Happy Birthday Obamacare!

Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

This week, before a crowd of students attending the obligatory Monday morning convocation at Liberty University, Ted Cruz announced that he was running for President in 2016. This makes Mr. Cruz, a first-term senator from Texas, the first major Republican to officially declare their candidacy.

That Senator Cruz made this announcement on the 5th anniversary of the Affordable Care Act’s signing into law is not surprising. Mr. Cruz has made the repeal of Obamacare (as the Affordable Care Act is colloquially known) a cornerstone of his campaign. Curiously enough, the Senator will also soon be a beneficiary of this program.

Mr. Cruz’s wife Heidi, through whom he previously had health insurance, has taken an unpaid leave of absence from her job as a managing director for Goldman Sachs for the duration of the presidential campaign. The Cruz family will now obtain coverage through the federal insurance exchange program, and will receive the government health insurance subsidy provided to all lawmakers and congressional staffers under the Affordable Care Act.

A lot of pundits have called that hypocritical. I don’t quite see it that way. It’s not hypocritical to follow (and even benefit from) a law that you oppose and are working to repeal. It’s just tacky. What I do have an issue with, however, are the blatant lies told by Senator Cruz and his Republican colleagues about Obamacare.

In a recent interview, Senator Cruz explains his opposition to the Affordable Care Act thusly: “What is problematic about Obamacare is that it is killing millions of jobs in this country and has killed millions of jobs. It has forced millions of people into part time work. It has caused millions of people to lose their insurance, to lose their doctors and to face skyrocketing insurance premiums.” But none of that is true.

Consider, for example, the oft repeated claim that fewer people have health insurance now than before Obamacare was signed into law. The numbers that Cruz, House Speaker John Boehner, and other conservative politicians use to support that assertion? Between March 2010 and March 2015, approximately 6 million Americans received cancellation notices from their health insurance plans. In this same period of time, only 4.5 million Americans signed up for new plans through one of the federal- or state-run health insurance exchanges. That’s a net loss of 1.5 million from US health insurance rolls, right?

Wrong. What those figures don’t include is the number of people who signed up for new plans through other means, such as insurance brokers. It also ignores the 9.1 million people who signed up for Medicaid, the government-run insurance plan that was greatly expanded under the Affordable Care Act. A recent Gallup poll found that the number of uninsured Americans has fallen to 13.4%, a record low. That drop has been greatest in those states, like New York, that have openly embraced Obamacare by expanding Medicaid and by setting up state-based insurance exchanges.

Of course, all these people are paying vastly more for their health insurance now then before Obamacare became the law of the land. Or so opponents claim. But are they? In the years immediately prior to passage of the Affordable Care Act, individual health insurance premiums increased an average of 10 percent annually. By contrast, premiums for mid-level plans offered through health insurance exchanges increased by only 2 percent in 2015, and price for insurance plans in the largest metropolitan markets actually dropped.

Finally, one of the largest criticisms of Obamacare is that it is a “job killer.” Specifically, critics believe that cash-strapped employers unable to provide health insurance to their employees will be forced to lay off workers. Alternatively, since the Affordable Care Act only requires that health insurance coverage be provided to those who work more than 30 hours a week, employers will eliminate full-time positions in order to sidestep this mandate. Thankfully, this is also not the case. The United States has seen 60 months of consecutive job growth since the Affordable Care Act was passed, the longest stretch of employment gains in history. The number of Americans involuntarily working part-time jobs has also declined steadily.

In fact, none of the arguments or predictions used by conservative lawmakers opposed to the Affordable Care Act have proven to be true. The economy hasn’t collapsed, workers haven’t lost their jobs, the federal deficit hasn’t skyrocketed, insurance premiums haven’t risen steeply, and doctors haven’t fled the healthcare industry in droves. In addition, the number of uninsured has dropped and those who obtained new plans though the health insurance exchanges are largely happy with their coverage.

It’s time for opponents of Obamacare to accept these facts. The Affordable Care Act is not an unmitigated disaster, as Ted Cruz and other conservative politicians would like you to believe. Rather, it is an unprecedented success. It has achieved exactly what it set out to do by reducing the number of uninsured while containing health care costs.

Those on the right might have ideological objections to Obamacare. Some of these objections might even be valid. But if you’re going to spend most your time repeatedly trying to repeal this successful law, instead of tackling other looming crises like immigration reform and student debt, at least have the courage to stand up for your convictions and back them with concrete arguments and supporting data.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 26, 2015, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Understanding the Latino Patient with Cancer

by Beatriz Lorena Hurtado, Bioethics Program Alumna (MSBioethics 2014)

As a Latina working in healthcare I have always felt the responsibility to provide education about my culture, and to clarify cultural differences and misconceptions. It is always surprising to witness how eliminating misconceptions eventually translates into an increase in patient satisfaction, and less apprehension about cultural differences from the healthcare team. This is one of the reasons why, in my view, education on Cultural Competence in healthcare is probably the most appropriate way to avoid generalizations and achieve equality in healthcare.

