Ethical Dimensions of Health Care Reform:

1

• Ethical Dimensions of Health Care Reform
• Whats Really at Stake?
• Larry R. Churchill, Ph.D.
• Center for Biomedical Ethics and Society
• Ann Geddes Stahlman Professor of Medical Ethics
• Professor of Medicine, Philosophy, Religion
• Vanderbilt University
• September, 2009

2
A Quick Inventory

• The status quo is not perfect but its about as
  good as we can do.
• or
• The system is badly broken and a fix is
  imperative.
• Im currently well-insured and worried that
  reform will mean losing coverage choices.
• or
• Im currently well-insured but worried that no
  reform will mean losing coverage choices.
• The best way to manage health care is through
  private insurance market forces
• or
• The best way to manage health care is through
  government policy regulation

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Whats not at Stake

• Rationing not a future possibility, already a
  fact
• ability to pay, employment status, age,
  disease, race, gender, geography,
• Socialized medicine
• Death panels
• Abortions

4
Who are the Uninsured?
SCHIP covers some near poor children
Most employed and their families receive coverage
through work, although many small employers do
not provide coverage
Medicaid program covers the poor, blind disabled
The wealthy generally have full coverage
Children
Adults (under 65)
Elderly over age 65, are covered by the federal
Medicare program
Dual Eligibles - poor elderly may be covered by
Medicaid and Medicare
Elderly (age 65 and over)
Uninsured 45.5 million Americans are uninsured
and tend to be near poor and middle class
Poor
Near Poor
Wealthy
Middle Class
Source The Uninsured, The Kaiser Commission on
Medicaid and the Uninsured, January 2006 (2004
Data Update). Note graphic is not drawn to scale.
5
How Do Americans Under 65 Receive Coverage for
Care?
6
How Big is the Problem?

• Growing uninsured and unstable coverage
• 45.7 million in 2007
• 85 million over a four year period
• 25-35 million underinsured
• gt52 of underinsured adults in U.S. reported
  going without care due to costs

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Is Being Uninsured Really a Problem?

• Among The insured
  receive
• Chronically Ill Adults 70 more services
• Children 400 more services
• Hospitalized Adults 90 more services
• Lack of health insurance results in 27,000
  premature deaths in the U.S. every year
• ---Urban Institute , 2007
  

8
Illness and Medical Costs,A Major Cause of
Bankruptcy

• 45.6 of all bankruptcies involve a medical
  reason or large medical debt
• 326,441 families identified illness/injury as the
  main reason for bankruptcy in 1999
• An additional 269,757 had large medical debts at
  time of bankruptcy
• Norton's Bankruptcy Advisor,
  May 2000

9
Why is the U.S. the Only Industrialized
Democracy without Universal Coverage?

• Political tradition that prizes liberty over
  security
• Self-Reliance, and moralizing about (other
  peoples) health problems
• Rescue Impulse results in excess
  deprivation

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• Commitment to markets as the basic method for
  allocating resources
• Distrust of government
• Entrenched interests of the status quo
• Americans as impulsives and deniers absence
  of long-term thinking
• We already have the best health care system

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The Best Health Care System By What Measure?

• U.S. Ranking, 2004 data
• 10th for age-adjusted mortality
• 13th for low-birth-weight percentages
• 13th for neonatal mortality and infant mortality
  overall
• 13th for years of potential life lost (excluding
  external causes)
• 11th for life expectancy at 1 year for females,
  12th for males
• 10th for life expectancy at 15 years for females,
  12th for males
• 10th for life expectancy at 40 years for females,
  9th for males
• 7th for life expectancy at 65 years for females,
  7th for males
• 3rd for life expectancy at 80 years for females,
  3rd for males
• Comparison set includes Japan, Sweden, Canada,
  France, Australia, Spain, Finland, the
  Netherlands, the United Kingdom, Denmark,
  Belgium, the United States, and Germany

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The Best Health Care SystemFrom Whose
Perspective?

• The moral quality of any healthcare system should
  be judged by how the vulnerable are treated.
• Uninsured children --- 8.1 million in 2007
• Uninsured children are more likely than children
  with insurance to receive no care from a
  physician for all 4 conditions sore throat with
  high fever or tonsillitis ear infection 2 ear
  infections in the last 12 months asthma or
  wheezing in last 12 months
• ---Newacheck, P. et al, Pediatrics 2000
  105989-997.
• ----Commonwealth Fund, 2008

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The Uninsured as an Ethical Issue

• Health care is a good fundamental to democracy
  essential to fair equality of opportunity
• ---Norman Daniels, Just Health Care, 1985
• Those who lack insurance have a double
  deprivation the threat to health and to
  self-esteem lack of health insurance is not
  only dangerous but degrading
• ---Michael Walzer, Spheres of Justice,1983

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Unfairness as a Threat to Democracy

• Of all the dangers to a nation . . .there is no
  greater one than having certain portions of the
  people set off from the rest by a line drawnthey
  not privileged as others, but degraded,
  humiliated, made of no account.
• ---Walt Whitman, Democratic Vistas,
  1888
• The uninsured are health care beggars
• ---Uwe Reinhardt, JAMA
  19972781091-96

15
The Uninsured as An Economic Issue

• Solving the countrys economic problems depends
  fundamentally on controlling the escalating costs
  of health care.
• Lack of portability of health insurance and tying
  insurance to employment status creates job lock
  for individuals.
• U.S. businesses are less competitive
  internationally with burden of health costs.
• No industrial democracy has been able to control
  health care costs except through an inclusive
  system and government regulation.

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Whats Really at Stake?

• Ethics our national identity in U.S.
• systemic intentional injustice
• I vs we culture
• commodity vs right/responsibility
• Economics Long-term health of the economy the
  nation

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More Precisely Whats Really at Stake?

• Health of the populace --Are we interested in a
  system that meets health needs as its primary
  goal?
• Quality of care -- Are we willing to modify the
  system to achieve better health outcomes?
• Fiscal Responsibility Are we able to curb our
  appetite for technology and assume greater
  responsibility for our own health, recognizing
  limits on what we can afford in healthcare?
• Medical professionalism Are health
  professionals willing to advocate for the health
  of the public generally, and not just their
  patients or their pocketbooks?

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Strategies for Action (Assuming Support for
Reform)

• Stay focused Dont get deflected from the larger
  agenda by responses that dont address the
  systemic problems
• Be well-informed (less subject to
  misinformation), aware of the injustice,
  fragility and inability to sustain the current
  system.
• Be a leader in educating the community (those who
  work in health care have special knowledge and
  greater responsibilities)
• Demand responsiveness from our elected
  representatives