Medicare at 50: Our Moral Imperative

Last year, on the 49th anniversary of Medicare, I wrote a post advocating the expansion of Medicare to ensure that everyone in the United States can have access to basic healthcare. In the past year, I have read and heard many arguments against the expansion of Medicare and, in fact, single-payer systems in general. As I read the arguments, I realize that in a sense “Medicare for All” and “single-payer” have become a shorthand way of saying we need to guarantee “universal access to healthcare,” but I still think Medicare for All is the way to go in the United States.

I happily admit, though, that my commitment is to universal access to healthcare, not Medicare. The first step, in my opinion, is to declare that we will provide access to medicare for allhealthcare to all United States citizens. Take this simple idea, and make it law: We will provide healthcare to every citizen of the United States. Once that law is passed, we can have extended debates about whether Medicare can fulfill the purpose of guaranteeing that all citizens will have access to healthcare (my repetition is intentional).

Here are some of the objections I’ve heard and read to expanding Medicare along with my replies:

I don’t want to pay for healthcare for people who are too lazy to work.

Many people I talk to are extremely optimistic about their ability to pay for their healthcare in the case of extreme illness or injury. The fact that you’ve made it so far only means you’ve been lucky, not self-sufficient. Mary Brown, who sued the government over the Affordable Care Act because she didn’t want to purchase insurance, went bankrupt and was unable to pay her bills. In response to her own bankruptcy, Brown reportedly said, “”I believe that anyone has unforeseen things that happen to them that are beyond their control.”  Yes, and the Affordable Care Act was designed to reduce the impact of unforeseen illness and injury. Unlike Mary Brown, many people who become medically bankrupt had insurance but weren’t able to cover their medical bills, anyway. A study in 2007 found that three-fourths of people who were medially bankrupt had insurance.  A study by NerdWallet Health found in 2013 that “Despite having year-round insurance coverage, 10 million insured Americans ages 19-64 will face bills they are unable to pay.”

For people who do have insurance, most get it through their employers. Too many people seem to forget that when they face unforeseen illness or injury, they will also be unable to work and are likely to lose their employer-provided insurance. If not immediately, it will happen sometime further down the road. Whether the road is long or short, it leads to bankruptcy. While some are rich enough to be impervious to mounting medical debt, most of us are not. A few hundred thousand dollars may sound like a safe cushion against medical disaster, but many life-saving treatments exceed that amount quickly. Selling your house and other assets to pay your medical bills may not be a solution. In fact it probably is not a solution.

The fact is that supporting a national program to guarantee access to healthcare free from the risk of burdensome medical debt is not something you should do only for other people. It is something you should do for yourself. And it is something we should do for our country.

As a nation, we share many burdens: national defense, national safety, public health, personal security. Like infrastructure and security, we are not talking about items we can choose to forgo in leaner times. These are basic human needs. Any society that does not meet the basic needs of its citizens will falter. If we can share the cost of providing a strong military, food inspectors, fire fighters, and police, we can share the cost of providing health services. The financial life you save may be your own.

Most countries don’t have a true single-payer system.

The argument here is that many countries that do guarantee universal access to healthcare do not use a “true” single-payer system. I am willing to concede that even Medicare for All might technically require the use of more than one payer. What is important, really, is that the payers are not invested in fleecing their clients, which often seems to be the case with for-profit insurance companies. In fact, if we had a single for-profit insurance monopoly, we might find our processes somewhat more efficient but not beneficial for consumers, so it matters who the single payer is as well. Just to repeat: we must have a system that guarantees access to healthcare without the risk of bankruptcy.

Medicare is fraught with fraud and abuse.

No one can deny that fraud and abuse exist within the current Medicare system. We need greater transparency, oversight, and regulation of the system and of the providers. Also, Medicare must have the ability to negotiate prices, unlike the disastrous Medicare Part D that currently exists for prescription drugs.

Corporations will game the system.

It is true that for-profit providers, whether they are pharmaceutical companies, for-profit hospitals, biotechnology companies, medical equipment suppliers or food vendors, will strive to earn as much profit as is humanly possible. This is why we need a system that empowers taxpayers to hold bad actors accountable and demand transparency regarding pricing and profit. Corporations will serve the common good only when common people demand that they do. Fatalism is an excuse to avoid the hard work of diligence.

