Opinion: House Approves Bill that Defies Basic Standards of Medical Ethics

by Michael S. Dauber

On May 4th, 2017, the Republicans in the U.S. House of Representatives voted to pass the American Health Care Act, an Act that, if enacted into law, would repeal and replace many central elements of the Affordable Care Act, commonly known as Obamacare. The measure has received widespread criticism from many Democrats and from professional medical associations such as the American Medical Association and the American Cancer Society. Many people have questioned various parameters of the bill. This article questions it from an ethical perspective, and in particular, the potential consequences of abandoning health care protections designed under Obamacare to ensure that the most vulnerable people in society receive the care that they need.

The American Health Care Act would strip away protections that have facilitated access to care for pregnant women, patients with disabilities, patients that cannot otherwise afford health care, and patients with pre-existing conditions. While any attempt to discriminate against the sick and needy is unjustifiably wrong, the Act appears to directly target members of groups that are defined as most vulnerable and in most need of protection under most formulations of ethical practice.

For example, the Act would allow states to opt out of Obamacare requirements that prohibit insurers from charging patients with pre-existing conditions higher premiums for health insurance. It further classifies pregnant women, women who have had C-sections, and victims of domestic violence and sexual assault as patients with pre-existing conditions. It also targets elderly patients by allowing insurers to charge elderly patients up to five times as much as members of younger age brackets. Currently, under Obamacare, insurers cannot charge the elderly more than three times the amount they charge younger patients. The Act also includes plans to gradually eliminate $880 billion in Medicaid funding over the next ten years, funds that could have otherwise been utilized to extend coverage to low-income families.

In short, the Act specifically targets some of the most vulnerable members of society who might suffer immensely without health care and who may not be able to afford to pay the costs that many insurers may demand, or may be unable to pay for other essential expenses after paying their insurance premiums. Ahead of the vote in the House of Representatives, Senator Bernie Sanders called the Act “an abomination” and, in a CNN interview with Anderson Cooper, Sanders said, “thousands of Americans would die because they would no longer have access to health care.” Proponents of the Act argue that it is engineered to reduce the burdens of health care cost on the government and on insurers. Yet, the overall effect will be a higher cost for patients. Many patients will suffer and will lose their access to care because of circumstances beyond their control.

In this regard, the Act conflicts with basic principles of contemporary bioethics.  For instance, the Belmont Report (1979), as a blueprint for ethics in human subject research, stresses the importance of respect for the “dignity of persons” while ensuring protections in accordance with justice. The Belmont Report, though focused on ethics in human subject research, has become a defining document in the history of medical ethics, establishing a system in which patients must be respected and special protections must be given to members of vulnerable populations. If a patient falls into a protected class, health care providers have an ethical obligation to ensure that the patient receives the care he or she needs and that the patient is not denied care solely on the basis of disability, economic status, or prejudice against specific medical conditions.

There is an apparent conceptual link between commitment to protecting vulnerable populations in the clinical and research context and commitment to ensuring that vulnerable populations have access to care. The American Health Care Act has not yet become law. It must first obtain approval in the Senate and be signed by the President. Most recently, the Senate decided to modify the bill before voting on it and, as a result, the bill must be sent back to the House for a second vote. As the Senate prepares its own version of the bill, government officials should recognize that a policy that effectively precludes access to health care for members of vulnerable populations is unethical by virtually every principle of medical ethics.

New Genetic Testing Bill: Potential for Progress or Potential for Discrimination?

According to a recent article published in The Atlantic, the House Committee on Education and the Workforce recently approved H.R. 1313, a bill that would allow employers to pressure their employees to undergo genetic testing and share the results as part of an employer’s “workplace wellness program.” If an employee opts not to share the results, he or she could be forced to pay significantly more for health insurance.

Proponents of the bill note that it simply builds on programs already in place from the Affordable Care Act; however, critics are worried that the bill will take away many of the privacy, discrimination and insurance protections of the Genetic Information Non-Discrimination Act (“GINA”).

From The Atlantic, “The GOP’s New Bill Would Seriously Disrupt Genetics Research”

Excerpt from article:

“‘People are already being discriminated genetically without mandatory genetic testing—that’s what sexism and racism is . . . . This [bill] would result in a higher resolution of discrimination and more individualized ways of targeting people.’ The dark mirror of personalized medicine is personalized discrimination.”

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Is Medicaid Expansion Good for State Economies? A Michigan Case Study says so.

In 2017, the federal government is expected to cover 95% of Medicaid costs in states that have expanded their Medicaid programs pursuant to the ACA.

One study in Michigan highlighted three major trends: decreased state level spending on health services, increased economic activity in areas such as construction and retail services, and increased spending in consumer goods (the less Medicaid recipients spent on healthcare costs, the more they spent on other items).  Although the researchers concluded that the expanded Medicaid program benefited Michigan, the study did point to some potential limitations including new spending that actually results from cost shifting from states and consumers to the federal government.

From The New England Journal of Medicine, ” Economic Effects of Medicaid Expansion in Michigan”

Excerpt: “Similar economic benefits are almost certainly accruing to the other 30 states that have expanded Medicaid, but not to the 19 states that haven’t done so. State policymakers can consider these benefits along with health and financial effects for enrollees as they decide whether to continue or initiate Medicaid expansion.”

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The New Trump Presidency Brings Uncertainty to the Health Care Industry

As one of his first items of business after taking the Oval Office, President Trump signed an executive order “instructing federal agencies to grant relief to constituents affected by the Affordable Care Act.”  In an already unstable market, this order leaves many questions unanswered, not only for states and other lawmakers, but also for consumers, medical professionals, and insurance companies. Senate Republicans insist that they are working with the Trump Administration to ensure “an orderly process.” However, without a replacement plan in place, many stakeholders are concerned that several insurance companies will leave the state health insurance exchanges by 2018, and Trump’s executive order will result in anything but an “orderly” transition away from Obamacare.

