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October 10, 2021
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Most of us are unable to prove what we claim to know. We rely on others or on past experiences to shape our thinking – and we leave it at that. So when something is set, it becomes hard to break precedent.
The Affordable Care Act (ACA) is a prime example. Once it became law, the many legislative and judicial efforts to curtail or limit it fell flat. It appears the ACA is here to stay, and healthcare will continue along its expansionist journey, soon to encompass dental, vision, and hearing benefits.
At first blush, expanding healthcare seems logical. Healthcare disparities contribute to economic disparities, and as the pandemic revealed, economic disparities contribute to healthcare disparities in turn, forming a vicious cycle.
But like most things at the confluence of politics and healthcare, not what it initially appears to be. Healthcare expansion is not a uniform process, and expansion often leads to gaps in coverage for certain states, particularly states that have more conservative delegates.
For example, in Georgia many African Americans fall into healthcare coverage gaps and expanding healthcare benefits, particularly through additional Medicaid benefits, would do little to address the coverage gaps for minority populations. Expanding additional healthcare benefits would disproportionately help non-minority populations and ironically worsen healthcare inequity in the state.
In many ways, healthcare expansion does not mean healthcare equity. Rather, it correlates more strongly with increased government control, implemented through funding mechanisms and selective coverage options.
Government control, as we have seen throughout American history, often leads to moralizing medicine through legal statutes and litigation, something epitomized when discussing the issue of abortion.
It is the most polarizing healthcare issue today. State legislation on abortion restrictions instantly becomes national news. The Supreme Court is obsessed with it. The Department of Justice sued the state of Texas over its recent abortion law, creating a schism within the state’s federal court system.
Amidst all the political turmoil, abortion has become less of a medical issue and more of a legal construct – a transformation that comes at the cost of maternal outcomes.
The World Health Organization (WHO) found that abortion-related deaths are more frequent in countries with more restrictive abortion laws (34 deaths per 100,000 childbirths) than in countries with less restrictive laws (1 or fewer per 100,000 childbirths).
But in the United States, legislators and judges seem more concerned with restricting abortions through the pretense of medicine than in optimizing maternal outcomes. As a result, we see laws use flimsy clinical justifications such as fetal heart rate to define the start of life and accordingly, the legality of abortions – pretenses that have little conventional medical basis.
These two trends, healthcare expansionism and the excessive regulation of abortions, when combined create a dangerous precedent for American society.
Healthcare expansion is presented as a means to address healthcare equity, but it leads to increased government control. Increased government control leads to more regulations in healthcare, which lead to policies derived not through established medical care, but through the moralization of medicine passing as healthcare policy.
We see this with abortions, leading many to travel long distances to obtain out of state procedures. We see this with chronic pain and addiction medicine, leading to the criminalization of opioid prescriptions. And we will continue to see this as more and more healthcare conditions are legislated and litigated into legal constructs.
This process will worsen patient outcomes and worsen the impact of medical debt on society – by eliminating patient autonomy in healthcare. Patient autonomy is an understated aspect of healthcare, but one that is essential in optimizing patient outcomes.
A diabetic patient must actively manage his or her medications on a daily basis. No amount of persuasion at the physician’s office or some reminder widget can replace individual patient autonomy – a patient’s willingness to improve his or her own health.
A woefully understudied aspect of healthcare, the scant number of studies that have evaluated patient outcomes as a function of patient autonomy found a direct correlation between the two.
This should not come as much of a surprise. If patients are more engaged in their healthcare management, then they are more likely to take action to improve their health. Increasing decisional control in patients leads to an improvement in patient outcomes.
Ultimately this should be the goal for all healthcare policy. Unfortunately this is not the outcome we see in current healthcare policy. Expanding healthcare uses the pretense of healthcare equity to increase government control. Excessively regulated healthcare conditions and procedures use the pretense of medical care to moralize medicine into law.
Both of which worsen patient outcomes, by directly restricting individual patient autonomy. Yet we press on, looking for more ways to expand healthcare and to regulate hot button health issues, creating a disconcerting precedent – one in which healthcare policies no longer reflect individual patient care.
Hopefully we can break this precedent before it sets in. The path to a dystopian future begins with undue government encroachment into healthcare.
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