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December 19, 2013 | Posted By Wayne Shelton, PhD

There are some ominous social and political trends currently in American society on which the field of bioethics should focus more attention. In this informal and admittedly polemical blog, I would like to briefly explore a couple of them.

Governors from about half of the states, mostly from the Tea Party GOP, have invoked their constitutional right to deny healthcare coverage to individuals in their states who make less that 138% of the federal poverty level. These governors calmly claim that pragmatism, not politics, is the basis for their decision to refuse their states the opportunity to participate in the Medicaid expansion program under the Affordable Care Act (ACA). It’s just too costly and the Medicaid program is broken, so they say.

Never mind, that the ACA requires the federal government to pay 100% of the costs of Medicaid expansion for the next three years and will cover 90% of the costs thereafter. Never mind that states that refuse to participate in Medicaid expansion will still be responsible for providing emergency room care for uninsured patients, which means costs will be written off as losses by hospitals and passed along to taxpayers. Never mind that participating states in Medicaid expansion, according to a study by the Commonwealth Fund, will be rewarded with new federal funds, and those states that refuse to participate will lose out on billions of dollars. Both Tennessee and Indiana are still considering whether or not to participate in Medicaid expansion and if they do not, each could lose more than $2 billion.

And even if there were some burdens created by states participating in Medicaid expansion, would those burdens be greater than those governors face daily in maintaining the status quo in healthcare delivery? In fact it seems pretty clear, as the Commonwealth study concludes, that none of the governors from states that refuse to participate in Medicaid expansion are making financially prudent decisions. It seems abundantly clear that nothing about these decisions is based on sound pragmatic reasoning pertaining to the hard economic realities.

Let me be blunt: It seems clear to me that the governors refusing Medicaid expansion are ideologues and just don’t believe in large government programs that provide free benefits to the poor, quite independently of the facts. It is comparable to the ill will between the Senate and House conferees over their very different versions of the Agriculture bill which includes a $4 billion dollar cut over 10 years in food stamps by the Senate versus a $40 billion cut by the House version. In spite of the complaints about fraud and abuse by Republicans, there is ample empirical evidence that the overall effects of the food stamp program are positive and that there is a genuine need for this program to continue. We know that poverty rates, according to the Urban Institute, remain at historic high levels, roughly as high as it has been in any year since 1965—15% or almost 47 million people live in poverty. Sadly, children have the highest rate of poverty than any other age group. About 1 in every 5 children is growing up in poverty, which puts them at great risk for poor health and living in a continual cycle of poverty. Even worse, over 38% of all black children and over 27% in the general population of black Americans live in poverty. We cannot forget the obvious: poverty is deeply affected by overall economic conditions, which have been dire since the financial crisis of 2008.

Somehow politicians forget that many Americans living in poverty are working but have incomes below the poverty level. Never mind there will be an economic stimulus effect from putting money into the hands of these people affected by poverty since they will spend it on immediate needs. In the current U.S. economy, it is far from clear if and when we will ever see a significant increase in living wage jobs. In fact, we could be facing long-term structural conditions in which poverty and inadequate health care are chronic features of life for a large percentage of citizens. From a purely economic perspective, how could it possibly be pragmatic for states and for our nation as a whole to reduce funding for the food stamp program any more than it could be to refuse Medicaid expansion? Does anyone really think there are not significant adverse implications to our nation’s economy from allowing widespread poverty and a lack of healthcare to continue?

The aggregate impact of the so-called pragmatic decisions to refuse Medicaid expansion will be that about 5 million poor people in the U.S. will not receive healthcare coverage. This result, along with allowing millions to live in poverty, including many children without enough food to eat, reflect profound social justice issues, topics that gets little traction in contemporary American political discourse. There seems to be a propensity in the American psyche that praises fierce individualism and self-sufficiency as well the highest levels of economic success. In recent decades, and especially in the last decade, the American mythology of hard work and individual success has turned both logic and morality on its head and has blinded too many people from seeing the random historical and social conditions that have contributed to distribution of wealth and success in America. In this light, I suggest that it is time for bioethics to take a new look at some old questions.

What does it mean for individuals to have free will and be responsible for their own plights in life and to be responsible for the lives of their families? What happens when large segments of the populations fail to achieve basic levels of wealth and success such that they cannot adequately feed themselves and their families, not to mention provide healthcare for themselves through employment? What happens when the divide between those who are wealthy and successful and those who are not becomes wider to the point of reflecting vastly different social, economic and political realities? At what point, if ever, does government have an essential role to step in and rectify these conditions? On another level, how can we find ways to help both citizens and legislators view facts more broadly in relation to both economic conditions and principles of morality and justice, as opposed to their ideological perspectives in which information is often distorted according to one’s narrow assumptions?

Given the dire social and economic conditions in the U.S.—the way millions of people today are being denied healthcare and allowed to live in poverty in a time of unprecedented wealth for those at the top of the economic ladder—it is time we have a renewed interest in these questions. In particular, it is time for bioethics to move these questions toward to top of its agenda and to see them as pressing and urgent ethical and social justice issues that they are.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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