Wednesday, September 16, 2020

MEDICAL BANKRUPTCY, PERSONAL LUCK AND A NATIONAL SIN

By Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair at the Center for Practical Bioethics
Professor of Pastoral Theology—Ethics & Ministry Praxis, Central Baptist Theological Seminary
Clinical Professor, School of Medicine, University of Kansas Medical Center
Director, Hospital Ethics Consultation Service, The University of Kansas Health System

I was raised on a farm up in Minnesota by Fundamentalist Depression-era parents. Among the many rules taught by words and deeds was that you don’t buy what you can’t afford. And never accrue debt. Save enough to buy a car when it’s needed, and then only buy the car that costs the amount you have saved.

That policy worked well for my nuclear family because of white privilege and a whole lot of luck. Others in our family had not always been so lucky, however. My grandparents, on both sides, had bad luck during the 1930s. They had accrued debt that they couldn’t pay when times got hard. Family farms were lost. Everything gone to debt collectors, some of whom were luckier neighbors. So “Never buy what you can’t afford” became our mantra. Not cars or even farms. Never acrrue debt. 

What works for some and in regard to cars or farms doesn’t work as well when what one cannot afford is healthcare. I can live with a cheap set of wheels, or maybe none at all. But my Depression-era father could not live without expensive cancer and cardiology care when he needed it. And there were no cheaper options. In healthcare emergencies, there is no Ford instead of a Lexus. It’s all Lexus. Or Lamborghini. Thank God my Dad had Medicare. Thank God I have employer provided insurance. 

But not everyone is so lucky. That is the truth we all know and of which we’re reminded by a recent (September 1, 2020) West Health and Gallup report on bankruptcy due to medical costs. What researchers learned is summarized in the title: “50% in U.S. Fear Bankruptcy Due to Major Heath Event.” https://news.gallup.com/poll/317948/fear-bankruptcy-due-major-health-event.aspx  

While half of all adults reported that they are either “concerned” or “extremely concerned” that medical bills will bankrupt them, 64% of non-white adults are in that category, an increase from 52% reported in 2019.



 


There are no real surprises here. Why wouldn’t at least half of U.S. adults be concerned or extremely concerned about the specter of financial disaster if they get sick? On an inventory list of healthcare products and procedures for sale, there is virtually nothing the average person could afford to buy out of pocket. Yet when healthcare is really needed, we either buy or die. Or perhaps we don’t die but suffer instead, including the financial stress of accrued debt. For lack of good alternatives, many have bought what they couldn’t afford.

Of what am I reminded when reading this Gallup report? That Depression-era wisdom applicable to car-buying doesn’t work when it comes to healthcare—or only if one is very lucky. Surely in this nation we can and should depend on something other than luck. Shouldn’t we?

Actually, my people never used the word “luck”. We talked in terms of being “blessed”. We were blessed even if others were not when medical and then financial disasters struck. 

Really? I have come through my own faith journey to see things differently. Being blessed or not implies the intervention of a higher being, the actions of God. While remaining devout in my faith tradition, what I no longer believe is that God is the agent of inequity. When it comes to healthcare disparities and consequent financial disasters, I have stopped blaming God, even by implication. This mess is our fault. As a people, we have failed each other. It is a failing that many who believe as I do recognize as sin, both personally and socially. And individuals like my father and I who have thus far escaped the consequences of our national sin are indeed lucky while others are not. 

But even for those most fortunate and privileged, luck has a way of running out. If only as a matter of self-interest when it comes to healthcare costs, or possibly out of compassion as well, we all ought to be “concerned” or “extremely concerned.” Shouldn’t we?

[Portions of this essay were previously published Sept 14, 2020 in an article at GoodFaithMedia.org by Zach Dawes. https://goodfaithmedia.org/reaction-and-response-medical-bankruptcy-concerns-half-of-us/.]


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Monday, June 29, 2020

SUPPORT MISSOURI MEDICAID EXPANSION

Register by July 8 to Cast Your Vote on August 4 Ballot

On Tuesday, August 4th, voters in Missouri will have the opportunity to vote on a ballot measure called Amendment 2, which amends the Missouri Constitution to “adopt Medicaid Expansion for persons 19 to 64 years old with an income level at or below 133% of the federal poverty level.” Your vote is critical.

The referendum prohibits making eligibility requirements more strict for the expanded group than what the more limited group faces. It requires state agencies to maximize funding received from the federal government for expanding Medicaid in Missouri, making millions of dollars available for health coverage to Missouri’s poor.

Medicaid is a critical part of our healthcare system, providing coverage for people with limited incomes. But in states like Missouri that have not yet expanded Medicaid, many people fall into what is called the “coverage gap” - a no-pay zone where poor and mostly working Missourians live without the benefit of health insurance and cannot receive subsidy or help with their premiums as their peers in 36 states across the nation do.

Medicaid expansion would allow those poor Missourians to get basic coverage they need to take care of themselves and face health crises of any kind head on –  even things like COVID-19!  Employer-based health coverage is being cut drastically due to COVID and people need help, NOW!  Nearly one-quarter million Missourians would receive help through expansion - and that’s a figure before COVID-19 happened resulting in thousands more laid off workers who now have no income for health coverage.

