Showing posts with label Arizona. Show all posts
Showing posts with label Arizona. Show all posts

Saturday, April 2, 2011

MSNBC reports that “Arizona's cash-strapped Medicaid program is considering adding a $50 tax on single patients who smoke, have diabetes or are overweight. Arizona Health Care Cost  Containment program spokeswoman Monica Coury says the tax is intended to push patients to take better care of themselves. Coury says the issue is getting at the cost of health care while trying to stretch dollars and get people to take better care. ‘If you're not going to manage those things and take some personal responsibility, and in turn that costs the state more money, then you need to have some skin in the game,’ Coury said. . . . ‘You need to be responsible for the fact that your smoking costs us more.’ . . . State Sen. Kyrsten Sinema of Phoenix says it isn't fair to charge diabetics $50. Sinema says the fee fines people who may have medical conditions beyond their control. . . . The changes are part of a major revamp of Arizona's Medicaid program to find funds to restore transplant coverage — eliminated amid much controversy [in the fall of 2010].”

Ethical Analysis:

Focusing here on the ethical dimension of the proposed changes, I lay aside here the worthy question of whether the proposed changes are the optimal way to restore transplant coverage, or, more generally, to make up the funding shortfall facing Arizona’s Medicaid program. Ethically speaking, Coury’s reference to personal responsibility clashes head-on with Sinema’s claim of the conditions being beyond the patients’ control. Responsibility presumes that the agent has control over that which he or she is to be responsible. It makes no sense, for example, to hold President Obama responsible for the weather (unless the federal government has a top-secret way of controlling and changing the weather over U.S. territory).

In terms of smoking, the question is perhaps whether a drug addict has control of his or her addiction. To be addicted, according to the World English Dictionary, is to be dependent on something. Meriam-Webster’s Medical Dictionary asserts that dependence in turn involves being “unduly subject to the influence of another.” The question is thus whether being “unduly subject to” implies or involves the loss of control as opposed to merely control being more difficult. The qualifier of “unduly” suggests being subject to something excessively, according to the World English Dictionary. This does not signify the loss of control. Therefore, ethically speaking, smokers can be held responsible for their addiction to nicotine even though it is very difficult for them to quit. That smokers have quit demonstrates that those who do not quit cannot fall back on the fallacy that they have no control over their addiction. So to the extent that the smokers cost others, it is ethical to charge smokers more.

With regard to diabetes and obesity, a distinction can be made in terms of control. Losing weight, if only from restricting the quantity (and types) of food ingested, is within a person’s interval of control unless the excess weight if due to a disease and cannot be lost without risking the loss of minimal nourishment and health. I suspect that this qualification is misapplied by overweight people who presume that their “condition” is a result of an illness when over-eating (as well as a refusal to exercise) is the actual cause. Such persons, doubtless the overwhelming majority of obese people, can be distinguished ethically from those whose excessive weight is caused by a disease and cannot be lost without risk to one’s health and perhaps even life.

Apart from the illness caveat, the argument that overweight people have no control over their excess weight is effectively countered by the success that people have had in losing weight. Prima facie, one can reduce one’s consumption even in the midst of a presumed overwhelming urge to eat more. Therefore, it is ethical to hold overweight people responsible for their weight, and thus to charge them more if they cost others more. Diabetics are a more complex case.

Regarding obesity and (the ensuing?) diabetes, it may be that once a patient has the disease, nothing she could do would cure her of the disease. Otherwise, the person’s failure to reduce his weight while diabetic would be a basis for holding the person responsible not only for remaining overweight, but also for suffering from worsening diabetes. Furthermore, if being overweight is necessary for the onset of the disease, the diabetic could be presumed to be responsible for having developed the disease, and thus properly charged more for having it treated. However, to the extent that overweight people do not necessarily become diabetic, it may not be reasonable to assume that an overweight person should have acted to avert what is a mere possibility. In terms of a diabetic’s choices, if losing weight lessens or eliminates the (chances of, or continuance of) the sickness and the diabetic does not lose weight, a diabetic could rightly be held responsible and thus properly charged for the extra cost borne by others.

A few nuances should be made transparent. First, if the charges are not merely to reimburse others for the increased cost, but also to manipulate the “offender” to change his or her ways, it can be asked whether such manipulation is itself ethical and effective. If a person believes that his addiction, eating habits, or disease is a “condition” rather than a result of his choice, then it is unlikely that he would suppose that having to pay more would have anything to do with even a potential change in his “condition.” In other words, a link in the chain of reasoning presumed in the manipulation would not exist for the person to be manipulated.  Moreover, manipulation itself may be unethical unless, as in Kant’s categorical imperative, the rational being to be manipulated is treated not merely as a means, but also as an end in herself. If the end includes the patient recovering, this criterion may well be satisfied in Arizona’s proposal. In such a case, the noxious smell of manipulation may still pass the smell test.

Second, throughout this analysis, I have been assuming that the additional charges can be afforded by the patients and/or their insurance companies. If a patient cannot afford the extra fee and still provide for necessities such as food, shelter and obviously health care, as well as incidentals, then a basic human rights factor intercedes and it could be quite unethical to impose the fine/fee. Relatedly, to the extent that Arizona’s proposal involves reducing the number of enrollees in Medicaid, the goal itself may be unethical from the standpoint of the human right to survival, or life.

