Bioethics Forum Essay
Morally Indefensible Health Care Bills
“Nobody dies because they don’t have access to health care” was Republican Congressman Raul Labrador’s response to a woman who expressed her concern that the bill he supported would result in people who depended on Medicaid dying. Labrador, a member of the House Freedom Caucus that was so influential in shaping the legislation, later issued a written statement in response to the furor kicked up by his comment. His statement is unintentionally revealing for what it tells us about the moral foundation for health care: “I was trying to explain that all hospitals are required by law to treat patients in need of emergency care regardless of their ability to pay and that the Republican plan does not change that.”
The Congressman doesn’t dwell on the fact that the ER is a terrible setting for the delivery of almost all forms of health care. It can be chaotic and rushed, and it’s a very, very expensive way to provide primary care—but it’s often where people without health insurance go because they lack alternatives. I want to focus on the moral sentiments behind the federal law that requires ERs to treat everyone, whether or not they can pay. If I walked into a Verizon store and said I desperately needed a new iPhone, they’d want assurance I could pay for it. No money or credit, no phone. That’s just how it is with market transactions. So what makes visits to the ER different?
I had my first extended opportunity to reflect on this when I chaired the Task Force on Genetic Information and Insurance for the Human Genome Project’s ELSI Working Group. An article in the Hastings Center Report, “Genetics and the Moral Mission of Health Insurance,” summarized what I’d learned. At that time (1992), there was great concern that insurers would treat genetic predispositions to diseases the same way they treated pre-existing conditions such as diabetes and cancer. Insurers could charge unaffordable premiums for policies that would cover such conditions—or devise policies that excluded coverage for them entirely. The nominal justification for this practice was dubbed “actuarial fairness,” which is the notion that the way to treat people fairly was to set premiums according to the risk each individual represented. Risk here means risk that the insurer would have to pay a claim. A woman with a history of breast cancer is more likely to have higher health costs in the future, so actuarial fairness dictates that she should pay more for her health insurance. The same logic applied to genetic variation would say that a woman with a gene linked to a higher risk of breast cancer should also pay more.
Fortunately, there is abundant evidence that most people see the flaw in this logic. People who come to an ER with a serious illness or injury need care. A morally decent society assures that care is provided. In the past, certain categories of people had difficulties getting health insurance. Older people were more likely to fall ill, therefore insurance companies wanted to charge them more, which often put coverage out of their reach. In response, we created Medicare. The poorest among us could not afford to pay for insurance. In response, we created Medicaid. GINA, the Genetic Information Nondiscrimination Act of 2008, prohibited using genetic risk information in health insurance. All of these measures testify to the broad and deep moral conviction that health care should be distributed according to genuine need and not left to the cold mercy of pure market forces or the logic of actuarial fairness.
Unfortunately, the proposed American Health Care Act (AHCA), passed last week in the House of Representatives, and other legislation threaten to undermine that moral commitment. A House bill, misleadingly named the Preserving Employee Wellness Programs Act, would undo certain protections provided by GINA. The AHCA would reduce funding for Medicaid by some $880 billion over 10 years, fundamentally altering the role of the federal government in that program, as Michael Gusmano wrote here. Paul Ryan, the architect of the AHCA, has had Medicare in his sights since 2008.
The reality is that the House bill would likely leave millions of Americans with pre-existing conditions without protection. A study by Avalere Health, released just before the vote, estimated that of the 2.2 million people enrolled in the Affordable Care Act’s individual market with pre-existing conditions, at best 600,000 could be covered by the funds specified in the bill, leaving more than a million and a half uncovered. The Kaiser Family Foundation, in an issue brief well worth reading in its entirety, estimated that at least 52 million non-elderly adult Americans—27 percent of that population—“have a health condition that would leave them uninsurable under medical underwriting practices used in the vast majority of state individual markets prior to the ACA.” You could be declined insurance for arthritis, diabetes, or sleep apnea, for taking a drug such as Clomid for infertility; Epogen for anemia; or Warfarin for preventing blood clots. Even your occupation could be enough to disqualify you if you were a firefighter, sheet metal worker, or drove a taxi, because these jobs are considered high risk.
Small wonder that Republicans in the House of Representatives and the White House have struggled with the truth in attempting to defend the AHCA. For the most part they are denying the likely consequences for Americans’ health care access should the bill become law. The Washington Post Fact Checker awarded four Pinocchios to Tom Price, the secretary of Health and Human Services, for his efforts to disguise the bill’s impact on Medicaid and his claims about the supposed unpopularity of the current ACA.
I’ve found, as a general rule, that when people try to defend a morally indefensible position, one of the first moves is to deny the reality of what it means. That was the quandary Raul Labrador encountered. It earned maximum Pinocchios for Tom Price. And it will continue to bedevil any politician who ignores the powerful, widely held conviction that health care, and health insurance, should be available to all Americans who need it.
Thomas H. Murray is president emeritus of The Hastings Center. @thmurray46.