We need price controls.

Again, simply removing all but one payer will not, on its own, lower prices. If Medicare simply sent checks to providers for whatever charges they submitted, the United States would continue to have the costliest healthcare system in the world. Medicare must have the ability to negotiate prices and set limits on unchecked profits.

We must limit unnecessary tests and treatments.

In a pay-for-service system, hospitals, labs, equipment manufacturers, and others make money every time someone is tested or treated for anything at all. More and more studies are finding that many tests lead to unnecessary treatment, waste money, and (even worse) cause more injury and death than they prevent. Unfortunately, limiting the number of tests and treatments available to patients is likely to be perceived as (shriek) rationing.

With our current system, we trust insurance companies to refuse payments for useless or harmful tests and treatments, but we know this does not always happen. When it does, clients fear they are being denied necessary tests and treatments. They fear this largely because it is sometimes true. Whether Medicare is expanded or not, we need better ways to evaluate what tests and treatments are beneficial, and we need better ways of educating patients on what is and is not beneficial.

Movements toward paying providers for results, not services, may reduce unnecessary and harmful services greatly. It may also force patients to become more responsible for their own health.

Finally

The only real imperative here is that we, as a nation, must decide whether we will provide access to healthcare for all our citizens. Once we agree that we will, we can begin to work out the most efficient and cost-effective means for achieving our goals. Almost no one in the United States is immune from the possibility of medical disaster and bankruptcy. This is a matter of caring for our fellow citizens, but it is also a matter of caring for ourselves.

On the 50th anniversary of Medicare, take a stand for healthcare justice.

The Ethics of Professional Ethics

When I was defending my dissertation a few years ago, a committee member asked me how I would respond to a tobacco company who asked me to advise them on the most ethical ways to harvest tobacco grown on farms in South America. I first answered, honestly, that I couldn’t imagine working for a tobacco company, but then I added that the only advice I could think of would be to choose a more ethical product in the first place and then worry about fair treatment of workers, protection of the environment, and so on.

It would, of course, be difficult to make a living as a professional ethicist if you simply Briberyadvised all your clients to go out of business. Accepting a paying job creates a financial conflict of interest from the beginning. If you want to keep your job, you will immediately know the parameters of your possible advice. In the worst case, you will simply be giving rubber-stamp approval to the activities of your boss. In the extreme case of a tobacco company, this conflict may be clear, but other conflicts are much less obvious.

The best problem for an ethicist to have, I think, would be an opportunity to work for a company or organizations with the same goals and values of the ethicist. It would make sense for a vegan ethicist to want to work for a company that sells cruelty-free products. If the company hired an ethicist to determine what practices ere ethical, it would be a perfect situation, but this is a case of an organization seeking out an ethicist whose conclusions are already known. This is hardly an ethics consultation. And just to vary the scenario a little, it is unlikely that a Catholic-owned organization is going to want to hire an ethicists who does not believe in the sanctity of life just as an organization providing contraception services would not want to hire a Catholic ethicists. If you can simply shop for an ethicist who agrees with your actions beforehand, there is no point in hiring an ethicist.

In some cases, companies really do want to seek expert advice on how to proceed on various products and actions. They seek out, naturally, ethicists who share their overall values but have additional training and demonstrated expertise in evaluating ethical quandaries. When helping some one choose between X and Y, ethicists can make a fairly objective evaluation, given that neither choice is presented as the preferred choice. Rather than “Have we been ethical?” the organization is asking, “Which of these two choices is the most ethical way to proceed?” In this case, asking more than one ethicist would seem advisable. Then, the organization is still responsible for its decision, but it is based on more (and more nuanced) information. Still, it is possible for people to use the ethicist for moral cover (“Hey, the ethicist said it is ok, so there!). Providing moral cover for your employer is just never going to look good.

Ethicists can proceed, though, by offering a thorough analysis without necessarily giving a green light to any particular action. With so much training behind them, ethicists should be well prepared to answer questions about agency, autonomy, rights along with background information on previous cases and debates. We don’t need to reinvent the wheel each time a new problem arises.