Third, if smokers and obese people are to be held responsible for their choices in health-care policy, it would be unethical to be selective in leaving out other choices that have negative consequences in terms of health (and cost). Even so, consistency zealously pursued can put the government into all of our lives with the result being that we have lost our liberty. That is, we might ask ourselves whether there is not a slippery slope involved in opening up our various decisions to governmental overview and charges. The imposition itself could be regarded as unethical, especially in a free society. Yet being forced to pay for the egregious choices made by others, such as by smokers and obese people, can also be regarded as involving an unethical transfer of responsibility. Accordingly, it is well and good, ethically speaking, that a society makes judgment calls respecting how far “egregious” extends. Being a matter of judgment and balance, there is no pre-established line in the sand to be sought in making this determination.

In conclusion, my ethical analysis supports the proposition that smokers and overweight people can be held accountable for their smoking and obesity, respectively, and perhaps even for being diabetic to the extent that mitigating the illness is within the patient’s previous or, more strongly, current control. This conclusion is of course beset by conditions. However, they do not deprive my conclusion of its main thrust—namely, that society has an ethical basis, and thus a right, to hold smokers and overweight people responsible for their inherently unhealthy choices by imposing an extra fee for government-supported health-care. To treat either smokers or the obese as somehow simply affected by, rather than as the agents of, their smoking or obesity is to engage in the subterfuge of an ideological agenda in the guise of science. Such a cloak is of course highly unethical.






Wednesday, March 2, 2011

On July 1, 2010, on the precipice of another July 4th celebration, President Obama told an audience that immigration was, in sum, “broken.” Furthermore, “everybody knows it.”  Yet neither he nor the Democratic leadership in Congress had any expectation of passing an immigration law in 2010.  Into this void, Arizona had months earlier passed its own law aimed at tightening enforcement. The New York Times reported that in his speech in July, Obama “used the opportunity to repeat his opposition to Arizona’s new law requiring law enforcement officers to question the immigration status of anyone they stop for other reasons if they suspect that they are in the country illegally, calling it ‘ill conceived’ and ‘divisive’.” The President said, “We face the prospect that different rules for immigration will apply in different parts of the country, a patchwork of different immigration rules where we all know one clear national standard is needed… . Our task then is to make our national laws actually work, to shape a system that reflects our values as a nation of laws and as a nation of immigrants.”  Different rules sounds like different immigration policies—as in who can enter the US.  If the President meant this, then he had a point. However, if he was arguing that tailoring different enforcement mechanisms to different regions, it could be argued counterwise that e pluribus union in a federal system not only allows for it, but thrives by it. In other words, the empire-scale of the US warrants a diversity of approaches. Furthermore, a federal system enables and indeed is strengthened by it.

Rather than looking at Arizona as a threat to the turf of the US Government, we can look at the state’s effort to enforce the US immigration law as a helping hand.  To be sure, there is a danger in the two governments helping each other out too much, for one of the benefits of federalism is that the state and federal governments operate (ideally) as checks on each other.  So they are not partners.  This is not to say that the state governments cannot act within federal law.  Arizona’s law does not conflict with federal immigration law, as the latter allows for people who are suspected of being in the US illegally to be stopped.  Arizona’s law requires another police matter—which is actually looser than the federal law.  The fear may be that enhanced enforcement would come with costs, and this cannot be denied. If the immigration system is broken as the President said, we ought to be willing to deal with them. Moreover, with the system being admittedly broken, the US Government is in no position to cherry-pick in accepting help.  Ironically, had that government been more focused on domains that cannot be covered by the state governments, it might have done a better job. The person who tries to be a jack of all trades does not do justice to any of them.  The President said that immigration is on his government’s turf, yet is there anything that is not? I contend that his government would be more effective were he to concentrate more on delimiting the enumerated powers rather than fighting for an exclusive right.

Source: http://www.nytimes.com/2010/07/02/us/politics/02obama.html?_r=1&hp

I once asked an official from a consulate office of the EU state of Britain about Turkey's possible accession into the EU as another state. He replied that it would be very disruptive—as much as if Mexico were to join the US as a state. The impact of another large state in union would be very significant, he observed. I was stunned that an official from a characteristically Euroskeptic state would make a reference that implies that the US and EU are on the same level. If his comparison is correct, then likening a Mexican state to a state in the US would evince a category mistake. That is to say, it would mean that a federal state could indeed apply to different scales of political organization, as Althusius had theorized in 1603.

Historically, Mexico was part of one colony of Spain called New Spain. For short-hand purposes, we could say that Mexico was a colony. So too was Virginia. While the latter joined a federative union with other colonies, and then sovereign (and then semi-sovereign) republics, Mexico remained as an independent state. At least by the beginning of the twenty-first century, a LAU (Latin American Union) had not formed. This does not mean, however, that Mexico is thereby a union in itself. Like many of the EU’s states, Mexico has provinces or regions, which in the American states would be intrastate regions or even counties. Some of the American states are sufficiently diverse that they would be good candidates for a federal system like that of Germany or Switzerland. Unfortunately, some of the intra-state officials in Europe and Latin America have been able to vaunt their status by calling themselves governors, as though their region were commensurate with France or Texas.

So in 2010 when all six Mexican border “governors” (six meaning that each is akin to a region say of Texas or Arizona and thus not equivalent with an American governor or a European head of state) wrote Gov. Jan Brewer of Arizona to inform her that they were boycotting the 28th annual conference between “governors” of the border “states” because of Arizona’s new law to beef up enforcement of US immigration law, she could well have replied, “Well, I should really be meeting with your head of state anyway.” Just because the semi-sovereign American states do much in common through their federation does not mean that the states have somehow shrunk, such that France, a state in the EU, is now somehow equivalent to the US. That would be like saying that Virginia and the EU are equivalent. Europeans would be very offended. Yet Americans turn a blind eye to the convenient category mistakes that are made by others—and even ourselves—at our own expense.

Source: http://www.nytimes.com/2010/07/07/us/07governors.html?_r=1

 

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