How do you think that our current political climate may affect the Affordable Care Act? And what do you consider to be one of the most important principles of public health ethics?
The Patient Protection and Affordable Care Act, Public Law 111-148, also known, mainly by its critics, as "Obamacare," was one of the most far-reaching and controversial legislative efforts of the past 20 years. While the full effect of the Affordable Care Act (ACA) was never going to be felt for at least a decade following its passage in 2010, the fact that its provisions represent the very boundary that separates conservatives and liberals in terms of views on the government's role in the economy and in dictating how privately-owned businesses operate virtually guaranteed that the ACA would continue to be the subject of innumerable political debates. Sure enough, that is precisely the situation that has evolved since the law's passage. Adding fuel to the fire is the fact that so few members of Congress had actually read the legislation before it was voted upon, relying on their staffs, special interest groups on both sides of the debate, and White House cajoling and pressuring to dictate the original bill's destiny.
While the full effects of the ACA remain to be felt, enough is known about the voluminous legislation that became law to suggest that its provisions will remain contentious for years to come, with most Republicans struggling to amend or even fundamentally gut the existing law and most Democrats struggling just as mightily to protect it. What the future holds for the ACA, therefore, will be contingent upon the balance of power between the two chambers of Congress and between Congress and the White House. With President Obama's term ending in January 2017, whichever political party occupies the White House following his departure will largely determine the law's future. Republicans currently hold majorities in both chambers of Congress, but have failed in their efforts to date at rolling back the ACA -- efforts not helped by two U.S. Supreme Court decisions that have upheld the law's constitutionality. The rules that govern the operations of the Senate are such that simply holding a numerical majority is insufficient to ensure passage of legislation favored by the majority party. Individual senators can filibuster and place holds on bills that come before the Senate, and that power is wielded almost every day by one senator or another on all matter of issues.
In short, then, the future of the ACA is dependent upon the outcome of the next presidential election, scheduled for November 2016. If a Democrat wins, then the law will likely remain intact; if a Republican prevails, and the Republicans continue to hold majorities in both chambers of Congress, than it will be very difficult for Senate Democrats to preserve the law in its entirety. Some changes in the existing law could occur.
With respect to public health ethics, what one considers the most important is dependent upon each individual's personal beliefs. Personally, this educator views as the most important ethical standard, even more important than patient confidentiality, is the thousands-year-old adage of "first do no harm." The ancient Greek figure of Hippocrates is considered the father of medical ethics, and it was his philosophical approach to the ethical responsibilities of medical practitioners that continue to guide physician training today. The Hippocratic Oath, sworn to by graduating physicians, includes the phrase: "I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism." What this means in practical terms is that doctors promise not to impose treatments on patients that they know or suspect are not really necessary. It has been known for ethically-challenged doctors to recommend medical procedures that are not really necessary for the welfare of their patients, but that will generate revenue for the medical practice. Similarly, doctor pledge, in effect, not prescribe expensive medications just because they are being paid by pharmaceutical companies to do so. In short, act ethically.