Friday, January 21, 2011

States are the Hotbed for Medical Ethics

On Tuesday, by voting to repeal the Patient Protection and Affordable Care Act (ACA), all 242 Republicans in the House of Representatives proved the truth of Winston Churchill's famous comment about us Yanks - "Americans can always be counted on to do the right thing...after they have exhausted all other possibilities."

The law is a prototypical legislative sausage - it's the best we could do at the time given the virulent politics of health care. I'm not a political pundit, but I anticipate that Tuesday's piece of Republican theater will backfire on the party in 2012.

But what is clear is that the states are emerging as the crucial laboratories for health system reform. It's symbolic that on the same day that the Republicans voted in favor of marching backwards to our failing status quo, the Vermont legislature received a bold proposal to create a distinctive state-based single payer system.

Here in New England, Massachusetts, New Hampshire and Vermont, are all hotbeds for creative efforts to get a grip on our failing health system. Massachusetts has achieved the highest level of insurance for any state, using an approach that includes a individual mandate. New Hampshire is conducting a vigorous pilot program of accountable care organizations. Vermont is entertaining a single-payer proposal that has been kept off the federal table by two dreaded words - "socialized medicine." And, with luck, "red" states will test out market-based reform ideas in serious ways.

We can't reform the health system without engaging with deep questions of values: what level of our resources should be allocated to health? how do we balance individual responsibility for our own health with communal responsibility for the vulnerable? what level of health services should a civilized society guarantee to its members? These, and many others, are serious ethical questions, and people of intelligence and good will can differ in their responses.

At the state level, especially in states with relatively small populations, it's easier to keep the political debate at a thoughtful, civil level. Nationally, that's been much more difficult, as evidenced by the "death panel" fiasco. I know from leading classes and meetings on ethics topics that it's crucial to create a safe space for gathering facts, identifying key values, explicating conflicts among the values, designing options, and making choices. As a country of 300 million, tremendous diversity, and limited public understanding of health system complexities, we've done poorly. At the state level, we're doing better. That's where the key learning is likely to occur.

(If you're interested in more on Massachusetts, New Hampshire, and Vermont, there are tabs for each of the states on the blog.)

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