COMMENTARY

Healthcare and Healthcare Ethics in the Trump Era

Arthur L. Caplan, PhD

Disclosures

January 11, 2017

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Hi. I am Art Caplan from the Division of Medical Ethics at the New York University Langone School of Medicine in Manhattan.

We have a newly elected president, Donald J. Trump. He will be making many changes to the policies of the Obama years. What will his election mean for healthcare? What will it mean for ethical issues that come up in the context of healthcare?

Trump has not said a lot about healthcare. He certainly made it clear during the campaign that he is skeptical of Obamacare. He has talked about the need to repeal it and replace it, but I doubt that will happen very quickly. It would be easy to abolish it virtually overnight; he could—almost with a stroke of a pen—eliminate government subsidies for the insurance plans for people who do not get health insurance through their employers. I believe that would bring Obamacare to its knees rather quickly.

But that may not be wise politically. People get used to certain kinds of benefits and certain types of coverage. For example, a lot of parents like being able to keep their children on their health plans through the age of 25 years. This makes insurance cheaper for children, and the parents can add them as dependents at a relatively low cost.

Another Obamacare feature that people are quite fond of is the mandate to make insurance available to those with preexisting conditions. This has been a problem for Obamacare, in terms of failing to contain costs. Insuring a group of people who have preexisting conditions is expensive if other, healthier people do not sign up and bear part of the cost of covering those who have diabetes or depression, for example. Still, pulling the coverage out from under folks with preexisting conditions will lead to a lot of upset.

Removing the prohibition on dollar limits of healthcare benefits would also be quite unpopular. For a child with a severe health problem, costs can easily rise above $1 million in terms of a cap on benefits. I am not sure that President Trump will want a public hearing with a lot of desperate parents saying that their children are now unable to get further healthcare because they have reached their dollar limit on healthcare costs. They were okay under Obamacare, but they are not okay if you just simply repeal it. I would look for some accommodation, some compromise.

Even though Trump has said that he will repeal and replace it, I suspect that certain features of Obamacare are so well embedded that they are going to be very tough to get rid of without politically uncomfortable complaints.

Trump is likely to turn over some of these healthcare issues to more conservative allies of his, such as Vice President Pence. In that case, we will see a return to more debates about topics such as abortion. President-elect Trump did say that he will appoint a Supreme Court justice who would overturn Roe v. Wade. Again, I am not so sure that it will be that easy to overturn, but it is certainly easy to begin to impose restrictions on the right to access an abortion. I believe we will see that.

I predict something else will happen. Despite efforts to hinder or even eliminate surgical abortions, we are beginning to see technology that allows women to choose a medical abortion by using the morning-after pill, or RU-486. This may not work for every woman; she may not know that she is pregnant, and the pregnancy may be further along than a few weeks. But if you have telemedicine and you can buy these pills online—and I believe that the big Internet providers are going to try to protect that right pretty aggressively—then women will be able to buy these pills no matter where they live in the United States. They will not need a doctor who knows how to perform an abortion. They may be able to do this in their homes; perhaps a family physician, an obstetrician, or someone else can prescribe the pill and explain how to use it.

I predict that, even though we are all used to demonstrations and yelling about abortion at the clinics, we will see a different kind of fight emerge in the next administration. That is, what is going to happen with the use of morning-after pills and emergency contraception? Who is going to write that prescription? Who is going to make it available? Can a person go out of state or have things sent in from another state? That is where I believe that battle will be.

One other ethical issue that is likely to loom large in the Trump Administration is the right of people to dissent because they have a belief that violates their conscience. We have seen it come up in everything from baking a wedding cake for a gay couple to pharmacists saying that they do not want to fill a prescription for a morning-after pill or some other agent, all the way to physician-assisted suicide. In the recent election, California, Colorado, and the District of Columbia have confirmed a right to physician-assisted suicide.

Physicians will be faced with the question of, will you do this? Remember that in the way these laws are written, any physician can certify someone as terminally ill and write the prescription to make the drugs available to that patient. If you will be working with patients or referring them, it will be important to know where you stand and to let your patients know where you stand. There is room for conscience in what physicians do with respect to their patients. Patients have a right to know the limits and restrictions from the start. Patients have a right to know that their doctors have strong moral beliefs that oppose physician-assisted suicide so that a patient can seek out someone else to achieve a better alignment between their values and their physician's values.

That is what I believe is coming in the age of Trump. It will prove to be interesting times, as the Chinese say. Many changes from what we have seen in the Obama Administration, and undoubtedly more, will be fodder for me to discuss in the years ahead. Thank you for watching. I am Art Caplan, at the NYU Langone Medical Center.

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