From The Washington Post, “With executive order, Trump tosses a ‘bomb’ into fragile health insurance markets”

Excerpt from article:

The political signal of the order, which Trump signed just hours after being sworn into office, was clear: Even before the Republican-led Congress acts to repeal the 2010 law, the new administration will move swiftly to unwind as many elements as it can on its own — elements that have changed how 20 million Americans get health coverage and what benefits insurers must offer some of their customers.

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Will the Threat of Decreasing Insurance Participation in ACA Exchanges Require Government Intervention?

United Healthcare, the largest health insurance provider in the country, recently announced that it is considering the possibility of ending its participation in the healthcare insurance exchange networks established under the Affordable Care Act.   According to UnitedHealthcare, the company’s earnings are down, due, at least in part, to its participation in the exchange networks and, as a result, the company will, at the very least, decrease its marketing efforts in connection with the networks.  While United Healthcare is the largest insurance provider yet threatening to pull its plans from the exchange programs, more than a dozen smaller health insurers have already dropped out of the programs, having previously covered approximately 800,000 individuals.

Experts opine that if this trend continues,  the lower number of plans available to consumers on the exchange networks could defeating the goals of the Affordable Care Act.  State and federal governments may be forced to intervene to ensure the continued viability of the exchange networks. Such invention could include a federal insurer bailout program, making participation on the exchange a prerequisite to offering plans elsewhere in the state, or mandating that private insurers offering insurance through Medicare and Medicaid offer plans on the exchanges.

Sources: http://www.forbes.com/sites/merrillmatthews/2015/11/30/will-the-government-force-health-insurers-to-sell-in-obamacare-exchanges/

http://www.hngn.com/articles/152202/20151119/unitedhealthcare-considers-quitting-obamacare-cites-unsustainable-conditions.htm

A Medicaid Card Does Not Necessarily Mean Access to Healthcare

Since the implementation of the Affordable Care Act (“ACA”), millions of Americans have enrolled in Medicaid. However, the government has not ensured that the new beneficiaries will have access to doctors. In fact, many Medicaid recipients are finding that they have to wait months due to shortages of doctors who accept Medicaid. Daniel R. Levinson, the inspector general of the Department of Health and Human Services, blames the lack of access on variations in standards between states. More specifically, most states rely on private insurance companies to comply with Federal rules in providing Medicaid beneficiaries with “adequate access to all services covered.” However, “adequate” is defined by each state. Some states opt for a “time and distance” standard for access, others set a maximum number of days a patient may have to wait to see a doctor, and some base the standard on a doctor/patient ratio. The result has left many Medicaid patients waiting up to 60 days to see a specialist, while others are forced to travel great distances because their state only requires one primary care provider for every 2,500 beneficiaries.

Mr. Levinson believes that the federal government should be more involved in developing and enforcing state standards of access. However, insurance companies worry that if the federal government forces a larger pool of doctors who accept Medicaid, it will upset the low premiums resulting from insurers limiting access.

Read more here.

Cyber Attack Implants a “Malicious Code” within Healthcare.gov

According to an anonymous source working for Health and Human Services, a “malicious code” was inserted into the healthcare.gov website in July. The website contains personal information about millions of Americans who purchased health insurance following implementation of the Affordable Care Act. Although it appears that no personal information was compromised, the hacker bypassed the website’s security in an attempt to control the website during future attacks, raising concerns about the website’s vulnerability.

Read more here.

Doctors Stop Offering Costly Immunizations

The Affordable Care Act mandates that childhood immunizations be covered at no “out-of-pocket” cost. However, many people are finding it difficult to receive immunizations because doctors have stopped offering them. This is due to the high cost of vaccines and the poor reimbursement from insurers. For example, Prevnar 13, which prevents pneumococcal bacteria diseases, has increased in price at “an average of 6 percent each year” since 2010.  Currently at $136 per dose, many states require children receive up to four separate shots of Prevnar 13. Because of this, more and more doctors feel that they are left with little choice but to stop providing immunizations.

Read more here.

Government Questions Eligibility for Health Insurance Subsidies

Since June 1st, hundreds of thousands of people have been contacted by the government regarding their eligibility for subsidized health care.  Of the eight million people who signed up for healthcare through the government exchanges, two million provided information that differed from information in government records. The Obama administration has been asking those individuals for additional documentation such as birth certificates, social security cards, and driver’s licenses.  The government will use the documents to correct irregularities in areas including income, citizenship, and immigration status.  Consumer advocates worry that many people who fail to provide the information will be forced to repay the subsidies next April.

Representative Diane Black, Republican of Minnesota, attributes the problem to the government’s having enrolled people “before the systems were in place to accurately confirm eligibility.” Others such as Representative Joseph Crowley, Democrat of New York, say such criticism stems from Republicans’ “unending zeal to undermine the Affordable Care Act.”

In any event, the government has put thousands on notice that they “need to follow up as soon as possible” and if they don’t send the needed documents, they risk losing their marketplace coverage.

Read more here.

Many Professional Investors are Flocking to Health-Care Stocks

The Affordable Care Act coupled with the aging baby boomer population has caused some professional investors to begin looking into Health-Care stocks.  They believe industries related to medical devices and pharmaceuticals will see large upticks in their stock because the Affordable Care Act has brought more customers into the market.  However, some investors are weary about focusing too much attention on the Affordable Care Act when there is a growing global market. Others fear that the Affordable Care Act may actually cut into the medical industry’s profits making health-care stocks a bad pick altogether.

Read more here.