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.

Making Health Insurance More Portable: GOP’s Plans for Insurance

In an article dated February 28, 2017, the author discussed a GOP plan to make health insurance more portable by allowing consumers to take their plans with them if they move, retire, or change jobs.  Although a popular idea for many, it does present some structural concerns due to the  setup of insurance markets and networks.

From NPR, “What If You Could Take It With You? Health Insurance, That Is”

Except from the article:

“To be truly portable, consumers must be offered plans regardless of their health status, age or other considerations. Before the health law was enacted, insurers could reject people with medical conditions. But the ACA prohibits insurers from redlining sick people or charging them higher premiums. Although popular in opinion polls, those Obamacare provisions may face some changes under the GOP plans.”

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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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Federal Rule Blocks Many Rehabilitation Facilities from Treating People Covered Under the Affordable Care Act

The Affordable Care Act (“ACA”) allows states to expand Medicaid to cover more low-income individuals, as well as cover alcohol and substance abuse treatment programs. However, a Federal rule enacted half a century ago prohibits Medicaid coverage for “community based” rehabilitation facilities that have more than 16 beds. As a result, many facilities are unable to provide treatment to the increased number of individuals now eligible for substance abuse treatment under the ACA’s Medicaid expansion. Although some facilities have sacrificed beds to fit within the guidelines and others have simply absorbed the cost of taking in more patients, only Congress has the power to change the rule to provide Medicaid coverage for larger treatment facilities.

Read more here.

Closely Held Corporations Are Not Required To Pay For Contraception

The Supreme Court recently held in Burwell v. Hobby Lobby Stores, Inc. that the Department of Heath and Human Services (“HHS”) could not require three closely held corporations to provide health-insurance coverage for “methods of contraception that violate the sincerely held religious belief’s of the companies’ owners.”  Justice Alito’s opinion stated that such regulations violate the Religious Freedom Restoration Act  (“RFRA”) of 1993 by creating a substantial burden on the free exercise of religion.  The Court’s 5-4 decision rejected HHS’s argument that owners of a corporation forfeit RFRA protections.

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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.

Health Care Debate in Florida Veers Off the Beaten Path

Florida is one of the twenty-four states that declined to expand their Medicaid programs.  As a result, approximately 760,000 Florida residents who would qualify for Medicaid under an expanded Medicaid program do not qualify so qualify. In addition, these residents do not qualify for federal subsidies to help them purchase health insurance. Recently, some Florida legislators honed in on an obscure provision in the Affordable Care Act, which allows low-income documented immigrants to qualify for federal subsidies in order to buy health insurance. The legislators intend to publicize this information in an effort to get the Medicaid expansion approved during the next legislative session. Republican state Sen. Rene Garcia of Hialeah stated that the issue is one of “fairness,” and not immigration.

Read more here.

Denver Nuns Reject Any Participation in Providing Contraceptive Coverage

Though churches and other places of worship are exempt from the Affordable Care Act’s (ACA) requirement that insurers provide birth control coverage, institutions with religious affiliations that provide services to the public are not exempt. Health plan administrators for these institutions must provide birth control coverage to employees. However, religious groups may sign a government form objecting to the coverage and submit it to their health plan administrators, in order to “distance” themselves from perceived violations of their religious tenets. A group of nuns, the Little Sisters, run a nursing home in Denver, and they object to this compromise. The nuns maintain that signing the form makes them “complicit in providing contraceptive coverage.”

The case now awaits a decision in the 10th Circuit, which will determine whether the Little Sisters must provide contraceptive coverage under the ACA. While the appeal is pending, the Supreme Court has dictated that the nuns do not have to sign the government form objecting to the coverage. Instead, the Court requested that the Little Sisters make their objection in writing to the Department of Health and Human Services, and do not need to provide copies to the administrator of their health plan.

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Health Care Providers Demand Payments Prior to Treating Patients

As health care deductibles rise, some health care providers are demanding that patients pay either a portion of their deductible, or, in some cases, their entire deductible prior to being seen or treated. Hospitals claim that, in order to survive financially, they must charge patients prior to treating them. The hospitals assert that it is much more difficult to collect on patient debts after the patients have received treatment.

Read more here.