Current Legal and Ethical Controversies in American Health Care Health Reform—Achieving Access to Affordable Health Care

Goals of HC System Access Affordability Quality

Where Are We Now? Conglomeration of public and private sectors Public Sector Providers (federal, state, local) Payers (Medicare, Medicaid) Private Sector Providers (for-profit and not-for-profit) Insurance Employer-supported Individual or group policies

“The people that are getting killed in this deal are small business people and individuals who make just a little too much to get any of these subsidies. Why? Because they’re not organized. They don’t have any bargaining power with insurance companies. And they’re getting whacked. So you’ve got this crazy system where all of a sudden 25 million more people have health care, and then people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half…

“It’s the craziest thing in the world.” Former President Bill Clinton October 3, 2016

Fundamental Questions Does insurance=access=health? Purpose of insurance? Is health a “right”? Define Is health care a “right”? A “right” to what (e.g., contraceptives)? Corresponding “duty”? Alternative conceptions of health care? Market good Something people should have

Alternative Approaches Federal v. State approaches Nationalized health system (e.g., VA) Single payer system Free market Consumer choice with subsidies and incentives Regulated competition

HC Financing and Older Americans Should there be a separate program? Alternatives for saving/restoring/preserving Medicare? Status quo Repeal Change eligibility criteria Age Means test at front end Means test at back end (differential premiums)

Change provider reimbursement Change benefits Change provider reimbursement Methods Amounts Change program structure to voucher/premium support Medicare Advantage precedent Medicare Part D precedent

Paying for Long-Term Care Medicare Medicaid Benefits planning techniques Private pay Private LTC Insurance Adverse selection Paying family caregivers? Moral hazard (“Woodwork effect”)

International Comparisons Different goals (Quality of life) Compare apples to apples