The new millennium is still very young, so it is too early to declare National Federation of Independent Business v. Sebelius1 the health law “case of the century,” but that title would not be hyperbolic. Never before have we seen a case of such monumental importance for how health care is financed and delivered in the United States. At the Supreme Court, no decision has been more closely watched and more anxiously awaited since Bush v. Gore in 2000. In (...) the balance was the fate of President Obama's signature piece of domestic legislation, one that affects nearly every aspect of the largest segment of our economy, and so is perhaps the most important piece of social legislation since the New Deal. To no one's surprise, the decision was announced at the very end of the Court's term and was split five to four.What was very surprising, however, was the Court's embrace of the tax power defense of the individual mandate. And what was outright shocking was a seven‐to‐two majority in favor of finding the Medicaid expansion unconstitutional unless states are allowed to opt out of the expansion.The case holds great significance not only for the fate of the Patient Protection and Affordable Care Act—and, thus, for the nation's health care public policy—but also for constitutional doctrine that applies much more broadly than in the health care arena. (shrink)

Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article evaluates the impact of the ACA (...) on equitable mental health care delivery according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities. (shrink)

The most prominent — and certainly the most controversial — feature of the Patient Protection and Affordable Care Act is the so-called “individual mandate,” which attempts to address the problem of 50 million uninsured by requiring nearly all Americans, beginning in 2014, to obtain health insurance. While expanded access to health insurance has been both the cornerstone and the lightening rod of the ACA, the Act also contains significant public health provisions focusing on, among other things, promoting the (...) availability of prevention and wellness services. Although these public health provisions have been greeted with mixed reviews, there has been very little discussion of what may be the ACA’s most significant public health feature: the preventive services mandate. In a bold stroke, the ACA changes the way evidence-based preventive services will be provided and paid for by private health insurance plans, Medicare, and Medicaid. By requiring these health plans to provide evidence-based preventive services with no out-of-pocket costs, the ACA transforms the U.S.’s public and private health care financing systems into vehicles for promoting public health. (shrink)

This article reviews the primary avenues of judicial challenge to the ACA, focusing on those that have reached, or have the potential to reach, the Supreme Court. The review demonstrates how deep-seated public policy opposition can be expressed through litigation.

The fourth of five commentaries on “Bloomberg's Health Legacy: Urban Innovator or Meddling Nanny?” from the September‐October 2013.

Interest in NFIB v. Sebelius has been extraordinarily high, from as soon as the legislation was passed, through lower court rulings, the Supreme Court’s grant of certiorari, and the decision itself, both for its substantive holdings and the purported behind-the-scene dynamics. Legal blogs exploded with analysis, bioethicists opined on our collective responsibilities, and philosophers tackled concepts like ‘coercion’ and the activity/inactivity distinction. This volume aims to bring together scholars from disparate fields to analyze various features of the decision. It comprises (...) over twenty essays from a range of academic disciplines, namely law, philosophy, and political science. Essays are divided into five units: context and history, analyzing the opinions, individual liberty, Medicaid, and future implications. (shrink)

The passage of the Patient Protection and Affordable Care Act in March 2010 represents a significant turning point in the evolution of health care law and policy in the United States. By establishing a legal infrastructure that seeks to achieve universal health insurance coverage in the United States, the ACA targets some of the major impediments to accessing needed health care for millions of Americans and by extension attempts to strengthen the health system to support key (...) determinants of health. Yet, like many newly passed legislative provisions, the ultimate effects and significance of the ACA remain uncertain. Those charged with implementing the ACA face formidable obstacles — indeed, some of the same obstacles that have been erected to impede other major pieces of social legislation in the past — including entrenched political opposition, constitutional challenges, and what will likely be a prolonged struggle over the content and direction of how the law is implemented. As these debates continue, it is nevertheless important to begin to assess the impact that the ACA has already had on health law in the United States and to consider the likely effects that the law will have on public health going forward. (shrink)

