serving two masters in correction settings. Providers have a duty to provide care that is in the best interest of the patient, but equally, they are also employed by the institution that has other, often conflicting interests, namely to confine, punish, and possibly, rehabilitate. This conflict is referred to as dual loyalty. The virtual societal silence on larger issues about the nature of the institution of incarceration is problematic and makes many correctional health providers “complicit as the United States has embarked on a vast and unprecedented social program of mass incarceration.” Given this state of affairs, providers should use their professional power and work to advocate for and insist upon substantial reforms in clinical care within prisons. A key critical reform is to eliminate solitary confinement. Medical providers also must advocate for change in the criminal justice system. The current project of mass incarceration in the U.S. harms the individual health of prisoners and the public health of the community.

Because of lawsuits or the threat of lawsuits on behalf of prisoners, as well as the dedication of committed health care professionals, activists, and advocates, the quality of health care in prisons has steadily improved. Yet there remains vast room for improvement in clinical care. Physicians hold leadership and management positions in correctional institutions. Combined with the social privilege afforded them in the U.S., physicians have the power, and I would argue the obligation, to spearhead reforms in correctional health care and ensure that the incarcerated sick are at no greater risk than the non-incarcerated of pain, injury, or death.

Karen Kelly-Blake photoKaren Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine 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 Thursday, August 10, 2017. 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.

More Bioethics in the News from Dr. Kelly-Blake: White Horse, White Faces: The Decriminalization of Heroin Addiction; Racism and the Public’s Health: Whose Lives Matter?; Concussion in the NFL: A Case for Shared Decision-Making?

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No More Death Panels; Politically-Assisted Suicide Instead

This post is a part of our Bioethics in the News seriesBioethics-in-the-News-logo

By Leonard Fleck, PhD

Republicans have not coalesced around any comprehensive proposal to replace the Affordable Care Act (though one is now on the table and intensely disputed). This has been named the American Health Care Act. At this writing (March 10) two congressional committees have approved a bill endorsed by Paul Ryan. It is expected to go to the full House this week where it will likely receive a much rockier reception from a number of very conservative Republicans who have derided the bill as “Obamacare Lite.”

For purposes of this commentary I will put aside internal Republican bickering. My goal is to call attention to the most serious ethical deficiencies in the bill as it stands now. I confess that Obamacare Lite does not sound too ethically problematic. Many Democrats would support some reform of the Affordable Care Act. A more accurate moniker (in my judgment) would be “Obamacare Stingy.” That comes closer to capturing the serious injustices inherent in the American Health Care Act (AHCA).

Anyone familiar with my published work knows I am a strong advocate for the view that health care costs need to be constrained, and this needs to be done justly and for the sake of justice in the overall allocation of health care resources. Further, I have argued that those who are medically least well off and capable of significant benefit from access to effective costly health care services have strong just claims to have those needs met. But this is precisely what the AHCA does not do.

Instead, the AHCA eliminates two taxes that Obamacare imposed on the wealthy to pay for the subsidies needed by the poorer uninsured to gain access to insurance. To be precise, the top 1% of income earners in the U.S. (those who earn more than $774,000 in a year) would receive a tax cut of $33,000 while the top 0.1% of earners would get a tax cut of $197,000. In order to reduce the burden on the federal treasury the new subsidies under the AHCA would be given as tax credits and reduced significantly from those provided under Obamacare.* Further, the tax credits would be age-related, not income-related. A 25-year-old would get a tax credit of $2,000 while a 60-year-old would get a tax credit of $4,000. If that 60-year-old earned less than $20,000 under Obamacare, he would have received $9,900 in subsidies for health insurance. The average 60-year-old will have 3.5 times more health care expenses than the 25-year-old. Under the AHCA insurance companies could charge the 60-year-old five times what they charged the 25-year-old, unlike Obamacare which limited that difference to a factor of three. The cost of insurance for that 60-year-old (the silver plan) would be about $18,000 under the AHCA, which would be essentially unaffordable. Instead of the notorious Alaskan “bridge to nowhere,” we would have “subsidies to nowhere.” This is where the most objectionable ethics issues lie: the creation of massive pseudo benefits that provide political cover for members of Congress but no health care coverage for patients with substantial health needs.

