Ethical Issues and Obamacare

1. Ethical Issues and Obamacare Stuart Sprague, HEC-C

2. Is there a right to healthcare? • What is a right? • Natural rights • Life, liberty and the pursuit of happiness (security of person) • Social contract rights • Bill of Rights • Social structures • What is healthcare? • Services needed to maintain health • Wide spectrum of options • Requires decision by some person or administrative decision

3. Not a binary question for all (Yes or No) • Healthcare not a natural right • Could be connected to a right to life and right to happiness • Social contract rights of two kinds • Negative rights • Freedom from interference • Freedom of speech • Freedom of religion • Positive rights • Provided to all • Right to vote • Right to an education • Should healthcare be included? • We have said Yes and No • Yes to some people and not others • Yes to some services and not others

4. We live in a mixed system • Some people have a right to some healthcare • Senior adults over 65-Medicare • Disabled-Medicare • ESRD patients needing dialysis • Active military and those eligible for VA benefits • Prisoners • Some of the poor, especially children, pregnant mothers, elderly nursing home residents-Medicaid • To determine for whom and what is available • Some method for allocation decisions required • This means politics

5. Obamacare-a.k.a. The Affordable Care Act • Begins with the premise that healthcare should be available to all • Realized that a single system of medicine for all would not be passed • Settled on a mixed system • Began with idea that all could keep what the currently have • Employer based plans • Medicare, Medicaid, other plans offered by public entities • Private insurance and private pay • Those without currently would be added to Medicaid or subsidized to purchase private insurance if needed.

6. Obamacare-a.k.a. The Affordable Care Act • Several provisions which added a moral dimension • All citizens had to be covered by some plan • No penalty for pre-existing conditions • Relied on a mixture of private and public funding • This was a boon to insurance companies • Those two funding mechanisms have different moral footing • The poor are included • Lowest income covered by Medicaid expansion for all in that category • Lower income covered by direct monthly subsidy for premiums based on a sliding scale

7. Moral Issues • Whether there is a right or not, some system of allocation required • 1. Socialized medicine-government owns facilities and employs doctors • 2. Single-payer system-government collects resources and pays private doctors and facilities-(Medicare for all) • Administration (allocation) needed but consumes small fraction of premium • 3. Health resources are allocated to private individuals by a market system • Risks of high costs addressed by spreading risk through private insurance • Administration, executive salaries, and profit for shareholders (limited to 20% of premiums collected under ACA, not previously limited) • We currently have 2 and 3, but not 1

8. Moral Issues • The ACA was designed as a single entity with all its pieces working together to make a moral statement about all having access to healthcare. • When any one piece of the puzzle is removed, it changes the moral dynamics. • Congress and the courts have not removed the ACA as a unit. • They have removed parts one at a time • First was the provision of Medicaid for those with the lowest income. It was made optional by state • Second was the provision that all must participate in some plan for coverage • There is debate about removing the assurance of coverage for pre-existing conditions

9. Moral Issues • The overarching issue is whether there is a positive right to healthcare • If so, the social order (government?) is obliged to provide the resources • The method of allocation most efficient and least expensive would seem to be called for • We have not been able to settle that debate in the U.S., leaving us with a mixed system. • The dismantling of the ACA has raised additional moral issues • The failure of some states to accept Medicaid expansion • The removal of the mandate for all to participate in the system • The removal of the obligation to cover those with pre-existing conditions

10. Moral issues in Medicaid expansion • The failure of some states to accept Medicaid expansion is based on a Supreme Court decision. • Variation among the states creates a double standard. Some citizens have rights that others don’t. • States which declined based that on arguments similar to those of other items of the “safety net” • Persons who lack the resources to pay for health care are in that condition because of poor personal choices (moral failure,) and government has no obligation to provide • The poorest are left with the greatest burden while others slightly less poor benefit from subsidies to pay for private insurance. • Choices made by others, e.g. employers, often dictate who will have insurance coverage

11. Removal of mandate to participate • Original ACA required all to participate in some health insurance plan • Intent was to distribute risk in a just manner • Objection raised was that all were being “forced” to buy a commercial product, private insurance • Failed to see it as a communitarian obligation to share the burden • Had it been a system of taxation it would have had a different moral sense • Not necessarily more popular, but coercion of a different sort • 20% margin above premiums collected for administration, salaries, and dividends seemed an unfair advantage for insurance companies • Congress succumbed to political pressure and removed mandate

12. Pre-existing conditions • Allowing all to participate at the same price, regardless of chronic illness based on a communitarian sense of sharing risk justly • Insurance companies bargained to not count pre-existing conditions if all required to participate • System not economically viable unless both requirements in place • One requirement is politically popular, while the other is not • Pre-existing conditions arise from different sources • Natural lottery-sickle cell disease and glioblastoma • Human choices-poisoning from agent-orange and lead pipes in Flint, MI • Personal choices-Obesity, Type 2 diabetes, alcoholism • Should they be treated differently?

13. Where to go from here? • As Donald Trump said, “Healthcare is complicated.” • The ACA was conceived as a single piece with complex components • The political debate has led to piecemeal critiques and changes • The system does not work well in this manner • Objections based on personal animosity to or personal affinity for “Obamacare” • Many critics (and supporters) do not understand how it works or how it fits together • No calls to repeal it wholesale have proposed a viable alternative

14. Where to go from here? • Positive rights are under attack as a general category • The right to vote manipulated by gerrymandering and suppression • The right to an education undermined by withdrawing from public education • The right to healthcare undermined by a complex political process • Healthcare treated as a commercial commodity leads to reliance only on the market as a means of distribution • Can corporations (insurance companies) allocate with a conscience or only on the basis of a bottom line for shareholders? • Is a government system of allocation potentially better?

15. Where to go from here? • Markets are necessary for the creation of wealth • They are the most efficient means of distributing many goods and services • Children’s toys, automobiles, electronics, recreation, and a host of others • They are not well suited to allocate some goods and services for which the community senses some obligation to share • Education, Healthcare, Infrastructure, Mutual Defense • The remedy is to develop a communitarian vision in which the market plays a role in some decisions (How many and what kind of sterile gloves do we need?) and not others (Should we require pre-existing conditions to be covered?)

16. Where to go from here? • We lack a common moral framework on which to base a health system • Countries which have a system of healthcare for all have a large enough consensus on which to base the political decisions • Our debate has been primarily a political one based on vested interests • Insurance lobbyists have persuaded the Congress to retain private insurance as a major player • The Supreme Court entered a political, not a moral, debate by deciding not to require Medicaid expansion. • Congress made a political decision to remove the mandate for all to have insurance while maintaining the requirement for coverage of pre-existing conditions • Moving the conversation from the political to the moral realm would be a positive step in the right direction.