In 2015, the U.S. Supreme Court issued its ruling on the Patient Protection and Affordable Care Act (ACA). Among other things, it found that states may refuse to expand Medicaid to all individuals earning less than 133% of the federal poverty line. In this article, I evaluate the strongest conservative objection to the Medicaid expansion, which runs as follows: "Defenders of the ACA promised that the Medicaid expansion (and all other parts of the ACA) would be paid for (...) with compensating cuts. However, it’s arguable that that claim is false and that the government is likely to follow its well-worn pattern of charging at least some of the increased spending to the national debt. Debt is already at dangerous levels, and adding to it increases the risk of a serious fiscal crisis. We should therefore oppose the Medicaid expansion." After laying out this argument, I evaluate its central claims and draw three main conclusions. First, some people could reasonably believe the assumptions behind the fiscal objection, and thus reasonably oppose the Medicaid expansion as well. Second, despite the fact that reasonable critics could hold those assumptions, most critics do not, and so they should not reject the Medicaid expansion on these fiscal grounds. Third, supporters of the ACA and the Medicaid expansion can reasonably reject the assumptions behind the fiscal objection, and thus the objection itself. (shrink)

In March 2010, President Obama signed into law The Patient Protection and Affordable Care Act (ACA). Although there is much in the ACA that is endorsed by the Catholic health ministry, the many positive provisions of the ACA have been overshadowed for the Catholic Church and the Catholic healthcare community by the controversial provisions requiring access to all FDA-approved sterilization and contraceptive medications (75 Fed. Reg. 137 (19 July 2010)) Typically, these drugs and services have not been covered (...) by the health plans of many religious employers including Catholic hospitals, universities, and social service agencies. Acknowledging the existence of religious-based objections to the provisions of these .. (shrink)

Two major safety net providers – community health centers and public hospitals – continue to play a key role in the health care system even in the wake of coverage reform. This article examines the gains and threats they face under the Affordable Care Act.

The U.S. Supreme Court has likely already decided how much, if any, of President Obama's signature Affordable Care Act it is going to strike down as unconstitutional; its holding will be published this summer. No matter what the Court decides, though, it will send state and federal legislators scrambling—either to implement the law or to deal with the consequences of its alteration. There are various decisions the Court might make, but it is still most apt either to leave (...) the ACA standing, or to selectively invalidate some of its mandate‐related provisions. In either case, there will be exchanges to design and manage, subsidies to allocate, transparency standards to design and enforce. The Court's decision will thus mark the beginning, not the end, of health reform. (shrink)

The U.S. 2010 Patient Protection and Affordable Care Act exempts members of health care sharing ministries from the individual mandate to have minimum essential insurance coverage. Little is generally known about these religious organizations and even less critical attention has been brought to bear on them and their ACA exemption. Both deserve close scrutiny due to the exemption’s less than clear legislative justification, their potential influence on the ACA’s policy and ethical success, and their salience to current (...) religious liberty debates surrounding the expansion of religious exemptions from ACA responsibilities for both individuals and corporations. Analyzing documents of the United States’ three largest health care sharing ministries and related material, I examine these organizations and their ACA exemption with particular consideration of their ethical dimensions. Here a thick description of the nature and workings of health care sharing ministries precedes a similar account of the ACA exemption. From these empirical analyses, five ethical and policy concerns emerge: the charity versus insurance status of these ministries; the conflation of two ACA religious exemptions; the tension between the values of religious liberty and of justice; the potential undermining of ACA policy goals; and the questionable compliance of health care sharing ministries with ACA exemption requirements. An accurate and informed understanding of HCSMs is required for policymakers and others to justify the ACA exemption of health care sharing ministry members. A sufficient justification would address at least the five ethical and policy concerns raised here. (shrink)

The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA (...) is neither uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the health care system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry. (shrink)

In this paper, I analyze Simone de Beauvoir’s goals for women expressed in The Second Sex and compare these goals to the opportunities created by the Affordable Care Act’s contraceptive mandate. Though the contraceptive mandate advances Beauvoir’s goal of concrete equality by supporting economic independence and recognizing women’s sexual freedom, there are social and political limitations to these advancements.