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Image description: a woman with white hair wearing a red shirt is displaying a sign that reads, “health care for profit is sick!” Image source: Sage Ross/Flickr Creative Commons

We must also mention that Medicaid funding would be reduced to the states, apparently through a per capita funding mechanism. Over a period of years, the share of Medicaid funding from the federal government would be reduced and the financial responsibility for “adjusting” would be left to state legislatures. The same might be true for high-risk pools for the uninsurable. Again, individuals faced with reduced subsidies would be forced to “freely choose” health plans with very high deductibles, high co-pays, and restricted benefits. This is “fig leaf” insurance, sufficient for political modesty, but insufficient for even modest health care coverage.

The common denominator among these items is reduced federal spending and the shifting of responsibility for making painful cost control (rationing) decisions to states, hospitals, physicians, and individuals. Congress thereby spares itself a Palinesque death panel fulmination. The reason this works is that there are numerous mechanisms for doing rationing invisibly, the most common of which is rationing by ability to pay.** The target for these efforts will be primarily those who are medically and financially among the least well off (not to mention politically powerless), such as our marginally employed 60-year-old above.

If individuals “freely choose” to not purchase health insurance (because it is unaffordable), or “freely deny themselves” needed care (because of high deductibles or co-payments), then responsibility for any bad outcomes (premature death) is widely dispersed among “irresponsible” individuals and effectively rendered invisible to prying media eyes. This is the logic embedded in Representative Jason Chaffetz’s (R-Utah) comment that people should “invest in their own health care instead of getting that new iPhone.” One individual responded that their $117,000 broken ankle was worth 234 iPhones.

A 2012 Families USA study concluded that 26,100 individuals between the ages of 25 and 64 died prematurely in 2010 as a consequence of being uninsured. Of course, the death certificates themselves would not have listed “lack of insurance” as the cause of death. These individuals would have died of their (untreated or undertreated) cancer or heart disease or diabetes, all natural causes, certainly unfortunate, but nothing that would capture any media headlines. These are patients who would have “refused” their life-prolonging $100,000 targeted cancer therapies or their $250,000 left ventricular assist device for their late-stage heart failure. That is what makes these outcomes politically invisible. Patients, apologists for invisible rationing will argue, made the choice to refuse these $100,000 cancer drugs “freely,” which is “better” (for whom?) than mandating and subsidizing their purchase of health insurance. Consequently, Congress and the President are shielded from charges of heartless rationing by a thick political “veil of (willful) ignorance.”

The ethical reality, however, is that this is politically-assisted suicide. If federal funding to the 31 states that have expanded Medicaid to 138% of the poverty level is reduced, and if state legislatures in those states are unwilling to raise taxes to support that former expanded funding, and if taxpayers fail to rise up in revolt and demand higher taxes for compassionate reasons, and if rural hospitals are forced to close because of the size of their uninsured patient base, and if anonymous patients die for lack of timely care and ability to pay, then who should be responsible for “assisting” those deaths?

Judge Neil Gorsuch has made it clear that he is profoundly ethically and legally opposed to physician-assisted suicide. He should be questioned closely at his hearing whether he is equally opposed to the politically-assisted suicides now in the process of being legalized by Republican legislation aimed at replacing the Affordable Care Act. Or will he plead that it is unreasonable to demand that he see what is in reality “invisible”?

Finally, President Trump has committed himself to supporting “universal access” to health insurance. In his tweets he should make clear that such access would be restricted to paytients, who alone seem to have the requisite visibility.

* Lest any of us who are securely in the middle class feel ethically superior to the rich beneficiaries of this tax giveaway, we should be reminded that we were the beneficiaries of $270 billion in tax subsidies in 2016, which reflects the value of the taxes we did not pay on our own health insurance provided by our employers.

