Tag: community services

Bioethics Blogs

Whatever Happened to Long-Term Care Reform?

From the Trenches: A Prescription for Change

I have enjoyed looking at the pictures of protestors being arrested in our nation’s capital. I concur with many commentators who credit the civil disobedience of the protestors – many of whom are members of the disability rights activist group ADAPT – with the defeat of the Senate bill to abolish the Affordable Care Act. It’s also been fun because I know so many people in the photos.

The Affordable Care Act was a massive piece of legislation. The complexities and moving parts are best understood by people who have very closely followed or implemented the law. I generally think of the ACA as three things:

1. Reform of the private insurance market with the goal of providing greater access to insurance coverage;

2. Changes to Medicare, such as closing the prescription drug donut hole; and

3. Changes to Medicaid. 

Mike Oxford, Executive Director for Policy at the Topeka Independent Living Resource Center and a member of the national chapter of ADAPT, was one of many who protested against the Senate bill to repeal the Affordable Care Act.

Community Services Optional?

The Medicaid issue that has drawn the most attention is the matter of expanding access, appropriately called “Medicaid expansion.” But the law contains other Medicaid provisions as well. It provides incentives for states to continue to “re-balance” their systems of providing long-term care. “Re-balance” is often mentioned in quotation marks because states were never in balance. Nonetheless, through the ACA, states were provided additional federal matching funds if they would transfer more long-term care to community services and away from institutions, such as nursing homes.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Whatever Happened to Long-Term Care Reform?

From the Trenches: A Prescription for Change

I have enjoyed looking at the pictures of protestors being arrested in our nation’s capital. I concur with many commentators who credit the civil disobedience of the protestors – many of whom are members of the disability rights activist group ADAPT – with the defeat of the Senate bill to abolish the Affordable Care Act. It’s also been fun because I know so many people in the photos.

The Affordable Care Act was a massive piece of legislation. The complexities and moving parts are best understood by people who have very closely followed or implemented the law. I generally think of the ACA as three things:

1. Reform of the private insurance market with the goal of providing greater access to insurance coverage;

2. Changes to Medicare, such as closing the prescription drug donut hole; and

3. Changes to Medicaid. 

Mike Oxford, Executive Director for Policy at the Topeka Independent Living Resource Center and a member of the national chapter of ADAPT, was one of many who protested against the Senate bill to repeal the Affordable Care Act.

Community Services Optional?

The Medicaid issue that has drawn the most attention is the matter of expanding access, appropriately called “Medicaid expansion.” But the law contains other Medicaid provisions as well. It provides incentives for states to continue to “re-balance” their systems of providing long-term care. “Re-balance” is often mentioned in quotation marks because states were never in balance. Nonetheless, through the ACA, states were provided additional federal matching funds if they would transfer more long-term care to community services and away from institutions, such as nursing homes.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Ethics of the Trump Budget: The Social Contract is Dead

by Craig Klugman, Ph.D.

President Trump released his blueprint for a 2018 federal budget. From an ethical standpoint, the President seems to operates from a Hobbesian standpoint—life is nasty, brutish and short. However, unlike Hobbes who believed that we came together to protect ourselves from this reality, the new budget seems to encourage this idea. The new budget makes deep cuts to all social and scientific programs while boosting the military. In Hobbesian terms, Trumps’ social contract is all about bullying outsiders while leaving insiders in a state of hopeless diffidence.

Since World War II, the United States has invested heavily in science and technology, developing transportation, and building a better world (and winning wars). Since the 1960s, the US has provided a safety net for the poor, support for the arts, and public broadcasting. Since 1970, the U.S. has worked to ensure that people have the opportunity for flourishing by protecting the environment, providing financial aid for college, and strengthening our relationships with international partners—peace through diplomacy.

The 2018 budget undoes 80 years of social progress and support. The new budget defunds the Corporation for Public Broadcasting, National Endowment for the Humanities, National Endowment for the Arts, and most development agencies. Also eliminated are environmental management, research and education; after school programs, clean energy, chemical safety, community services and development, national service programs, clean air, home investment programs, energy assistance programs for low income adults, minority business development, science education, support for the homeless, and peace.

In addition, the budget significantly reduces funding for science (medicine, basic research, NASA, climate science), health care, the Environmental Protection Agency, the State Department, Departments of Labor, Agriculture, Commerce, Education, Housing & Urban Development, Transportation and Interior.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Politicians, Delusional Managers and the Future of the NHS: Have NHS Leaders Failed to “Speak Truth unto Power”?

Guest Post by David Lock QC

[NB: This is a slightly longer version of a post that appeared on the BMJ blog earlier today.]

Politicians, delusional managers and the future of the NHS:  have NHS leaders failed to “speak truth unto power”?

This blog is not a rant – well not too much of a rant.  It is an expression of serious frustration about the way the NHS is run and about the willingness of senior NHS managers to become complicit in dishonesty.  It also needs to acknowledge the brave role of some in the NHS – particularly in NHS Providers – who keep telling it as it is and being decried for doing so.

Everyone at the frontline knows the NHS is running on empty.  The more perceptive know that more money for the NHS alone will not improve services for patients.  But – and this is perhaps the unpopular “but” – NHS senior managers ought to accept their share of the responsibility for the present crisis.  The problem is the failure of NHS managers to “speak truth unto power” to those above them and to our political masters for too many years.  Long before Sir Ivan Rogers used the phrase, a 2015 FCO blog explained the centrality of this concept as part of public service as follows:

The UK Civil Service doesn’t have an official motto – but if it did, it would almost certainly be: “speak truth unto power”. It’s a maxim that’s in the blood of good civil servants, even if they know that it won’t make their lives any easier.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

British Medical Association Issues Report – “End of Life Care and Physician Assisted Dying”

The British Medical  Association has just published a two volume report on end-of-life care.  

BMA calls for UK Governments to prioritize end-of-life care.  New research finds the current provision does not consistently match either the public or doctor’s expectations.

The research found that while there were pockets of excellence in end-of-life care across the country, the current system has led to a variation in the level of care between regions, within hospital authority areas, and based on a patient’s condition.  Four areas of concern were raised:

1. Communication

End-of-life care and dying were seen to be a topic which many people found uncomfortable, even to discuss between family and loved ones. Doctors recognised that communication between them, the patient and the family could be critical in making end-of-life easier to understand and accept, but many doctors felt uncomfortable about the prospect of having to give uncertain answers particularly on the timescale of life expectancy. 

During the study, very few doctors claimed to have had adequate training in discussing death and the dying process with patients, with many doctors having to develop these skills ‘on the job’. One doctor said: ‘We should say, ‘You are coming to the end of your life’. I think that is where we are failing patients. We are not preparing them. We are not even mentioning the word… So it all comes as a huge surprise… We should be far more frank.’ 

2. Medical services

Doctors were concerned that the quality of end-of-life care is varied. There was a generally held view that patients dying from cancer received better medical care because of the way cancer services were organised.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Ethical Dilemmas In Prison And Jail Health Care

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.