The case for: a leading American bioethicist defends the Obama Administration’s proposals as fairer, cheaper and more trustworthy.
What is the system now?
The current United States healthcare system can be summarized in a few words: under-performing, over-priced, and inequitable. Unlike the UK or Canada, the US has for a large employer-based healthcare system, which means that many -- children and adults -- receive healthcare benefits via their employer. The remainder receives benefits from three other government sponsored programs: Medicaid (for those of a socioeconomic status too low to be able to afford to pay for health insurance and do not qualify for employer-based insurance) and Medicare (for those over the age of 65) and the Veterans Administration system. There are a few other categories of individuals who qualify for these government programs including the chronically disabled, etc, but this is it in a nutshell.
So if I had to add a fourth word to describe the United States healthcare system I would use: potpourri; and I don’t mean the good smelling kind. I mean a mish-mash of systems and providers. Worst of all, when the United States has an unemployment rate of 9.5 percent as of October 2009, this adds another nearly 10 percent of people who cannot receive insurance via their employer. This is where an employer-based system of providing healthcare coverage breaks down.
There must be another way. Millions of Americans are using COBRA (short-term gap coverage for recently terminated employees offered by employers) now subsidized by the government now under ARRA, plus Medicare, plus Medicaid. Thus, the public option so hated by critics of reform is doing quite well, thank you, IS effectively providing health insurance for a HUGE proportion of the nation. Failing to extend insurance options to the rest of the American 45.7 million Americans is a true moral failing.
What will the new system probably look like?
The "new system", most commonly known as the "public option", scares many people because critics have obscured the fact that most Americans use government sponsored healthcare -- including everyone in Congress.
However, in fact the current proposal passed by the House of Representatives this past Sunday simply adds one more option to what everyone has. There will still be private insurers; patients will still be able to choose whatever doctors they want. Choice will still be a huge part of the "new system."
"So what has changed?" one might ask. The federal government is guaranteeing that there will be a federally run insurance program that will be available to all Americans, the same insurance program that Senators and Congressmen use, and it will allow an additional 90 percent or more of uninsured Americans to have access to health insurance. This program is most likely to be utilized by the young who cannot afford insurance premiums in the earliest years of their careers and the working poor who cannot afford premiums or who are not offered insurance in their jobs. The program will compete directly with private insurers, hopefully driving prices down, and creating greater competition in the healthcare market -- something all free market capitalists love! This could result in a reduction of premiums by 25 percent within the next 5 years. Yet private insurance plans will still exist and will still be available just as they always have been -- so the employer-based insurance system we know and some love will persevere.
This system would allow for public provision of health insurance options with the provision of care from any provider patients choose. This kind of system would put us in very good company. Canada, Western Europe, Japan, Australia, New Zealand and Taiwan all do it -- and with far better health outcomes and far less healthcare spending.
Is the fear over Obamacare "death panels" exaggerated?
I mean, come on, "death panels"? When I first heard this expression, I assumed that the Grim Reaper would be one of the committee members.
Then I read the ridiculous stories about how Ezekiel Emanuel wanted to kill my grandmother, I laughed out loud. Anyone who ever has even met Zeke knows that he’s an oncologist by medical training and would prefer that people NOT die of cancer, for one, or anything else for that matter.
Second, his argument -- —which is actually quite sound -- simply says that we have to allocate effort to different cases according to those who will receive the most benefit from the care we give them. This is the nature of rationing, which all healthcare systems have. So tough choices have to be made in situations when there are scarce resources. But on these panels, no one is going to make decisions about individuals. No one is going to say, "Washington is calling. It’s time to turn off Grandmother’s ventilator. She’s costing the public health insurance plan too much money."
Americans have to trust someone to make the big decisions. For more than 40 years they have trusted private insurance companies, whether they have been aware of it or not, to make the decisions about whether Aunt Sue gets that angioplasty or that new drug. It really isn’t the doctor. Doctors recommend; insurers approve. Anyone who has ever received a denial letter from an insurance company knows that.
So the question is whether Americans are willing to trust the United States government to set the healthcare budget and provide a third way to have access to healthcare for all, reduce overall healthcare spending, and hopefully over the long term improve healthcare outcomes.
I can’t see how we can do worse than we are doing now. I really can’t.
Can you trust members of the ethics committee to treat patients with dignity?
Healthcare professionals treat patients with dignity, not government panels. They take their needs and interests into account. But it is doctors who provide the care, not health policy advisors.
In the context of health reform, it is the job of policy analysts and health advisors to ensure that the system will provide the well, the sick and the dying with adequate care.
Much ado has been made of President Obama’s "Independent Medicare Advisory Panels", but I would happily put Harvard’s Atul Gawande MD and the National Institutes of Health’s Ezekiel Emanuel MD, PhD in a room with former Governor and vice-presidential candidate Sarah Palin and let them duke it out over health reform any day and let the chips fall where they may. They have two MDs and one PhD on their side; she has rhetoric and a moose gun.
Yet, Palin tries -- and fails. She has supported reimbursement for time spent counseling for living wills and advanced directives (even though the latter do not work); it’s the prior conversations between loved ones and the dying that matter, not the piece of paper
Yet Palin’s attacks upon the (imaginary) pro-euthanasia bioethicists are clear. When talking about "Obamacare", she has described it as a "system [that] is downright evil". She refuses to accept a healthcare system where her parents or her child would have to stand "in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society' whether they are worthy of healthcare".
Yet I wonder what Ms Palin (and others who support her view) find more morally reprehensible: leaving 47 million Americans without any access to health insurance AT ALL or creating a government panel that would make decisions about how much care would be given to which Americans, all of them having had access to health insurance over their life span.
And yes, Ms Palin, that might mean that your aging parents might not get that third bypass surgery or that state-of-the-art hip replacement over providing well care for all children. Or is it "downright evil" in your view to leave the most productive members of our society -- the chronically underinsured or uninsured Americans aged 18 to 34 -- without access to affordable healthcare coverage? I wonder, is she or anyone else okay with leaving young women to die because they are unmarried and uninsured?
Generally, though, I am more sanguine than most about the ability of ethics committees or commissions to make good decisions about what should be done in terms of making policy. I think what patients don’t realize is that most decisions about what kinds of care and what procedures are covered and in what amounts, about what percentages of procedures are paid versus unpaid, and about the reasons for all this, are actually done by committees. But in the current system, it’s all done behind closed doors inside meetings of actuarial scientists and executives at pharmaceutical benefits companies and insurance companies.
So let me ask you this.
Would you rather have your healthcare decisions made out in the open as part of public debate by a public committee comprised of ethicists, public members, politicians, health policy analysts and others who specialize in making these kinds of decisions on a large scale to save taxpayers money -- or by the (much more) self-interested persons who work for the companies who have a bottom-line to make for their pharmaceutical benefit management company, insurance company and its shareholders?
For my money (and my health), I’d opt for the public panel any day.
**Thanks to Myra Christopher and Arthur Caplan for comments on previous drafts of this post.
Summer Johnson PhD is Executive Editor of the American Journal of Bioethics, AJOB Neuroscience, and AJOB Primary Research. She blogs at the AJOB Editors' Blog.