The ability to clinically diagnose and treat medical conditions within the home is rapidly becoming a reality for millions of Americans. In parallel, the vast majority of older adults currently report a preference to age in place, in part because of the independence and autonomy this affords, as well as the enhanced ability to socially distance oneself during a pandemic. The interest in receiving long-term services and support in the home is exemplified by the 820,000 Medicaid-eligible Americans on waiting lists nationwide for home- and community-based services (HCBS), with an average wait time of over three years. As a result, many Americans today face the difficult decision of whether to move to a nursing home or stay in their home, facing the risk of falls, medication adherence errors, and other safety challenges. Diagnosing and monitoring health in the home has the potential to abate this distressingly difficult decision as a cost-efficient, patient-centered alternative to reduce HCBS waiting lists and expand the long-term care options for millions of non-Medicaid-eligible Americans. This chapter delineates the ethical, social, legal, and regulatory issues around implementing diagnostic and digital health in the homes of older adults, in the context of this population’s unique vulnerability to abuse, social isolation, declining cognitive health, frailty, and diagnostic error. Broad-based conceptual and practical reforms to modernize HCBS follow, addressing the adoption of self-administered diagnostic tests for highly prevalent chronic conditions, validated decision-support tools to foster consent, and real-time health data acquisition and management strategies that support government oversight and equitable access to home telehealth.

Chapter 14 provides a brief overview of major health insurance provided by the government in the United States. The majority of the chapter goes through the major programmatic details of the Medicare and Medicaid Programs: who is covered, what services are covered and how generously, and how providers are paid by the programs. The discussion of Medicaid also explains the nature of the federal-state partnership and explores ways in which states have and use their freedom to expand upon the program. The remainder of the chapter briefly describes other public insurance (or insurance-related) programs: the VA and CHAMPVA, TRICARE, CHIP, COBRA, and the IHS.

The default governance architecture for public and individual health care in the United States is federalism, the division of responsibility between federal and state governments. A public health emergency such as a pandemic typically produces swift federal actions to support affected individuals, businesses, and states. Such actions include exercising executive emergency power to disseminate supplies, enacting relief bills, and triggering agencies to facilitate financial and regulatory relief. An emergency also typically involves coordination between federal and state governments, as state and local public health officials need federal funding and guidance but also perform key functions such as isolation orders, testing, contact tracing, and vaccine dissemination. In the case of COVID-19, some of the usual patterns have been disrupted. The two major federal response bills enacted in March 2020 followed prior playbooks, offering financial assistance such as increased Medicaid funding and unemployment insurance benefits as well as novel policies such as paid leave to care for COVID-19-positive relatives. The bills largely relied on states to take up funds, implement emergency assistance, and exercise regulatory options to reach those harmed by the pandemic and its attendant recession. This approach built on states’ preexisting policies, heightening differences between states and intensifying the pandemic’s inequitable impact. This chapter evaluates the atypical federal pandemic response – which witnessed an executive branch rejecting much of the centralized responsibility necessary for addressing emergencies – and the wildly variable state response – some of which prioritized politics over health, and all of which depended on the strength of preexisting social programs – to determine the legacy of the novel coronavirus for federalism in public health emergencies.

Chapter discusses practical things seen in her practice that make people afraid of dying. She offers tips from many of her patients who have died a peaceful, comfortable death. Don’t be afraid to talk about dying. Chapter explains 5 things that dying looks like. If we work through our fears, plan as best we can, and talk with our primary care provider about getting hospice in a timely way, we can die comfortably with a good ending and leave our family feeling peaceful about our death.

We have a choice of when and how to plan. We can choose to plan proactively or reactively. Optimal time to start is when you are young and healthy. Studies show a direct correlation between the quality of life of those who are suffering from illness or incapacity and their level of planning. Creating a clear and comprehensive plan is a gift to your loved ones. Estate planning is too important to be considered a “do-it-yourself” project. Principal estate planning documents explained: 1. Last Will and Testament. 2. Trust. 3. Power of Attorney. 4. Health Care Proxy. 5. Living Will. Chapter give strategies on the best estate planning through the decades.