Latinos currently constitute seventeen percent (17%) of the nation’s population, making them the largest racial and ethnic minority in the US. They are also amongst the fastest growing minorities the United States. Should current demographic trends continue, it is estimated there will be 41 million Latinos in the United States by 2020.

These numbers should not only indicate the rising presence of Latinos in the United States, but also highlight the need for developing pathways to improve language and cultural services in the healthcare arena.

This need is particularly in oncology: as the American Cancer Society notes, cancer is the second leading cause of death for Latinos. It is also important to add that the most common cancer diagnosis in Latino women is breast cancer, while prostate cancer is the most common diagnosis in Latino men (with colon, lung, melanoma, stomach, and liver cancer following closely behind).Therefore, as it happens with any chronic disease, the medical visits are usually recurrent and the treatments involve an extensive group of healthcare professionals.

As a Latina I believe there are three important characteristics of Latino cultural expressions, meanings, and value systems that warrant specific attention:

First, family is the foundation that supports life for Latinos in general. Medical decisions are in most cases a family affair. The presence of family signifies emotional support, empathy, and togetherness, and is always favored in a difficult medical situation. Moreover, if facing a difficult moment or vulnerability, like a cancer diagnosis, family support is at the top of the list of necessities of the Latino patient. Latinos place much of their identity and self-worth into the family structure and customs.

Although it is recognized that the Latin American family has undergone changes in its structure in recent decades, it is important to note that these changes haven’t shifted the sense of group, affective value, and financial support in the immigrant family. Latinos are gregarious, often moving in culturally-defined groups. They also identify themselves within their group and by the role they play in it. Failing to recognize the place family has in medical decisions for Latino patients could be viewed as a lack of acknowledgement of who they are as persons, and their position in the micro universe that is their family life.

Second, in the Latino culture, talking about death is commonly viewed as summoning it. Acknowledging death can be seen as giving up hope, limiting a patient’s chances of surviving and a threat to their recovery. This has obvious implications for conversations about death, end-of-life issues, living wills and advance directives. Also, because of the substantial Catholic background and deep religious roots, most Latinos believe that talking about the possibility of a negative outcome is an expression of limited faith in God. It can symbolize doubt on God’s abilities to heal the sick.

Third, even though Latinos share many characteristics, they are also a very diverse group. They are united in their diversity. For instance, a Latino patient from South America may have a specific cultural response towards the healthcare team (e.g., a more entitled behavior) that may be very different from the cultural response of a Latino patient from Central America (e.g. a more humble and unassuming attitude).

Despite all the similarities that unite Latinos (language, religion, family union, etc.), there are several particular cultural conventions that vary depending on the country from where the person comes. Identifying that the patient may speak Spanish or may come from Latin America represents merely the basic steps in beginning a successful communication, but it does not contribute significantly towards building a strong a fruitful rapport with a Latino patient. To achieve this, establishing a conversation free of narrowly defined cultural assumptions is crucial. Even though Latinos share many characteristics, like the general value placed on family and the inclination to avoid discussions of death, there is a rich diversity of Latino cultures and healthcare providers must make it a point to avoid generalizations.

In the context of the Latino culture, to achieve a culturally competent treatment is to understand their culture and demonstrate respect for their differentiating traits while they are in treatment. This means providing care that recognizes and caters to those cultural differences. By acknowledging their gregarious behavior towards family and group, by attributing their reluctance to plan for the worse to their unceasing hope in their interpretation of death and dying, and by respecting the differences among these common traits, the healthcare team can provide culturally competent care. In turn, this will help the patient feel acknowledged and less intimidated by the medical environment, resulting in a more effective relationship, better care, and better outcomes.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Can Safety, Freedom And Rationing Co-Exist For The Elderly?

by Susan Mathews, Bioethics Program Alumna (2014)

In a recent op-ed article, Dr. Ezekiel Emanuel, former Special Advisor for Health Policy to the Obama Administration, stated that he did not want to live beyond the age of 75. At that point, his productive life would be over and he become a burden rather than a benefit to his family, his friends and his country.

Whether or not you agree with Dr. Emanuel’s provocative statement, he raised an important point in his article: in order to contain health care costs, Americans will have to make difficult decisions about rationing of medical care. This is particularly true of end-of-life care for the elderly, which is a significant contributor to medical spending in the United States.

