4 - A NEW ERA OF HEALTH CARE: THE ETHICS OF HEALTHCARE REFORM

ACA 2010

: Major reform in U.S. healthcare system.

• Public Opinion: Divided — 43% favorable, 46% unfavorable (Dec 2016).

• Political Changes: 2016 election increased calls for ACA repeal.

• Public on Repeal: 47% opposed full repeal, 28% preferred to wait for a replacement plan.

• Key Issue: Lack of consensus on healthcare policy and social justice.

Act

= major healthcare reform

ACA 2010 and Health Care and Education Reconciliation

HEALTH REFORM IN THE UNITED STATES

Goal: Access to high-quality, affordable healthcare for all Americans.

1. Access

2. Quality

3. Cost Control

Reform focus in US:

1. Private insurance mandate

2. Government-provided services

3. Government-provided insurance

3 MODELS OF THE UNIVERSAL COVERAGE AND U.S. SYSTEM

(Bismarck Model)

Private insurance mandate

(Beveridge Model)

Government-provided services

(National Health Insurance Model)

Government-provided insurance

➢ Mixed system: private mandates (Massachusetts),

➢ Government-run (Veterans Health),

➢ Government insurance (Medicare, Medicaid).

U.S. System:

HEALTH SYSTEM REFORM IN THE U.S. (EARLY 20TH CENTURY)

• Global Context: Europe had wage-protection health insurance by early 1900s.

• U.S. Early Efforts: Theodore Roosevelt supported health insurance (1912).

• American Medical Association (AMA) initially supported, then opposed reform (1920).

Social Security Act (1935)

: Health insurance excluded.

National Health Act (1939)

: Proposed compulsory insurance, died in Congress

Wagner-Murray-Dingell Bill (1943)

: Proposed national insurance, never passed.

Truman's Proposals (1945–1948)

: Universal insurance plans proposed but blocked.

POST-WWII DEVELOPMENTS AND EMPLOYER INSURANCE

• Rise of employment-based insurance during/after WWII.

• By 1952: 50% of Americans had employer coverage; by 1980: 80%.

• 1954: Health insurance premiums made tax deductible

Medicare

: Coverage for seniors 65+.

Medicaid

: Care for low-income families.

REFORM ATTEMPTS IN THE 1970S–1990S

Focus shifted to cost control instead of expanding access.

Nixon (1971)

: Proposed employment-based universal coverage — failed.

Clinton (1993)

: Proposed National Health Security Plan — strong opposition, failed.

1. Greater access

2. Improved quality

3. Cost control

THE ROAD TO ACA 2010

Goals:

Medicaid Expansion

: States can extend Medicaid to people earning ≤133% of the poverty level.

Medicare Improvements

: Preventive care without copays; closing the "donut hole" in drug coverage.

donut hole

spend a large money first before the insurance helps

1. No denial for preexisting conditions.

2. No lifetime/annual caps.

3. Minimum insurer spending on care (80– 85%).

Insurance Reforms:

Insurance Exchanges

States or federal government provide marketplaces to shop for insurance

Quality Improvement

: Investment in comparative effectiveness research and value-based payments.

Healthcare Workforce Incentives

: Scholarships, loan forgiveness, and bonus payments for providers.

Funding

: New taxes (e.g., on high-income earners, insurers, and device makers), penalties, fraud prevention, and Medicare Advantage payment cuts.

2010–2011

: Young adult coverage (up to 26), no preexisting exclusions for children, small business credits.

2012–2014

: Claims standardization, Medicare payment changes, insurance exchanges open

2016–2020

: Full Medicaid expansion, taxes on "Cadillac" plans, Medicare Part D donut hole phased out.

Global Perspective:

➢ International agreements (e.g., Universal Declaration of Human Rights, WHO Constitution) recognize health care as a fundamental human right

American Ideals:

➢ U.S. Declaration of Independence implies health care as necessary for "Life, Liberty, and the pursuit of Happiness."

➢ Historically, 70%–89% of Americans support universal health care.

U.S. Declaration of Independence

implies health care as necessary for "Life, Liberty, and the pursuit of Happiness."

Religious Support

: ➢ Major religious traditions (Catholic, Protestant, Jewish, Muslim) affirm health care as a human right.

egalitarianism and market-based libertarianism

ACA represents a balance between

The U.S.

remains divided on whether healthcare is a right or a personal responsibility, fueling continued political debate.

Egalitarian/Rawlsian

Libertarian

Justice Theories

Egalitarian/Rawlsian

equality

: Policies like Medicaid expansion and subsidized exchanges align with the difference principle (benefiting the least advantaged).

Libertarian

freedom

: Elements like preserving individual choice and limited government intervention are also reflected (e.g., small penalties for no insurance).

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

THE PREAMBLE OF THE U.S. Declaration Of Independence

The ACA 2010 and H.R. 4872

have caused major shifts across all parts of the U.S. healthcare system.