** Invisible rationing is intrinsically unjust. The most central element of our understanding of just policies and practices is that they are public, visible, transparent, and available for criticism, most especially by those most directly affected. John Rawls, the philosopher, emphasizes this point in his book, A Theory of Justice. I have argued at length for that same point in the health care context in my book, Just Caring: Health Care Rationing and Democratic Deliberation (Oxford University Press, 2009), chapter 3.

leonard fleck photoLeonard Fleck, PhD, is a Professor in the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine and 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, March 28, 2017. 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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Bioethics for Breakfast: The Future of Medicaid and the Affordable Care Act: Ethical and Policy Challenges

bioethics-for-breakfastSteve Fitton and Jane Turner, MD, presented at the Bioethics for Breakfast event on February 2, 2017, offering perspective and insight on the topic, “The Future of Medicaid and the Affordable Care Act: Ethical and Policy Challenges.”

We assume that Republicans in Congress will follow through with their promise to repeal the Affordable Care Act. We also assume that there will be some sort of replacement. The expansion of Medicaid coverage represents just about half the increase in newly insured individuals. The proposal that seems to have the greatest likelihood of being enacted would include block-granting Medicaid. From the perspective of the federal government a block grant is a “fixed budget” as opposed to open-ended funding.

Our speakers discussed what this means for those who are dependent upon the Medicaid program for meeting their health care needs. For example, 31 states have expanded their Medicaid programs to 138% of the poverty level, and 95% of those additional costs are supposed to be covered by the federal government. Will those 31 states have those funds included in their block grant but have it denied to the other 19 states? Is it likely that the size of the block grant will be less than what Michigan would otherwise receive under the current funding mechanism? If the size of the grant is reduced, what sort of health care priorities will Medicaid use to determine the allocation of that more limited funding? What do we imagine might be the consequences for hospitals and or long term care facilities if funding is more constrained? These questions and more were addressed by speakers and attendees during the presentations and moderated discussion.

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Left to right: Jane Turner, Leonard Fleck, and Steve Fitton pose for a photo after the Bioethics for Breakfast event. Photo courtesy of the Center for Ethics.

Steve Fitton
Steve Fitton is a principal with Health Management Associates. He has extensive expertise in Medicaid financing, federal waivers and reinventing healthcare delivery systems. As Michigan’s Medicaid director, he oversaw a budget of more than $15 billion with programs that served over two million residents. Steve played a key leadership role in the approval and implementation of the Healthy Michigan program, the state’s expansion of Medicaid. Steve led the creation and implementation of several Medicaid programs and initiatives to improve access and quality of care while increasing efficiencies and lowering costs. He earned his bachelor’s degree from Michigan State University.

Jane Turner, MD
Jane Turner is a general pediatrician and professor in the Department of Pediatrics and Human Development. She enjoys all aspects of caring for children and youth and has a special interest in working with children who have chronic health conditions. She has served on the faculty of the College of Human Medicine for more than 20 years as a teacher, clinician, and administrator. Dr. Turner also works for the Michigan Department of Health and Human Services as assistant medical director of the Office of Medical Affairs and chief medical consultant for Children’s Special Health Care Services. She went to medical school at the Oregon Health Sciences University and completed a pediatric residency at Children’s Hospital of Pittsburgh.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

Bioethics for Breakfast: ACOs: Are They New or Just HMOs in Sheep’s Clothing?

bioethics-for-breakfastJanet Olszewski, MSW, and Ann Mongoven, Ph.D., presented at the Bioethics for Breakfast event on Februray 20, 2014, offering views on the topic, “ACOs: Are They New or Just HMOs in Sheep’s Clothing?”

The Affordable Care Act (“ACA”) and many contemporary health policy analysts promote the development of Accountable Care Organizations (“ACOs”) as a desirable change in the health care delivery system and insurance landscape. They believe ACOs will be able to increase health care value by simultaneously improving quality and lowering costs. Currently, Medicare demonstration projects initiated by the ACA are developing ACOs, while private payers are also experimenting with them, including “the Blues” in Michigan.

Accountable Care Organizations have been introduced as a new attempt to integrate finance and delivery systems, develop global budget targets for regional populations, improve quality and efficiency of care through increased coordination of care and better align financial reward with efficiency and value of care provided. That set of goals is quite similar to those set forth when Health Maintenance Organizations (“HMOs”) were introduced last century. The speakers examined the history and evolution of HMOs, assessed the extent to which ACOs resemble HMO health financing and delivery schemes, and explored ethical tensions embedded in new ACO configurations.