The problem will only become more acute in the coming years. The 65 and over population is projected to grow from 13 percent of the population today to 20 percent by the year 2030. In that same period, the population of the “old-old” (85+) will quadruple as the large baby boomer cohort reaches these advanced ages.

So as explicit rationing of medical care becomes a reality, how can costs be managed while still respecting the rights and safety of the elderly?

To read more, click here.

[This post is a summary of an article published on Life Matters Media on January 16, 2015. The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

 

It’s the Little Things That Matter

by Courtney Jarboe, Bioethics Program Student

“It’s not good news.

In a small exam room, we heard these words as my sister’s tears began to fall. No one wants to hear that you have breast cancer. Beyond the discussions of treatment options, however, there are a number of issues that clinicians need to consider. The following are recommendations based on my personal experience with my sister’s diagnosis.

1. A Folder

At the test result meeting, my sister received several medical record documents, along with various resources, pamphlets, journals, and business cards. However, there was no folder to house all of this. As we approached the close of the appointment, juggling the paperwork I ended up having to ask the physician assistant for a folder. Why is this a problem? First, these are important documents. The documents should be kept organized and together in one place. Keeping things together was not necessarily on the top of my sister’s list. By simply providing a folder, the clinicians would decrease the likelihood of her losing important information.

More important, most of the pamphlets and resources had ‘Breast Cancer this… Breast Cancer that…” on the covers. Often this was in big, bold headers.  What if she isn’t ready to brand herself in pink moments after receiving such devastating news? Does she want everyone in the waiting room to know her diagnosis as she walks out of the clinic? Does she want have her children come across these items accidentally before she is ready to share? By keeping these items in a folder, this gave my sister at least some degree of privacy about her results and diagnosis.

2. Appointments and referrals

 In my sister’s situation, she was told she that may want to meet with an oncologist, who was resident at the hospital. She was told that it would be easy to set the appointment, but to do this my sister would need to go back to the registration desk. Easy, right? Not necessarily. For a woman who just received such devastating news, setting up something as simple as an appointment may not be all that easy. Her schedule was the last thing on her mind, let alone how she was going to ‘fit’ cancer into it.

It wasn’t as easy as the clinician claimed.  My sister went to the registration desk and the staff member was apparently new. After much back and forth, my sister finally said (loudly, for everyone to hear) I have cancer.

Rather than send the newly diagnosed cancer patient up front to schedule these appointments, process these transactions in the exam room out of the public eye (and certainly not with a new staff member). Even though physician assistant or clinical might not have access to the scheduling system, couldn’t they quietly work that out with the registration staff and then circle back to the patient? During my sister’s result meeting the physician’s assistant stepped out of the room while the surgeon discussed her options for surgical procedures. During that time, they could have worked out the other details for the next appointment. Perhaps they could have gotten a list three of available times from the registration desk and circled back after the surgeon’s conversation.

3. Bras

After surgery my sister was in a predicament. One would think that it would be common sense to say hey, after surgery, your typical bra isn’t going to be useful or practical. However, she only received the usual wound care information sheet, not information about which bras are best following a lumpectomy. Give women a heads up. There are more important things to spend energy on than trying to find a bra.

Perhaps these recommendations are already in place in other hospitals and clinics, but my sister’s experience wasn’t as smooth as it could have been. Attention to the little things could go a long way to alleviate some of the unnecessary burdens that in my sister faced. More so, a woman’s trust and confidence in the healthcare community can be found even in the little things.

[The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

A Cold Day’s Concern About a Warming Planet

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

My husband and I usually spend both Thanksgiving and Christmas at my in-laws’ house in Western New York, located about 30 minutes outside of Buffalo. This year was no exception.

What was different this year was the unusual weather. The Thanksgiving holiday was a white one, with sub-freezing temperatures and lots of snow on the ground. In fact, at that time the Buffalo area was still recovering from one of the worst storms in recent history, with some areas receiving over 8 feet of lake-effect snow in the two weeks prior.

By contrast, the Christmas holiday was a green one, with temperatures in the mid-fifteens and not a flake of snow to be seen. We did, however, experience high winds that knocked over trees and toppled power lines. My grandfather-in-law was nearly killed when he struck a downed telephone poles while driving home late on Christmas Eve.

It’s tempting to chalk up these weird weather patterns to global climate change. According to the vast majority of climate scientists (over 97% of them, to be precise), we can expect to see increasing temperatures, changing rain and snowfall patterns, and more extreme weather events like droughts, floods and blizzards over the coming years. These changes are the result of increasing levels of carbon dioxide and other greenhouse gases in our atmosphere, largely as a result of industrial activity.