In Smith v. Rasmussen, an Eighth Circuit case from 2001, the original opinion upheld Iowa’s Medicaid ban on coverage for gender confirming surgery, finding it was reasonable and consistent with the federal Medicaid Act. Craig Konnoth’s feminist rewrite finds that the ban on gender confirming surgery is discriminatory on its face and impermissibly relies on gender stereotypes because it permits coverage of particular procedures for individuals perceived as sufficiently cisgender—such as those who are intersex but have conformed to expectations associated with their sex assigned at birth—but not for others. Konnoth draws on empirical research showing that enforcing gender roles in this context seeks to prevent men from debasing themselves as women and to prevent women from claiming the privileges of men. Heather Walter McCabe’s commentary highlights how litigation related to transgender issues reveals the socially constructed nature of gender and provides useful insight into how gender and sex relate to each other and to theories of antidiscrimination.

In Does v. Gillespie, Medicaid beneficiaries sued the director of the Arkansas Department of Human Services claiming that terminating Planned Parenthood’s Medicaid provider agreements violated their federal right under the Medicaid Act to choose any “qualified” provider that offers covered services. The Eighth Circuit held that the free choice of provider provision in the federal Medicaid Act did not create rights enforceable by individual beneficiaries. In their feminist judgment, Melissa Alexander and Jennifer Oliva argue that the clear language of the Medicaid Act unambiguously demonstrates that Congress intended to confer a private right of enforcement under the free choice of provider provision. Elizabeth Kukura’s commentary emphasizes the importance of focusing on the lived experience of Medicaid beneficiaries who rely on Planned Parenthood for basic health care needs. Kukura highlights the influence of anti-abortion politics and ideology on health care access and the structural forms of discrimination that shape it.

In National Federation of Independent Business v. Sebelius, decided in 2012, twenty-six states as well as private individuals and an organization of independent businesses challenged the constitutionality of two key components of the Affordable Care Act. The Court upheld the individual mandate but converted the Medicaid eligibility expansion from mandatory to optional for states. Elizabeth Weeks’ feminist rewrite breaks down the public law-private law distinction to get beyond the traditional view of health insurance as a commercial product providing individual financial protection against risk and instead to view it as effecting a risk pool premised on cross-subsidization of the health-care “haves” by the health-care “have-nots.” Weeks also rejects the original opinion’s dichotomy between “old” and “new” Medicaid as an artifice evidencing a fundamental discomfort with extending public assistance to able-bodied people who are judged capable of providing for themselves on the private market. In their commentary, Mary Ann Chirba and Alice Noble assess the original opinion and Weeks’ feminist rewrite in terms of their concrete effects on women’s lives.

Linton v. Commissioner of Health & Environment was a 1965 case from the Sixth Circuit Court of Appeals in which the plaintiffs alleged disparate-impact racial discrimination. The Tennessee Medicaid program covered the skilled nursing facility care but allowed facilities to certify a limited number of beds for Medicaid patients (for whom the facilities typically received lower rates). The plaintiffs argued that the limited bed policy violated the federal Medicaid statute and had a disparate impact on black Medicaid recipients in violation of Title VI of the Civil Rights Act. In the original opinion, the court side-stepped the discrimination issue, relying instead on the finding that the state had violated the Medicaid statute. Professor Gwendolyn Majette’s feminist concurrence corrects the Sixth Circuit’s failure to address the Title VI issue and provides a fuller, more comprehensive analysis that addresses the intersection of gender, race, class, and age. Professor Ruqaiijah Yearby’s commentary explores whether the opinion in Linton could have done more to ensure that the unique harms experienced by patients because of their race would be fully addressed in the remedial plan.

In Doe v. Mutual of Omaha Insurance, a Seventh Circuit case from 1999, the plaintiffs challenged lifetime coverage caps for AIDS-related conditions, which blocked patients with HIV/AIDS from accessing antiretroviral therapies and other lifesaving medical care. Doe and Smith alleged that the caps violated the public accommodations clause of the ADA. The original opinion sided with the insurance company, finding the caps permissible under the ADA, even though the defendant offered no proof they were supported by sound actuarial data. Professor Valarie Blake’s feminist judgment focuses on the plain text of the disability rights statute, relevant legislative history, and valid guidance from the Department of Justice. Blake also highlights the social and cultural context in which gay men and people with AIDS have been subjugated and stigmatized. Professor Christina Ho’s commentary contrasts the disability-rights approach the plaintiffs advanced before the court with the statutory restrictions on health insurance underwriting based on health status-related factors eventually included in the Affordable Care Act passed more than a decade later.