Janet Olszewski, MSW
In her current role as Principal of Health Management Associates, Ms. Olszewski assists institutional clients with strategic planning related to health reform. Formerly, she was the Director of the Michigan Department of Community Health during the Granholm administration (2003-08). While director, she oversaw the development of a new Medicaid managed care program and a patient-centered medical home initiative. Ms. Olszewski spent more than 23 years working for the State of Michigan in various capacities. She is also a former Vice President of M-Care, a health plan owned by the University of Michigan.

Ann Mongoven, Ph.D.
Ann Mongoven is an assistant professor in Michigan State University’s Center for Ethics and Humanities in the Life Sciences and Department of Pediatrics. She is the author of Just Love: Transforming Civic Virtue (Indiana University Press, 2009). Her research interests are in public health ethics. She directs a multi-faculty health policy course for MSU medical students.

About Bioethics for Breakfast:

In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

Should Women Pay More for Health Insurance?

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Leonard M. Fleck, Ph.D.

In a recent commentary in Time (Aug. 23, 2013), Hadley Heath argued that women ought to pay more for their health insurance than men. Fairness, she contended, required this. She was criticizing the requirement of the Patient Protection and Affordable Care Act [PPACA] that prohibited unequal insurance premiums for men and women. There seemed to be two primary reasons for her view: (1) Women live longer than men; (2) Women consume more health care than men. I will start by accepting both these statements as factually true. But I find deeply problematic the normative claim that women are not paying their fair share of health care costs.

Behind Ms. Heath’s normative conclusion is a premise for which she offers no argument. If I buy a more luxurious car, a larger home, or finer wines, then I ought to pay more for these goods than individuals who are content with a used Chevy, a 1000 square foot ranch home and Boone’s Farm. If I consume more health care because I have colorectal cancer and late-stage heart failure, then I ought to pay more for my health care than someone with a broken arm from falling off their polo horse. That is, needed health care should be thought of as just another consumer good, not as anything morally special. If someone wishes to use more health care, then they ought to pay more for that health care.

The wording in that last sentence ought to get our attention. Who is it who “wishes” to use more health care for their cancer and heart disease? Do I wish to use more health care in the way that I wish to have a second piece of turtle cheesecake? The very asking of the question makes manifest its absurdity. I need health care for my cancer or heart disease unless I am willing to accept a premature and painful death. This is what motivates us to think of needed and effective health care as being morally special instead of as just another consumer good to be distributed in accord with desire and ability to pay.

There is another unstated principle in Ms. Heath’s essay that is even more morally troubling than my first point. It is that those who use more health care, or are likely to use more health care, ought to pay more for that health care (or be denied it.) At any point in time the vast majority of women in our society are in excellent health, so it seems there is something silly about this whole debate. However, a large fraction of the uninsured and uninsurable in our society have that status because they have (or are likely to have) very costly health problems which insurers will not cover or for which insurers will charge unaffordable premiums. This is not a silly or trivial problem. At the moral core of the PPACA is the rejection of the idea that individuals with greater health needs must pay for their health care in proportion to need. That is the principal Ms. Heath is really attacking. Women are being used by her as a Trojan horse for attacking the moral fortress of the PPACA.

Finally there is the issue that women live longer than men on average. Again, the principle seems to be that if one lives longer, then it is assumed (maybe falsely) that one will use more health care during those extra elderly years. If that is the principle, however, then there is no good reason why women alone should bear those extra insurance costs. Rather, all persons who can be reliably predicted to achieve greater than average life expectancies ought to be saddled with extra insurance costs. This is hardly the sort of message we would want to give to citizens whom we are encouraging to make healthy lifetime choices for a longer life. The predictable outcome of such a message would be that economical men would rationally choose to spend yet more time watching sports on TV and guzzling beer while gulping down burgers and brats. Does that yield the logical conclusion that women should be charged more for health insurance?

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Leonard FleckLeonard M. Fleck, Ph.D., is a Professor in the Center for Ethics and Humanities in the Life Sciences at Michigan State University and the author of Just Caring: Health Care Rationing and Democratic Deliberation.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Friday, October 11, 2013. 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.