The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether (...) or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties. (shrink)

This special issue addresses the legacy of the U.S. Public Health Service Syphilis Study on health reform, particularly the Affordable Care Act. This article offers readers a guide to the themes that emerge in this issue. These themes include individual consent interrelated to consequences in populations issues, need for better government oversight in research and health care, and the need for overhauling our bioethics training to develop a population-level, culturally driven approach to research bioethics. We hope the (...) guidance offered in this issue will help shape a new framework to bioethics that can be integrated into the foundation of health care reform. (shrink)

This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act illustrate the weakening of those ideas and the institutional practices embodying them.The opening identifies the dominant role of physicians in American medical care in the two decades after World War II. By the time Medicare was enacted in (...) 1965, associations of American physicians were almost completely in charge of medical education, specialist certification, and the enforcement of professional norms on their members. Who could be a doctor, what education and training would be required, and what collegial oversight was operative was first a professional matter and only secondly implicated the state through malpractice or major corporations via the employment of physicians. (shrink)

Many observers claim that business has become a powerful force in medicine and that the future of health care cannot escape that reality, even though some scholars lament it. The U.S. recently experienced the most devastating recession since the Great Depression. As health care costs rise, we face additional pressure to rein in health care spending. We also have important new legislation that could well mark a significant shift in how health care is provided and who (...) has access to care, namely the Affordable Care Act. These changes underscore the need to bring new thinking to the conversation about health care and to move beyond conceptual and practical obstacles that inhibit our progress.In this paper we do not to claim to have solutions. Rather, our aim is to try to identify some obstacles to fostering a better conversation about the future of health care and to envisioning a better health care system. (shrink)

Heath care and public health are typically conceptualized as separate, albeit overlapping, systems. Health care’s goal is the improvement of individual patient outcomes through the provision of medical services. In contrast, public health is devoted to improving health outcomes in the population as a whole through health promotion and disease prevention. Health care services receive the bulk of funding and political support, while public health is chronically starved of resources. In order to reduce morbidity and mortality, policymakers (...) must shift their attention to public health services and to the improved integration of health care and public health. In other words, health care and public health should be treated as two parts of a single integrated health system. Furthermore, in order to maximize improvements in health status, policymakers must consider the impact of all governmental policies on health. (shrink)

The Affordable Care Act has been touted as a long‐overdue remedy for what is perceived to be the chronic problem of large numbers of Americans living without adequate health insurance. While much of the discussion of the ACA has focused on its legality, it should also be assessed on the basis of its economic implications and its moral acceptability. On its face, the ACA appears to do well on both counts. Given that the uninsured often secure their health (...) care from expensive emergency room treatment (from which they cannot be excluded and whose cost is often borne by third parties), expanding insurance to cover them (and hence to give them access to less expensive treatments) appears to make economic sense. Similarly, it might appear that providing access to insurance for people who otherwise could not afford it, or who would be denied it as a result of having medical conditions that they are not responsible for, would be morally laudable. But these appearances deceive: The ACA is neither economically sound nor morally acceptable. To paraphrase Oscar Wilde, to fail on one of these criteria may be misfortune; to fail on both looks like carelessness. (shrink)

The Affordable Care Act is an essential first step toward making health insurance more affordable for lower and moderate income Americans. It has accomplished historic reductions in the proportion of Americans who are uninsured. The number of Americans reporting delaying medical care for financial reasons has declined by approximately one-third since 2010. Medicaid expansions, in particular, have significantly reduced financial burdens and accompanying anxieties experienced by low-income Americans in states that have embraced this opportunity. Consistent with (...) these finding, one recent analysis of credit report data finds that Medicaid expansion was associated with between a $600 and $1000 decline in collection balances among individuals who gained coverage. Notwithstanding these gains, premiums and cost-sharing are still too high for many Americans. And cost-sharing has continued to edge higher for the majority of Americans who have coverage through employer-based plans. Measures to address these challenges must build on the ACA to provide greater protection to millions of Americans and to address continued dissatisfaction with our health care financing system among middle-income Americans. (shrink)

Evidence suggests that the nurse’s role as an advocate for patients and for the professional right to conscience is being eroded because of a lack of conscience protections in the Patient Affordable Care Act and because of a faulty understanding in general of the separation of church and state. While the main task of the principle of separation of church and state is to secure religious liberty, the principle is increasingly interpreted in a secularist way to mean that (...) religion must be confined to the home and church and that people of conscience may not object to immoral practices in the workplace or public square. If nurses must risk their jobs to advocate for their patients, patient care will suffer. National Catholic Bioethics Quarterly 14.1 : 47–52. (shrink)

