Showing posts with label medicaid. Show all posts
Showing posts with label medicaid. Show all posts
Thursday, April 14, 2011
A Basis for Entitlement Programs in Individualism via Collective Means
0 comments Posted by Find Insurance Online at 11:30 AMIn his speech on April 13, 2011 on reducing U.S. Government deficits, President Obama identified two strains that have run through the country’s political history and inform our political culture even today. “More than citizens of any other country, we are rugged individualists, a self-reliant people with a healthy skepticism of too much government. But there has always been another thread running throughout our history – a belief that we are all connected; and that there are some things we can only do together, as a nation. We believe, in the words of our first Republican president, Abraham Lincoln, that through government, we should do together what we cannot do as well for ourselves.” These two strains can be identified as individualism and collectivism, respectively.
I contend that collectivism enables both individual and collective security. Individual security is oriented to a person’s survival and collective security is exemplified by national defense. In his speech, the president explicitly placed individual security within the collectivist strain. “Part of this American belief that we are all connected also expresses itself in a conviction that each one of us deserves some basic measure of security. We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff, may strike any one of us. ‘There but for the grace of God go I,’ we say to ourselves, and so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, and those with disabilities.” In other words, the president rests entitlement programs on compassion for others with whom we share a society.
According to Obama, our societal connectedness with others implies a duty to contribute to the survival needs of those who cannot fend for themselves. I contend that most Americans are not likely to relate to this deontological basis that relies on the sentiment of compassion. Bluntly stated, too many of us are too selfish (or self-absorbed) to be motivated by such a normative basis. Fortunately, there is an alternative basis of individual security through collective means. Such a basis more firmly integrates the individualism and collectivism that the President identified as running through American history.
Specifically, as the president pointed out in his speech, hard luck can befall each of us; no one is immune from calamity and ruin. Perhaps the richest Americans feel confident that they will never be without their fortunes even in spite of the crushing experiences of many wealthy investors in the stock market crashes of 1873 and 1929, for instance. Yet for even the rich, and certainly for the rest of us, there is a basic psychological ease of mind in being able to have confidence that even in the worst case scenario concerning oneself, a safety net dependent only on the continued existence of the social contract (i.e., the collective) exists. Regardless of income, we all tend to ignore the foundational peace of mind that comes with security in
survival. Hence, each individual tends to understate the interest that he or she has in contributing to a fund even if he or she never has to use it.
In other words, self-interest and individual security by collective means are not incompatible. Therefore, the duty of compassion need not be relied upon as a motivation. Even if I never need to draw on Social Security (taking this program as insurance to be issued only to those who need it rather than as a combination of retirement savings accounts with the wealthy retirees having a claim on at least the money they paid in), it is in my self-interest that there be such a program available to me should I be impoverished at retirement. Even if I never need to draw on the program, the psychological security afforded to me by it through my life—and, indeed, to a society made up of people of such a psychology—makes being taxed to support the program quite valuable to me even if the value is subtle in my daily life. In a basic sense, each of us lives with a quiet anxiety concerning one’s own survival being less than certain. Perhaps the existence-anxiety is not consciously felt by those of us who have means; the poor surely are in touch with it. Yet we are all affected by it, like radiation, whether we know it or not.
Therefore, it is in an American’s self-interest to be taxed for survival-oriented entitlements even if the need is never actually realized; the psychological benefit begins immediately. We are “in it together” in that each of us, being a human being, is subject to the basic existence anxiety as well as to the beneficial effects from the reduction of it. Additionally, should a person be in need of an entitlement for survival, there is that more tangible benefit too. In isolating only this benefit and calculating the probability of one’s eventual need for it, the typical American tends to understand the value to himself of individual security by collective means. This understatement of the value may involve a rather narrow selfishness that is not in one’s own self-interest, fundamentally speaking. Besides being contrary to compassion for others in need, the narrow breed of self-interest (i.e., selfishness) is not even in one’s own interest.
Perhaps it is in each of us enjoying the same feeling that comes with having security in our survival being bolstered by social contract that we can feel community. Perhaps such a shared basis can trump even the different experiences in being rich and poor. That is to say, community may simply be the recognition of having the same feeling or experience. In the case of individual security by collective means, the basis of community can be located in individualism rather than the less reliable motive of compassionate duty.
Click to add a question or comment on President Obama on social programs and the deficit.
Source:
Barak Obama, “Text of Obama Speech on Deficit,” The Wall Street Journal, April 13, 2011.
Saturday, April 2, 2011
On the Ethics of Arizona Medicaid Charging Smokers and the Obese an Extra Fee
0 comments Posted by Find Insurance Online at 4:35 AMMSNBC 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.
Click to add a question or comment on the ethics of Arizona public health-care charing patients extra for smoking and obesity.
Thursday, February 3, 2011
It is odd that even after a bill becomes a law, it can be defunded. One would think that Congress would be required to pass the funding that is required by the law. The Republican Party is strategizing on how to deconstruct Obama’s health-insurance law through various means.
Republicans could turn to the annual appropriations and budget process or push stand-alone bills to delay or stop funding for provisions of the law they dislike, including the individual mandate, the health insurance exchanges and the Medicaid expansion. They might also work to weaken provisions in the bill that deal with Medicare physician reporting requirements that some physicians find onerous and block the creation of a nonprofit research institute to examine the effectiveness of various medical treatments. Mandatory funding, which comprises much of the health measure beginning in 2014, will continue unless Republicans can change current law, a heavy lift considering such initiatives would have to pass both the House and Senate and win Obama’s signature. Discretionary funding must be approved each year but differences between House and Senate versions of appropriations measures must be ironed out and that generally produces a compromise package. Why all of the law’s funding would not be mandatory—as the law is a law—is beyond me. Also, how the mandatory funding could comprise much of the law when the individual mandate, the exchanges, and the medicaid expansion can be defunded, is also beyond me.
A major problem with the defunding strategy is that since so much of the bill is inter-related, trying to dismantle it piecemeal could lead to unintended consequences. While the individual mandate is unpopular, “you can’t pull it out of the law without all sorts of other elements falling apart,” Reischauer says. And scrapping the mandate, which requires most people to have coverage or pay a penalty, would anger health insurers — a core GOP constituency. Insurers have agreed to abide by new consumer protections, such as not denying coverage based on a pre-existing medical condition, in exchange for 32 million new customers. Hospitals agreed to payment cuts on the premise that more people would have health care and hospitals would have less uncompensated care. In other words, because the health insurance industry got basically what it wanted—the mandate without a public option—it would be highly unlikely that certain parts of the law would be defunded unless it were in the interest of the health insurance companies. Therefore, the mandate is not apt to be defunded unless the rest of the law is to go down too.
I contend that law should not be allowed to be defunded. That is, upon passage, the law should have its required funding established as a matter of law. Secondly, I contend that private companies with a vested interest in a law should not be allowed to have such power that they can tailor the law to their liking. Extant industries have too much power in the US Government. As a reflection of this condition, we over-rely on private companies and the market—ignoring their downsides. Where basic necessities such as access to basic health-care is concerned, our over-reliance can be fatal.
Source: http://www.msnbc.msn.com/id/39295110/ns/health-health_care/
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