The permanently unconscious patient, non-feeding and euthanasia

Some sources condemn judicial decisions which authorize the withdrawal of artificial nutrition from permanently unconscious patients. These critics assert that withdrawal of nutrition from a preservable unconscious patient amounts to intentional killing of a helpless human being. Grave implications are seen for helpless patients. This article confronts these critics and their assertions. The author contends that the judicial approach which allows withdrawal of artificial nutrition is fully consistent with traditional medico-legal doctrines. The article articulates a standard--respect for human dignity--which justifies withdrawal of artificial nutrition from a permanently unconscious patient. The implications of this formula for other incompetent patients facing a protracted dying process is discussed. Finally, the article explains why active euthanasia can and ought to be distinguished from withdrawal of life-preserving medical intervention.     

Immigrant Health Care Access and the Affordable Care Act

In spite of major coverage expansions under the Patient Protection and Affordable Care Act (ACA), a large proportion of immigrants will continue to remain outside the scope of coverage. Because various provisions of the ACA seek to enhance access, advancing knowledge about immigrant access to health care is necessary. The authors apply the well‐known Andersen model on health care access to two measures—one focusing on perceptions of unmet health care needs and the other on physician visits during the last year. Using data from the New Jersey Family Health Survey, the authors find that prior to implementation of the ACA coverage expansions, immigrants in New Jersey reported lower levels of unmet health care needs despite poorer self‐rated health compared with U.S.‐born residents. The article concludes with a discussion of the use of Andersen model for studying immigrant health care access and the broader implications of the findings.     

Expanding health insurance coverage: who will pay?

Recent discussions on extending health insurance to the more than thirty million uninsured Americans have focused on two strategies: expanding the Medicaid program and mandating that employers sponsor coverage for their employees. This analysis, using a microsimulation model of the U.S. health care financing system, suggests that these two options would result in very different distributions of financial burden. Employer-sponsored coverage is financed in a highly regressive fashion, in contrast to the Medicaid program, which is proportional to income. Furthermore, the burden of paying for health care under Medicaid varies little among generations, whereas the cost of employer-sponsored care is lowest in households headed by persons over sixty-five years old. Low health status populations do not pay disproportionately higher taxes or premiums to finance either the Medicaid program or employer-sponsored coverage. Their incomes, however, are more effectively protected by Medicaid, because it offers more comprehensive benefits.     

Expanding dependent coverage for young adults: lessons from state initiatives

The Patient Protection and Affordable Care Act (ACA) requires that adults up to age twenty-six be permitted to enroll as dependents on their parents' health plans. This article examines the experiences of states that enacted dependent expansion laws. Drawing on public information from thirty-one enacting states and case studies of four diverse reform states, it derives lessons that are pertinent to the implementation of this ACA provision. Dependent coverage laws vary across the states, but most impose residency, marital status, and other restrictions. The federal Employee Retirement Income Security Act further limits the reach of state laws. Eligibility for expanded coverage under the ACA is much broader. Rules in some states requiring or allowing separate premiums for adult dependents may also discourage enrollment compared with rules in other states (and the ACA), where these costs must be factored into family premiums. Business opposition in some states led to more restrictive regulations, especially for how premiums are charged, which in turn raised greater implementation challenges. Case study states did not report substantial young adult dependent coverage take-up, but early enrollment experience under ACA appears to be more positive. Long-term questions remain about the implications of this policy for risk pooling and the distribution of premium costs.     

The relation between autonomy-based rights and profoundly mentally disabled persons

A chapter from his forthcoming book "Deciding for the Profoundly Mentally Disabled," Professor Norman Cantor argues persuasively for the right of incompetent persons to have a surrogate make critical medical decisions on their behalf, particularly in the context of refusing life-sustaining treatment. While abusive surrogate decision-making is always a concern, Professor Cantor recommends both substantive and procedural protections in order to preserve intrinsic human dignity for the profoundly disabled.