The professional ethicist can help with questions such as:

  • What are violations of autonomy?
    Is autonomy the only concern?
    What is the importance of narrative in moral decision-making?
    Do men and women operate with different moral frameworks?
    What are moral agents?
    Who is (or should be) of moral concern?
    What is the importance of virtue in organizational ethics?
    Is care necessarily part of ethical deliberation?
    What are positive and negative rights?
    Which moral choices are obligatory and which are supererogatory?
    What is the difference between human rights, human development, and human capabilities?
    Who is responsible for justice?
    Must ethical decisions be impartial (do family and friends matter more)?

The Problem with Telling Boys to Never Hit Girls

First, I should clarify that I do not think it is acceptable for boys to hit girls, but the admonishment to “never hit a girl” has two problems. 1. It gives tacit permission to hit other boys. 2. It tells boys they have no right to complain when someone hits them. Under this one maxim, boys are certified as aggressors and negated as victims of violence.

If parents and teachers simply told boys not to hit, it would go against everything masculinity represents, unfortunately, in our culture. Fathers would worry that their sons would never toughen up, “grow a pair,” or be able to attract mates. Surely, they say, if boys don’t enter the rough and tumble world of male aggression they will all grow up to be homosexual. Rather, they really mean they will grow up to be “feminine” (I use the quotation marks to show that I do not believe any particular traits are feminine or masculine, but these words are used in stereotypical fashion), which is the real fear. Misogynists assume feminine boys are gay without understanding the difference between orientation and identity or the simple human spectrum of personality traits. It is misogyny that drives the rage against non-conforming boys. It is hatred of who they are more that what they do.

To avoid recriminations, boys with take and give punches and other forms of violence on a regular basis as practice for adulthood. The boy who grows up in this environment isn’t shamed for being violent. Rather, he is shamed when he is passive. If you are a boy who has been told he must never hit girls, when someone hits you, the aggressor has done nothing wrong. In fact, if you don’t hit back, you have done something wrong. You are lacking. Violence is an obligation of masculinity.

If you fail to stand your ground, you will be reprimanded for letting some bully push you around. You will likely be put in self-defense classes. You will likely be told you must toughen up and learn to take care of yourself. While a girl in your position might be given the opportunity to learn self-defense, her status as victim protects her from similar shaming. Violence may be an option of femininity, but it is not an obligation. Boys are denied the status of victim. Boys are told they can only be bullied if they don’t stand up for themselves.

And if a girl hits a boy, the boy is in a double bind. The shame of being hurt by a girl is far greater than the shame of being hurt by a boy, but the opportunity of self-defense or retaliation is taken away. The boy will face shaming such as: “How could you let that happen? She’s just a girl. Don’t hit her! She’s just a girl. Be a man! Just walk it off!” We wonder how adult men become victims of domestic violence, but this pattern is carried into adulthood. The man who is physically assaulted by a woman is rarely recognized as the victim he is. A woman half his size (of course, not every man is married to a woman half his size) couldn’t possibly hurt him. Surely, a grown man can take care of himself? If he strikes back, he earns the label of abuser for himself. His explanations are unlikely to be believed.

In addition to teaching boys that they are acceptable victims of male-on-male violence and that aggression against other boys is expected, it does little to protect the physical integrity of girls and women. Some time back, a video PSA against domestic violence went viral. The video shows boys standing in front of a passive girl as a man off-camera tells them to touch her and caress her. The boys do not hesitate to touch her until the man tells them to to hit her. All the boys refuse, inspiring tears and celebrations around the world. At the end of the video, a boy is told to kiss her. He asks only, “On the mouth or the cheek?” The message, it would seem, is that girls, passive and beautiful beings that they are, should never be hit but should also never have agency over their bodies. They boys say they are against violence, but they appear to have no concept of consent. They are willing to touch her body without her invitation but with the approval of an adult male. Before venturing a kiss, the boy asks the man, not the girl, how to proceed. I find the message of the PSA disturbing.

We could instead teach boys and girls to respect the bodies of all others. Sure, teach the children self-defense techniques but teach them also that aggression is an assault on the bodily integrity of another. Furthermore, this aggression can come in the form of a slap, a kick, or a kiss. We can teach children to respect all bodies and that touching others requires consent, and we can begin by showing respect for the bodies of children. It is not all right to hit girls because it is not all right to hit people. And, as the video below shows, it is not all right to hit animals, either.