Barriers to Health Care

&

Access to Care

Philip Boyle, Ph.D.

Vice President, Ethics

www.CHE.ORG/ETHICS

Goal of Today’s conversation

• Is there a moral right to health care?– If so, how much do you get?

• Whose is obligated to provide?

• What process & criteria are there to fairly allocate it?

History

• How we got here?– The Social Transformation of American

Medicine, Paul Starr– The rise of social insurance in Europe– WWII & offering benefits

• Where are we going?– Consumer-driven health plans & high

deductible savings account

• Largely perceived outside our control

Case

• Joe 31-yr-old sentenced felon 14 yrs– $1 mil heart transplant– Viral infection

• Frank 41-yr-old CHF– Raised $150,000

• 83,00 on waiting list– 5000 die waiting– 17,000 get one annually– 8,800 donors

So what is (are) the moral problem(s)?

1. Identification of moral problem

2. Identification of interests

3. Need facts

4. Values at issue

5. Priority of values

6. Alternatives evaluated in light priorities

poll

• Is healthcare more valuable than other values?

• Why is healthcare valuable?

Why is healthcare a primary value?

• Purposes of healthcare– Relieves pain and suffering– Restores functioning– Prevents death– Improves opportunity for life plan– Provides valuable information

poll

• If health care is a primary good, is there any obligations in the way we distribute it?

HC needs to be distributed equitably?

• Well being

• Opportunity

• Information

• Interpersonal significance

Equitable means?

• Equality

• According to benefit or need

• Adequate level– Excessive burdens– Acceptable burdens

Poll

• Is it a social obligation?– Why?

• Is a social obligation the same thing as a right?

A social obligation?

• Requires skills and efforts of many

• Few can plan for it or secure it

• Illness is largely undeserved & unevenly distributed

• Rights – Liberty rights—free of restrictions– Entitlement rights—claim on another

poll

• If it is a social obligation, can people forfeit the claim?

Does personal responsibility limit access?

• Difficult to identify– Voluntariness difficult to ascribe

• Institutionalization leads to discrimination

• Fair share of burden

Who is responsible to assure ?

• Market?– People can’t plan to afford– No all places have markets– Lack of information

• Charity?

• Government?– Subsidiarity

• Local, state, federal

Home health: What’s fair?

Mr. Brown LSW• Client 1-- 4 hours 3X-a-week, niece cares• Client 2-- Home worth $10,000-15,000• Client 3– 85-yr-old cost sharing at 94%

– $15,000 in savings– Income $2155 monthly

What is adequate?

• Professional judgment

• Average current use

• List of services

• Overall evaluation

Social distribution

• When there are inadequate resources are there reasons to prefer some patients over other patients?– Severe & persistently mentally ill v. those

persons with mental illness for which we can do something

– Oregon experiment

Ethics of Process• Organizations are powerful moral

agents– Transparency

• Is it clear how the decision is made?• Who makes the decision? • The criteria that are used

– Participation • Whose interests are considered?

– Applied evenly and consistently – Appeals– Checks and balances

Ethics of Process

Due process – Notice: what alternatives exist– Means of meaningful appeal– Consistency in judgment and action– Transparency to those affected

Criteria

• What technology is being assessed & allocated?– New & old?– All ox being gored?

• What is the goal of managing the resource?– Whose goals?– Does it meet the goal?

Criteria • What measurements are used to

assess & allocate?– Unit of care?– Evidence-based

• Safer• Higher quality• More efficient• It works• Effectiveness? Effective for what?• Cost-effective

Criteria • What measurements are used to

assess & allocate?– What costs are relevant?

• ROI analysis– Over what period of time?– For a system or society?

• Non-financial costs

Criteria

• What measurements are used to assess & allocate?– Social Measures?

• Holistic care: high tech, low touch• Preference for those who are poor• Quality of life• Cost that could reduce access• Supports population health• Preventive care

• How does the mechanism work?– Was there a previous informal mechanism?– Who devised & when is it used?

• Is there clarity in definitions & consistency in application?

• Unintended consequences of process?

Conclusions

• Establishing why it is a right

• Rights are inviolable

• Allocation is a mix of fair process & criteria