SCOTUS, Roe, Reproductive Rights, and All Our Freedoms: We must act

 

Politico, and now other outlets such as the NY Times,  have reported on a 98-page draft opinion from the Supreme Court that, in no uncertain terms, overturns both Roe v Wade and Casey and removes federal protection for abortion rights. While it is true that this is a draft and individual justices’ final decisions could change, the fact that 5 of the justices (Alito, who wrote it, Thomas, Gorsuch, Kavanaugh, and Coney Barrett) signed on to it makes it unlikely that the final decision will change. The only uncertain vote is that of Chief Justice Roberts, but he is no longer the swing vote he once was; the only difference is whether the vote to say that women have no Constitutional right to control their own bodies would be 6-3 or 5-4.

And, absolutely, let us be clear: that is what overturning the 50-year old Roe decision would mean, that the majority of the justices on the Supreme Court will have ruled that the control over a woman’s body, on whether she has to continue a pregnancy regardless of the circumstances, is in the hands of others. It may be Congress, state legislatures, governors, husbands or other relatives, churches that they may or may not belong to or believe in, petty pettifoggers, vicious misogynists, non-vicious misogynists (?), and folks with their own right-wing agendas, but not the women themselves. When Roe was decided, Justice Blackmun, who wrote the opinion, said abortion should be a decision made by a woman and her doctor. That was itself a bit paternalistic, but it was 50 years ago; I think the way that still should be read is “with adequate medical advice”, understanding the potential (or likely) risks involved in the decision that the woman makes. And ONLY the woman whose body involved should be able to make!

The majority of justices on the Supreme Court obviously do not believe this, along with a substantial minority – but definitely a minority – of the American people (most polls put support for Roe at about 70%). Their anti-abortion movement, well funded by multi-millionaires and billionaires, and supported by both the Catholic Church and many fundamentalist Protestant sects, seems to have finally won their cause after 50 years of reactionary fighting to impose their will on everyone else. It is a coup, be certain of that. It was, most immediately, made possible by the fact that Donald Trump got to name 3 Supreme Court justices, through the hypocritically evil behavior of Mitch McConnell the GOP Senate majority, which decided both to block President Obama’s appointment of Merrick Garland, not even holding hearings, 9 months before his term expired, and then approving Trump’s appointment of Amy Coney Barrett just weeks before the election he lost! This alone should be enough to make everyone who cares about reproductive rights, women’s rights, LGBTQ+ rights, voting rights, any rights, pull out all stops to make sure that the predicted Republican victory in November does NOT happen, that McConnell (and I make no analogies since anything you might compare him to would be insulted by the comparison) does NOT again become Majority Leader. The Democrats are far from perfect, but every justice who voted to repeal was appointed by a Republican, and it was the Republican majority in the Senate that facilitated the appointment of the last three. The SCOTUS opinion will say that the decision is Congress’ and there is no possibility that legislation maintaining women’s rights will get 60 votes in the Senate, or even 50 given Joe Manchin. The pundits and pollsters are all predicting a big INCREASE in GOP seats in November. Unless we do something about it.

Make no mistake: this SCOTUS decision is that the opinions of some people are worth more than the lives of others. No one who is opposed to abortion has ever been required to get one by the decision of Roe. Of course, there were many “mental disabled” people or others judged incompetent who were required to get them in the past, vicious abuse in itself. Ironically, the issue is that the same logic is now being applied to ALL women; they do not have the Constitutional right to make their own decisions about their own bodies.  As Susan Matthews in Slate writes, Justice Alito could not find a justification for the right to abortion in the Constitution because “The Constitution was not written for women”. It didn’t even give them the vote!

Although it does not change the core issue, the choice of words in the debate has been unfortunate; anti-abortion people use the term “murder” of “babies” while abortion rights advocates have used the term “choice”, as if it were a matter of convenience, or what color bedspread to get. It isn’t. It is about the decision to carry a pregnancy, something that is medically risky even in the lowest risk people (but a risk that most people who want to have a baby gladly accept), to give birth, to probably raise a child, to completely change their life, to possibly be unable to care for already-born children, to give birth to a child of a rapist (perhaps incestuous rapist), to give birth to a child already unable to survive because of genetic or other malformations occurring in utero, etc., etc., being only the right of the woman who is pregnant, and not that of anyone else. Consulting them – family, friends, doctors, is fine, but the decision needs to be that of the woman alone, not the state legislature.

