All posts by Carthi Mannikarottu

Obamacare Lives On, For Now…

This morning, the Supreme Court of the United States ruled that individuals who purchase health insurance through the federal government’s exchange will continue to be eligible for tax subsidies.

This King v. Burwell ruling came after months of political upheaval and planning for the aftermath of the court decision. An estimated 87 percent of individuals who enrolled through are receiving subsidies. If the plaintiff had won the case, more than 6.4 million people would have lost the subsidies and faced an average premium rate increase of 47 percent, according to the RAND Corporation. The Urban Institute estimated that by using the available subsidy, a typical single person earning below 200 percent of the poverty level spends 4.1 percent of their annual income on insurance. Without the subsidy, it would take 30 percent of that person’s income to keep the insurance.

The case revolved around four words in the Affordable Care Act (ACA): “established by the state.” The plaintiff argued that this means the law prohibits the federal government from providing premium tax credits and cost-sharing reductions to residents who live in states that did not establish their own state health insurance marketplaces. Thirty-four states do not have state-based exchanges.

Today, Justice Roberts wrote in the ruling that “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them” and that the law must be read with its intent in mind.

The White House went on record multiple times that it did not have a contingency plan to restore subsidies if the Supreme Court ruled against the administration.

If subsidies were shut down, analysts predicted a classic “death spiral.” Insurers would suddenly have a risk pool filled with high-need, high-cost people, after having priced their 2015 premiums based on a balanced pool containing both healthy and sick people. Many insurers might leave the market, and remaining plans would be forced to absorb disproportionately high-risk customers from any exiting insurers, as they’re required to do under the individual mandate.

The insurance and hospital industries are hailing the rule for creating a “more stable” future. Share prices soared, with several hospitals hitting all-time highs. Democrats on the Hill announced the ruling as a win for America while many Republicans made it clear they will not give up their efforts to repeal the law. Presidential candidates on both fronts released statements and took to Twitter to share their views.

Rand Paul posted that “this decision turns both the rule of law and common sense on its head,” while Hillary Clinton tweeted, “Yes! SCOTUS affirms what we know is true in our hearts & under the law: Health insurance should be affordable & available to all.

Although there will continue to be hot rhetoric from Republican presidential candidates, this suit has been widely regarded as a “final test” for the ACA. It is highly unlikely that the ACA will have to face another legal challenge of this magnitude in the courts. The other controversial provision, the individual mandate, was upheld by the Supreme Court in 2012.

It appears the ACA is the law of the land – here to say forevermore… unless there is a total Republican sweep of Congress and the White House in 2016. Then the fun begins again.


Framing the Conversation on Dying in America

As a semi-typical middle schooler cramming for the Spelling Bee, my favorite thing about words was that they had both connotations and denotations. Denotations may be the dictionary definitions the announcer gives out, the ones I begrudgingly memorized, but the connotations were the ones that mattered. As more states look at end-of-life care and more articles crawl up the newsfeeds, I find myself thinking about how the words we use interchangeably are often masquerading as synonyms to further complicate already-complicated issues.

Dying is never easy. The ethics of physician-assisted dying is nuanced on both sides. Proponents argue for a right of self-determination; if we hold to our rights on living the way we want to live and receive healthcare to maintain our living capabilities, it only seems natural to receive help from the medical system to spend our last days in a dignified manner. For some people, this is much too simplified. Patients can feel pressured by families, psychological disorders, pain, financial problems, and the feeling that they are too burdensome on others. There is the possibility of developing into a weapon against the disabled community, or growing into a system of injustice against seniors.

At the same time, who can deny a terminally ill patient the right to remove himself from pain? The right-to-die and slippery slope arguments are complex, balanced on a multitude of factors that range from gender and economic variables to geographic location and religion.

How does this complexity relay itself to a world of click-baiting headlines and 140 characters? Not easily.

When the subject was “Dr. Death,” the enigmatic pathologist Jack Kevorkian who helped over a hundred patients die, the media was not as divided. Dr. Kevorkian often broke his own rules and many reports on both sides of the debate questioned whether his patients were even terminally ill. His “mercy machine” was dubbed the “death van” and his legacy remains exceptionally controversial. But activist and patient Brittany Maynard brought a different light.

“Brittany Maynard, because she’s young, vivacious, attractive, a newlywed, has a dog, and is a very different kind of person from the average middle-aged or older person who has to confront issues about terminal illness, changes the optics of the debate.”

According to bioethicist Arthur Caplan, her story grabbed the attention of a new generation. Her video went viral, blogs on both sides erupted and Twitter was all ears. Her courage and background captured imaginations and emphasized the relevance of the conversation to a broader audience. But it didn’t make it any less complicated.

Take the headlines in themselves- “physician-assisted suicide” is the key phrase that garners the most media hits, but supporters might prefer “physician-assisted death” or “aid in dying.” The “Death with Dignity” movement, discussions on the “End-of-Life Option Act” and organizations like “Compassion and Choices” remove the seemingly problematic connotation of “suicide.” Implicit within the understanding of that word is the notion that it is wrong; the person making this decision needs intervention, even involuntary psychiatric treatment but not drugs for dying. Those who attempt suicide are not generally seen as people making conscious decisions. Thus, their rights of self-determination are overstepped by a moral medical system that saves lives. The “end of life option,” on the other hand, highlights the autonomy each patient has in deciding how to die. The implication is that just as we plan for each stage in our lives, we should make informed choices on death as a natural extension of life.

When asked about allowing doctors to “end the patient’s life by some painless means,” a grand majority (70%) of Americans were in favor of allowing doctors to hasten a terminally ill patient’s death. But when asked about doctors helping a patient “commit suicide,” only 51% were supportive.

A 2013 Gallup poll is the perfect example of how much word choices say. There is no question of reaching an easy consensus on the issue, but framing the debate? That can be an important conversation to reduce noise. Dying vs. Suicide, Murder vs. Mercy, Choose vs Commit – the issue brings to light the myriad ways in which those who spark conversation in society direct the debate.