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually (...) increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity. (shrink)

Numerous studies have revealed that health care transitions for chronically ill older adults are frequently poorly managed, often with devastating human and economic consequences. And poorly managed transitions and their consequences also occur among younger, relatively healthy individuals who have adequate resources and are prepared to advocate on their own behalf. Despite the rich base of research confirming that evidence‐based transitional care enhances patients’ experiences, improves health and quality of life, and reduces costs, organizational, regulatory, financial, and cultural (...) barriers have, until recently, prevented widespread adoption of these proven approaches. Provisions of the Affordable Care Act, such as reductions in Medicare payments to hospitals with very high thirty‐day rehospitalization rates, have reduced barriers, but uptake of evidence‐based transitional care beyond demonstration projects continues to be sporadic and far too slow. With a rich understanding about how to better anticipate and respond to the compelling problems experienced by patients, family caregivers, and health care professionals throughout episodes of acute illness, the time has come to frame transitional care as a system's ethical responsibility in an aging society. Embedding transitional care within the ethical obligations of a health care system requires the perspectives and involvement of nurses and nursing because of this profession's integral role in every aspect of care transitions. (shrink)

In 1997 President Clinton apologized to the survivors of the U.S. Public Health Service Syphilis Study. Since then, two of his recommendations have received little attention. First, he emphasized the need to remember the shameful past so we can build a better future for racial'ethnic minority populations. Second, he directed the creation in partnership with higher education to prepare training materials that would instruct biomedical researchers on the application of ethical principles to research with racial/ethnic minority populations. This article proposes (...) the inclusion of these issues in the implementation of the Affordable Care Act. It asks, What is the right or good thing to do? What are our obligations to one another? Two challenges are examined: (a) Conducting research with African Americans without knowledge of bioethics specific to this population, and (b) the ethical dilemma of conducting research that does not adequately take into account the diversity within the Black population that is a contributing factor in health disparities. Training and policy recommendations responsive to President Clinton's Apology are presented. (shrink)

Proposals for how health care ought to be allocated and delivered in the United States have been debated for at least the last 80 years. The last major effort at expanding health-care coverage in the US was the Affordable Care Act, which went into law in 2010. The ACA increased the number of Americans who have medical insurance, but it has nonetheless fallen short of providing universal coverage, and as of 2017, 8.8% of Americans, or 28.5 (...) million, were uninsured. So far, Republican efforts to fully repeal the ACA have failed, but Republican lawmakers have whittled away at crucial elements of the Act (including, importantly, the individual mandate that compels individuals to obtain insurance or... (shrink)

In the debates surrounding the Patient Protection and Affordable Care Act, little attention has been paid to definitions of important terms like "health care," "disease," and "disorder." When health care is discussed, one assumes universal definitions of terms and a common understanding of their meanings. But delving deeper into the subject, one finds that a common understanding is lacking. Specifically, the liberal tradition, from which the health care act was derived, defines important health care (...) terms in ways that most people would not. This paper applies Alasdair MacIntyre's discussion of tradition-based rational enquiry to show that proper definitions of "health care," "disease," and "disorder" should be based on the normal functioning of the organs and organ systems of the human body. (shrink)

While the impacts of the Affordable Care Act will vary across the states given their different circumstances, Massachusetts’ 2006 reform initiative, the template for national reform, provides a preview of the potential gains in insurance coverage, access to and use of care, and health care affordability for the rest of the nation. Under reform, uninsurance in Massachusetts dropped by more than 50%, due, in part, to an increase in employer-sponsored coverage. Gains in health care access (...) and affordability were widespread, including a 28% decline in unmet need for doctor care and a 38% decline in high out-of-pocket costs. (shrink)

In The Ethics of Universal Health Insurance, Alex Rajczi shows how defenders of universal health insurance can address the ethical issues raised by these objections and make the moral case for an American universal health insurance system that improves on the gains made in the Affordable Care Act.

ABSTRACTThe health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance . In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee (...) education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives. (shrink)