The expansion of Medicaid in Missouri is funded by tax dollars that Missourians pay and receive no benefit. In effect, the expansion “brings our tax dollars home,” putting that money back into local communities, creating jobs and supporting hospitals from inner city urban areas to small rural communities  - the very settings that are struggling to keep their doors open.

We need every voter in Missouri to register to vote by July 8 in order to cast a ballot on August 4 for Medicaid expansion in Missouri. Do you part and take action, spread the word.

For more information about keeping our communities healthy through the Missouri Medicaid expansion and how you can support this initiative, go to yeson2.org 

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Wednesday, June 24, 2020

National Healthcare Decisions Day 2.0

In the future, those of us who survive 2020 will use words like “scary,” and “uncontrollable” in describing this pandemic year. But right now, you can control one very important aspect of your life – the end of your life. I’m not being flippant. It’s true.
Due to the pandemic, National Healthcare Decisions Day (NHDD), which is always the day after Tax Day, is doing a reboot or a second round – a 2.0. Since Tax Day was moved to July 15, NHDD is moving to July 16. NHDD has always used the “death and taxes” slogan to remind people to complete or review their advance care directive.
On the Center for Practical Bioethics website, we’ve made it easy to host an NHDD health fair-type event at your hospital or organization with your choice of two marketing kits.
If you’re an individual who hasn’t completed your advance care directive, we offer a free download from our website of our workbook in English or Spanish. 
Whether you are an organization or an individual, you can call us anytime if you have questions or need guidance on advance care directives.
So 2020 is scary and much of what’s happening may be uncontrollable, but hosting an NHDD event or filling out your directive can be an easier accomplishment in 2020 with the Center’s resources.

Written by Monica Delles

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Wednesday, June 17, 2020

Ethics Consultation in COVID Times

Q:  What happens to clinical ethics consultation in a pandemic?
A:  Ethics consultation continues, only more so.

During the first few months of the coronavirus pandemic, with a significantly lower overall inpatient census and fewer providers seeing outpatients, ethics consultation at the University of Kansas Health System (UKHS) increased rather than decreased. Not all of the increase is COVID related. Most consultations reflect issues that arise during normal times as well.

Typical Issues, New Perspectives

Some consultation has been COVID specific, including participation on the UKHS Pandemic Triage Team assisting in preparation of guidelines for allocation of scarce resources under crisis standards of care. If hospital admissions exceed our critical care capacity, who gets an ICU bed? If there is just one ventilator available and two patients need ventilation support, who gets it and who is allowed to die? Or the shortage may be of personnel, or dialysis, or medications. Who decides and how? These are matters of ethics.

Ethics consultation services, both at UKHS and the Center for Practical Bioethics, are always available. Always.

Early in this pandemic situation, we responded to queries about a provider’s duty to care and ethically appropriate exceptions to the rule. Other consultation addressed the need to encourage advance care planning further upstream of arrival at the Emergency Department by patients in COVID-19 crisis. Decisions then may need to be made emergently about resuscitation attempts on a patient who may not have wanted it, or for whom CPR will almost certainly be futile—and riskier also for those who provide it. Heightened risk to providers sometimes spawns awareness of ethics issues. This was discussed at great length most everywhere relative to shortages and conservation of personal protective equipment (PPE).

The UKHS Ethics Consult Service responded recently to several situations of ethics dilemma regarding decisions for patients who also are prisoners. Who decides for a ward of the state? Can the patient’s mother be contacted directly, or only by permission of the warden? Ought we allow prison guards in the COVID “hot zone”? Not all such cases arise as a direct result of a pandemic, but there seemed more of them recently, perhaps with correlation to the inordinately high incidence of coronavirus transmission within incarcerated populations.

Same Process, New Technology

Consult requests can come at all times, pandemic or not, and at all hours of the day and night. Health system ethics consultants typically are happy to respond with ethics assistance at 3 or 4 A.M. even on a holiday weekend, as happens occasionally for this consultant. I might heat up a cup of coffee before picking up the phone to return a call after the Ethics pager has gone off in the wee hours, but it is a privilege to collaborate with resident physicians and night shift nurses on ethical care to patients—whenever need arises.

The UKHS ethics consult service has been carried out during COVID times both virtually and with physical presence in clinical settings. For the most part, we are doing “tele-ethics.” Like tele-health generally, we too make optimal use of confidential email, phone calls, Zoom meetings, and ethics notes posted to the electronic medical record. Some of our consultation team members are considered “essential” healthcare workers in their primary roles of physician, nurse, social worker, or administrator. That has enabled us to offer physical presence at the bedside or on the unit when face-to-face communications are necessary or at least better than virtual only.

Ethics consultation continues during COVID times as it did before this global strangeness began. Pandemic conditions may have put the pause on elective services for a time, but Ethics is never elective. Ethics consultation services, both at UKHS and the Center for Practical Bioethics, are always available. Always.


By Tarris Rosell, PhD, DMin
Dr. Rosell is the Rosemary Flanigan Chair at the Center for Practical Bioethics and  Director of the University of Kansas Health System Ethics Consultation Service and Co-Chair of its Hospital Ethics Committee. He is also the Center for Practical Bioethics’ 2020 Vision to Action Award honoree.


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