EDITOR’S NOTE: Bioethicist Rory Kraft brings us this handy explanation of the complicated legislative processes in the U.S. Congress, and offers some recommendations for ethicists’ involvement in American healthcare reform going forward. For Kraft’s previous IJFAB Blog reflections on health care reform see this and this.

Last week, the U.S. House of Representatives passed the American Health Care Act (AHCA) 217 – 213. The bill now goes to the U.S. Senate.  For anyone who managed to miss the vote, no Democrats voted for the bill; Twenty Republicans voted against it (there are currently four vacant House seats; Republican Dan Newhouse of Washington state did not vote).

When it arrives at the Senate one of the first things which will happen to the bill is that the Senate’s parliamentarian Elizabeth MacDonough will determine if any portions of the bill violate the “Byrd rule” which holds that only budgetary matters can be included in a reconciliation bill (the AHCA is a reconciliation bill, roughly understood as dealing only with budgetary matters and avoiding policy changes; thus the “repeal” of the ACA is better understood as a change in funding mechanisms).  The remaining portions of the bill will be sent to committee for hearings, committee votes, and–one would assume–a vote of the Senate as a whole.  As a reconciliation bill, cloture is not needed to go to a vote so “only” 51 votes are needed to pass the resolution (Republicans currently hold 52 seats in the Senate).

Since the Senate does not have the comparative safety of gerrymandered districts, each senator will be feeling pressure from their constituents across their state – urban and rural, financially well off and those struggling, liberal and conservative, etc.  This need to appease a larger cross section of constituencies in order to be well placed for reelection historically means that the Senate is more politically moderate than the House.

From what can be gleaned in media reports, most senators are unlikely to support the massive funding cuts to Medicaid. What’s more, the additional $8 billion in funds provided through the Upton Amendment–which apparently was instrumental in getting enough moderate Republicans to move to a “yes” vote in the House–is being seen as both insufficient for needs and overly broad.

Thinking through the (bio)ethics here is in some ways the hardest part of confronting this legislation.  Most bioethicists approach the underlying questions of access to care and cost of care as falling under a Beauchamp and Childress principle for justice.  Others might find a motivation from a Utilitarian desire for the greatest good for the greatest number, or a deontological demand to treat others as ends-in-themselves.  For those convinced by the appropriate ethical scope of health care legislation, the AHCA does nothing to address the underlying problems of access while potentially leaving many with insufficient coverage at a more expensive cost. They see the AHCA as a move in the wrong direction, away from better access and toward wider disparities.
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But in the political sphere many have complained, and had their calls taken up by mainstream Republicans, that the Affordable Care Act (ACA/ “Obamacare”) is governmental overreach. From “Cadillac taxes” on coverage deemed too good to the prevention of selecting bare-bones (catastrophic) coverage, complaints from free-range advocates are easy to find. The implementation of the ACA revealed issues which do indeed call for repair of ACA, from employer mandates of expanding health insurance coverage to less-than-full-time employees to the murkiness of the difference between a well-visit (often not charged to the insured) and preventive care (often charged to the insured).

But the AHCA as forwarded from the House addresses few, if any, of these issues.  Instead (and in part because the bill was supposed to narrowly be a budget bill) it operates by removing the means of implementation of the ACA. Setting aside whether a repeal of the ACA is needed, the AHCA is not a clean repeal.

This reveals what should happen next.  The Senate needs to act like adults and put forward a bill which repairs and replaces the ACA.  Anything less than this is pandering to a narrow band of activists who are upset about the naming (“Obamacare”), but approve of the content of the ACA.  Report after report have shown that ACA’s provisions have broad appeal (no pre-existing condition exclusion, allowing individuals to remain on a parent’s plan until 26, etc.). What may be the ultimate “turn-off” for many seems to be the nicknaming of the coverage as “Obamacare.”

To restate my opening question, what now?  In light of the House’s passage of AHCA, what are we to do?

Ethicists and bioethicists should more fully embrace the opportunity to express – again – the arguments for why the ACA’s reform of the U.S. market-based health insurance did rely upon multiple understandings of ethical action.  Beyond this larger role of public philosophy, there are things that can be done as U.S. citizens.  Contact your senators and, if need be, encourage them to vote against the AHCA and hold hearings to do a real repair of the ACA.  Some early reports are hinting that the Senate will generally reject the bill and prepare their own version.  Then, after you have done this, encourage everyone you know to do the same.

If ethicists can agree on anything in this discussion, it is that getting problems with health care access solved is a just thing to do.  Now we need to join in the conversation to ensure that we can do so.