Federal/state tensions in fulfilling Medicaid's purpose.

Medicaid has been subject to reconsiderations of the proper role of government in providing for the health and welfare of populations over recent decades. Over the last decade in particular, a number of states have transferred many functions that they once performed to private entities, including, in a number of cases, express policymaking functions. The Patient Protection and Affordable Care Act (ACA) takes some crucial steps towards readjusting the equilibrium of Medicaid. Rather than further prioritizing the market in its reforms, it gives the federal government stronger charge of Medicaid policy, refocusing the program more directly on expanding eligibility and providing secure care for beneficiaries in the process. I argue that this reprioritization is in better keeping with the purpose of Medicaid, in contradistinction to the market-driven reforms undertaken during the Bush administration and sought by some states today. It does, however, shift more power from the states to the federal government. This has raised concerns not only from states that oppose the new health reform law, but also from a number that support it. These two groups of states share a desire for greater flexibility in their Medicaid programs than the ACA permits. Yet only one of these groups should be permitted to use federal Medicaid funds to make the reforms they seek. Federal administrations need to be particularly careful, when considering whether to grant state Medicaid waiver requests, to uphold Medicaid's purpose of giving lower-income Americans genuine access to the same health care that other Americans receive.

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy.

INTRODUCTION: The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation. METHODS: For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition. RESULTS: The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context. DISCUSSION: Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Professionally responsible malpractice reform.

Medical malpractice reform is both necessary and desirable, yet certain types of reform are clearly preferable to others. We argue that "traditional" tort reform remedies such as stringent damage caps not only fail to address the root causes of negligence and the adverse effects that fear of suit can have on physicians, but also fail to address the needs of patients. Physicians ought to view themselves as professionals who are dedicated to putting patients' interests ahead of their own. Professionally responsible malpractice reform should therefore be at least as patient-centered as it is physician-centered. Examples of more professionally responsible malpractice reform exist where institutions take a pro-active approach to identification, investigation, and remediation of possible malpractice. Such programs should be implemented more generally, and state laws enacted to facilitate them.

Defensive medicine, cost containment, and reform.

The role of defensive medicine in driving up health care costs is hotly contended. Physicians and health policy experts in particular tend to have sharply divergent views on the subject. Physicians argue that defensive medicine is a significant driver of health care cost inflation. Policy analysts, on the other hand, observe that malpractice reform, by itself, will probably not do much to reduce costs. We argue that both answers are incomplete. Ultimately, malpractice reform is a necessary but insufficient component of medical cost containment. The evidence suggests that defensive medicine accounts for a small but non-negligible fraction of health care costs. Yet the traditional medical malpractice reforms that many physicians desire will not assuage the various pressures that lead providers to overprescribe and overtreat. These reforms may, nevertheless, be necessary to persuade physicians to accept necessary changes in their practice patterns as part of the larger changes to the health care payment and delivery systems that cost containment requires.