Despite concerted campaigns by business groups, right-wing pundits, and conservative politicians to discredit the theory — and despite the fact that much of the US is currently shivering under abnormally cold weather — I do believe that climate change is real. I believe it is happening. I think we are already seeing the effects, even if we cannot ascribe singular weather events like the Buffalo blizzard to greenhouse gases in the air.

But I am a public health expert, not a meteorologist. What concerns me the most about global climate change is the effect it will have on patterns of disease and illness, both here in the United States and overseas.

The health-related impact of climate change is most directly observed during extreme weather events, such as increased mortality among the elderly and those who work outdoors during heat waves. But the long-term effects of climate change on public health are much more insidious, particularly the impact on the spread of infectious diseases.

We know, for example, that infectious diseases like cholera and cryptosporidiosis show seasonal patterns. Until recently, the Americas had been free of the deadly diarrheal disease cholera for more than 100 years. When that water-borne illness re-emerged in Central and South America in 1991, it coincided with a periodic weather event (El Niño) that resulted in much warmer than normal coastal waters. Vibrio, the bacterium that causes cholera, was able to proliferate in these unusually warm waters, setting the stage for increased exposure and transmission to humans.

Cholera is now re-established in the Americas, with outbreaks linked to weather events like El Niño. Unfortunately for those countries affected, over the last several decades the number of El Niño events increased, and studies of historical data show the recent variation is likely linked to global warming.

The spread of other illnesses is also climate sensitive, including the spread of vector-borne diseases like Lyme disease, West Nile Virus, malaria, and dengue fever. Several of these are already present in this country. For instance, Lyme disease is the most common vector-borne disease in the US, with the costs of medical treatment and lost productivity alone estimated to exceed $3.2 billion a year.

Other diseases that haven’t been seen in the US for centuries are likely to regain a foothold as the climate changes, particularly as increased temperatures and altered rainfall patterns allow the mosquitoes that carry malaria, dengue and other deadly or debilitating illnesses to thrive in American cities. I know this personally, as a recent business trip to Grenada left me suffering from the high fever and severe joint pain associated with the newly emergent disease known as chikungunya.

Global climate change seems to be an unfortunate reality, with the effects increasingly seen through changes in rain and snowfall patterns, decreases in crop yields, and extreme weather events like heat waves, cold snaps, droughts and floods. While the impact on human health has been limited to date, we can expect to see increasing morbidity and mortality as water-based illnesses and insect-borne diseases become more common.

All we can do now is try to mitigate the effects, through personal behaviors and public policies that reduce the amount of greenhouse gases produced. The more the planet warms, the more likely we will have devastating floods, disastrous droughts and deadly outbreaks of infectious disease. Sadly, in an era of $2.50-per-gallon gas and economic struggle, neither we nor our political leaders seem willing to make the hard choices necessary to limit the rate and magnitude climate change.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on January 1, 2015, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Does A Just Society Use the “R” Word?

by Susan Mathews, Bioethics Program Alumna (2014)

Healthcare spending in the U.S. is expected to grow by more than 5 percent annually over the next ten years. Should that prediction hold true, by 2023 health care spending will account for a fifth of the nation’s gross domestic product (GDP). Unfortunately, this level of spending is not sustainable and physicians, policymakers and patients will be forced to make difficult choices about how to ration limited medical resources.

How should the principle of distributive justice, one of the four tenets of medical ethics, guide decisions about the dreaded ‘R’ word: rationing of medical resources?

To read more, click here.

[This post is a summary of an article published on Life Matters Media on December 13, 2014. The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]

Striking the Balance Between Population Guidelines and Patient Primacy

by Susan Mathews, Bioethics Program Alumna (2014)

Breast cancer is the second leading cause of cancer death among North American women. Although routine mammography decreases the risk of death by about 15 percent, research on the effectiveness of wide-scale screening programs shows that 2,500 people would need to be screened to prevent one cancer death among women ages 40-49. Given this, the US Preventive Services Task Force (USPSTF) updated its population guidelines in 2009 to advise against routine screening mammography for women under 50.

These new recommendations were met with controversy and confusion, with many questioned the ability of “experts” to weigh potential benefits and harms of screening for individuals.

But how should population data like this, along with other epidemiologic, social, psychological and economic factors, be considered in medical decision-making?

To read more, click here.

[This post is a summary of an article published on Life Matters Media on November 25, 2014. The contents of this blog are solely the responsibility of the author and do not represent the views of the Bioethics Program or Union Graduate College.]