This decision, if it stands, will not end abortion in the US, as it will send us back to pre-Roe times when the decision was left to the states (indeed, several states had legalized abortion before Roe). So, abortion will likely remain legal in states like NY, CA, MA, IL, etc. But other states, including of course TX and FL, which have already passed draconian restrictions on access to abortion, will almost undoubtedly make it illegal again, along with many others. It has been estimated that abortions will decrease by 14% (“only”) but if this is true, it has to be taken in the context of geographic access. Women with money from TX, FL, and other states that severely limit access to abortion may be able to travel to another state, but poor women, on whom the burden always falls the hardest, will find it much more difficult or impossible, as will teenagers, including those who are pregnant as a result of incestuous rape (see “Who gets abortions in America”, by Sanger-Katz, Miller and Bui, originally published in the NY Times Dec 21, 2021 and republished on May 3, 2022). Health and healthcare are already incredibly inequitable in the US, and this decision will make it much worse. Jill Filipovic, writing in Substack, provides a number of other concerning likely outcomes,  including that there will be a 21% increase in maternal mortality!

And if that were not enough – more than enough – to get your blood boiling,  get you out to the streets, the likelihood that this will end with abortion approaches zero. Many of the opponents of abortion rights also oppose other reproductive rights, including cheap and easy access to contraception and sex education in schools. This would be illogical if preventing abortions were truly their goal, as it is precisely access to these two factors that are universally associated with lower abortion rates – see ‘Scandinavia’. When abortions were illegal in countries such as Ireland, sex education and contraception were also severely restricted – and the abortion rate was higher than in say, Denmark. But the women receiving these abortions, illegally, were at much higher risk. These arguments, however, get little traction, since those who would restrict all reproductive rights are doing it for other reasons – maybe they hate sex, maybe they hate women, but they surely believe that they know better and freedom is not important to them. If this is hypocrisy – they will fight for the right to own and carry a gun or not wear a mask – hypocrisy is not important to them either.

And it will not end with reproductive rights and contraception. Certainly the rights of LGBT+ people will be even more infringed. And our rights to read books and have our children learn science and history. And our right to vote. Listen to the far-right carry on about restrictions on their freedoms, but think about the freedoms that are at the core of the US and on which we depend.

And most important, these are freedoms we can no longer can passively depend on. If you don’t fight for them, they won’t be there.

US Health Rankings remain low and #Trumpcare will make them worse!

On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37^th in the world”  ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.

But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.  

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.

And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from  cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.

So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017)  I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.

Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI), and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.

So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”.  But they will, and we need to move up in the rankings, to be closer to other OECD countries.

Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.

Will the GOP "solve" access to health care? No, unless you can redefine "access"!

An editorial in the New York Times on February 20, 2017 (“Ryancare: You can pay more for less!”) does a very good job of concisely demonstrating what the new Republican plan is likely to do to access to health care, the cost of health insurance, and what it covers. The key to House Speaker Paul Ryan’s plan for replacement of Obamacare involves “…flat tax credits unrelated to income, that could be applied to the purchase of insurance” (Paul Krugman, “Death and tax cuts”, NY Times February 24, 2016). As Krugman makes clear, the credits would be insufficient for low and middle income families to buy insurance, but would be a small benefit to high income households. The obvious result would be the loss of health insurance for millions of Americans who gained it through either the ACA exchanges and accompanying subsidies or through Medicaid expansion.

Giving tax credits or deductions is a long-standing Republican strategy that pretends to be equitable but in reality always benefits the financially better off. Ivanka Trump (the President’s daughter who is not, it should be observed, elected or even appointed to anything) has her pet project, tax deductions for childcare. Again, this sounds good, especially to the more well-off, two-income couples who would benefit (but don’t get your hopes up; the $500 billion tab makes it unlikely to pass even with the First Daughter’s support), but would be of less benefit to the poor. The one thing that is certain about Republican and Trump policy is that it will benefit the better-off; the problem with such deductions, from their point of view, is that it is costly and doesn’t benefit a narrow enough slice of the highest income individuals and corporations (sorry, Ivanka).

