Endocrine Ethics Blog

Well, it’s time to bite our nails again over the Senate’s version of the “Kill Bill” called the Better Care Reconciliation Act of 2017. The name is deceiving because if passed, this bill will kill thousands of American citizens by denying them affordable access to healthcare, and dramatically altering Medicaid, which may leave many populations devastated. Drafted by only white, Republican males, this bill targets our vulnerable populations: the poor, the old – particularly those in nursing homes — the mentally ill, the disabled, pregnant women and their unborn children, and even NICU patients. (See: https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html?hp and https://www.nytimes.com/2017/06/23/opinion/senate-obamacare-repeal.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region).

The bill will allow states to opt out of covering vulnerable populations and essentially defunds Medicaid. It also eliminates caps on what insurance companies can charge people with complex health needs, and allows insurers to at least double what older people pay.

Here are the details of the bill: http://www.politifact.com/truth-o-meter/article/2017/jun/25/whats-senate-health-care-bill-here-are-five-key-pr/

Here is a nice summary by Atul Gawande: http://www.newyorker.com/news/news-desk/how-senates-health-care-bill-threatens-nations-health

Let’s be clear: this bill amounts to population control based on social Darwinism: the survival of the fittest. If you’re economically advantaged and can afford the ransom the insurance companies can now exact from this bill, you get to live. If you’re physically fit and free from chronic disease or disability, you get to live. The Republican Party argues this bill is “better” because you get to have “choices” the freedom to choose from a variety of unaffordable or inaccessible plans that will punish patients for their pre-existing conditions, and punish women for requiring prenatal and maternity care services. So if you like your healthcare, too bad – because you probably can’t keep it.

If you’re an endocrinologist burdened by too many diabetic patients, rest assured they’ll soon be gone from your practice if this bill becomes law. If you’re struggling with whether it’s more beneficent to observe “low risk” thyroid tumors (a still controversial practice), this healthcare law will remove your dilemma since many new thyroid cancer patients will not have access to treatment anyway.

When a healthcare reform bill drafted by the Republican party is so bad that only about 17% of voters approve of it, and even Republican senators are against it, it’s telling, but also perhaps a sign that reason will prevail with a bipartisan healthcare reform bill in the end. Indeed, if the “Better Care” bill passes, it will be America’s moral stain and shame. Even the American Medical Association states that this bill, as currently drafted, actually violates medical ethics. (See: https://www.forbes.com/sites/brucejapsen/2017/06/26/ama-says-mcconnells-trumpcare-bill-violates-do-no-harm-principle/#1674817b4040 )

Here is the AMA’s letter to Senators McConnell and Schumer, which states “Medicine has long operated under the precept of Primum non nocere, or “first, do no harm.” The draft legislation violates that standard on many levels.” For the full letter, see: https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2FBCRA-Letter.pdf

Not one single bioethics expert can endorse this “kill bill” – other than the endorsement of killing the bill itself. This bill is the health insurance equivalent of a travel ban – where insurance companies do “extreme vetting” of individuals with pre-existing conditions that will just cost too much to support.

Social Darwinism is not new; it was widely embraced throughout the early 20^th century and was the principal framework used to justify gassing the disabled, and other “undesirables” in Third Reich-era Germany. To recall a poignant line from the 2007 film, Sicko, a film that outlined the pre-ACA U.S healthcare system: “May I take a moment to ask a simple question? Who Are We?”

The biggest bioethics story this month was, of course, the “death spiral” of the repeal and replacement of the Affordable Care Act (ACA), known as “Obamacare”.

The proposed replacement law, unveiled as the American Health Care Act (AHCA), was a “Kill Bill” in every way. Under the new law, it was estimated that 24 million Americans who currently have health insurance and access to healthcare, would have lost their coverage. As proposed, the AHCA would have removed the current requirement under the ACA of that mandated coverage for “essential health benefits” comprising 10 services: outpatient care, emergency room visits, hospitalization, maternity and newborn care, mental health and addiction treatment, prescription drugs, rehabilitative services, lab services, preventive care and pediatric services. Republicans argued that such coverage leads to higher insurance premiums.  (See: http://www.vox.com/2017/3/23/15031322/the-fight-over-essential-health-benefits-explained).

Basically, the AHCA, which was being dubbed “Trumpcare” would have removed the requirement to cover what most would define as “healthcare”. Some columnists referred to the proposed bill as “cruel” (See: http://www.gq.com/story/trumpcare-exposed-gop-cruelty). Ultimately, once coverage of pre-existing conditions is removed, people die. (See: http://www.npr.org/sections/health-shots/2017/03/23/521220359/gop-health-bill-changes-could-kill-protections-for-people-with-preexisting-condi?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170323)

But there were many other problems with the bill that would have removed healthcare access, which included restructuring Medicaid, tax cuts, and eliminating the lubricant that allows the ACA to work in the first place: the individual mandate. (See: https://www.washingtonpost.com/blogs/post-partisan/wp/2017/03/24/your-guide-to-the-most-contentious-parts-of-the-gop-health-care-plan/?tid=a_inl&utm_term=.0d36a1dbe10f).

Ultimately, between thousands of protesters voicing opposition to the replacement bill and polling that demonstrated only 17% of Americans were in favor of the proposed replacement bill, the GOP killed the bill, preserving (for now) the ACA. Here are two postmortems from the New York Times:

• https://www.nytimes.com/2017/03/24/opinion/the-trumpryancare-debacle.html?action=click&_r=0
• https://www.nytimes.com/2017/03/24/opinion/sunday/trump-and-ryan-lose-big.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region&region=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region

But the ACA is not “saved”; it remains at risk of being underfunded or sabotaged (See: https://www.washingtonpost.com/opinions/the-real-way-republicans-can-deal-with-obamacare-actually-fix-it/2017/03/24/cef5eba6-10c8-11e7-9b0d-d27c98455440_story.html?hpid=hp_no-name_opinion-card-d%3Ahomepage%2Fstory&utm_term=.eb1a99cec9f0) and http://www.politico.com/magazine/story/2017/03/will-obamacare-really-explode-214949 )

As we ended the month, there were rumblings that there may be another attempt at crafting a Republican healthcare bill, which could be “Kill Bill Volume 2.” (And that may make some heads spin).