As summarized in MedPage’s Washington Watch Policy Papers on ACA Repeal: Many Question, Few Answers, no one, outside the Republicans pushing it, has any belief that the Ryan plan will provide coverage for most of the people who gained coverage from the components of the ACA, not to mention those who remained uninsured even with ACA in place, mostly poor people in states that did not expand Medicaid and undocumented people, as well as those who risked the penalties for violating the individual mandate rather than buy health insurance that they felt they could not afford. The first two groups are completely left out of any “replacement” plan (and of course undocumented people were never part of Obamacare). None of these plans will in any way benefit the middle and lower income people who voted for Trump in part because they wanted to get rid of Obamacare, which was costing them too much, and get the terrific, affordable health care coverage that the President promised them in the campaign. It is not going to happen, and people are beginning to understand that; CNBC reports that Obamacare is getting more popular in the first month of Trump’s presidency.

All that has been revealed so far about the content of a Republican “plan” indicates that it will cover fewer people than the ACA currently does. Some of this has to do with the mechanism of funding, with “tax credits” replacing direct subsidies for lower-income people. There is even a debate among Republican lawmakers about whether those tax credits should be “refundable” or not; if they are, then people will get the amount designated for the tax credit even if that amount is greater than the amount they would have owed in Federal income tax. Thus, it would be a subsidy, and thus many “conservative” (their word) Republicans oppose it. For a very large percentage of those who would be buying insurance and need help, the amount would likely be greater than the amount of Federal tax they owe. Of course, this depends upon how much the tax credit is determined to be; one thing, however, is that there is essentially no chance that it will be enough to actually purchase insurance.

Which brings up another big part of the way Republicans talk about health coverage. They use the term “access” rather than coverage, and have defined it in such a way that it is different from coverage; people, they say, will have the option of buying health coverage, not be forced to, the way that the ACA’s individual mandate did. This requires a conscious effort to ignore the crucial “ability to pay for it” as part of access, and makes the idea of “option” insincere. Something is not an option if you cannot afford it. Sen. Bernie Sanders said, in a good takedown of this use of “access”, that he had access to purchase a $10 million house; he just didn’t have the money to do it!

Insurance companies are a big part of the problem for ACA. The absence of a “public option”, not to mention a single-payer plan, meant that the law had to build in a way for insurance companies to be able to make money. To be able to profit, they have to either be able to charge a lot for coverage (or deny it altogether) for sick people, which was the pre-ACA status quo, or have a large pool of healthy low-cost people buying insurance. Thus, especially given ACA’s elimination of their ability to refuse insurance to people with pre-existing conditions, the individual mandate, requiring everyone to buy insurance, was needed. Despite the mandate, though, not enough healthy people bought insurance, and there was no rate cap, so it quickly has become unaffordable for many. Of course, we could have done what other developed countries do – have either a single-payer system where we have everyone automatically in the risk pool and everyone is actually covered, or have a highly regulated system, where benefit packages and rates are set by the government and insurance companies are non-profit, so compete on customer service. We actually have examples of both in the US. Medicare is a single payer plan (and while Medicare Part A, hospital, is paid for by the Medicare trust fund, Part B, doctor and outpatient bills, require individuals to pay, with high-income  people paying a supplement), as is the military health care system and the VA. Medicare supplement (Medigap) plans are regulated with regard to benefits; there are a number of plans lettered Type A to Type N (except there is no E, H, or I) with different benefit packages. The degree of comprehensiveness does not follow the alphabet (F is the best, K probably the worst) but at least they are standardized so all Type A, C, F, or K plans offer the same benefits regardless of which company you buy from, and so you can shop based on price.

I do not think that we are going to have such a simple situation as a highly-regulated marketplace, and certainly not single payer. We are likely going to back as far away from comprehensive coverage and affordable health care as the Republican Congress and President can get away with, which means as far as the American people will allow. Of course, the American people (other than the small number of, but incredibly powerful, wealthy ideological conservatives) do not want to lose their health coverage; they just want to pay less. Or not pay until they are sick. For them, and maybe for their families. For others, maybe not so much; some studies have found that as many as 2/3 of Americans support Medicare for All, while for Dr. Paul Gordon on his “Bike Listening Tour” across the US in 2016, one of his most upsetting findings (at least among the mostly white, rural, northern people he interviewed) was people’s lack of concern for others. Or at least “the other”, folks not like them.

It’s a real shame. We could have comprehensive quality care for everyone, at a more reasonable cost. Too bad the ideologues and the greedy are in control.