Barriers to Health Care

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• Barriers to Health Care
• Access to Care
• Philip Boyle, Ph.D.
• Vice President, Ethics
• www.CHE.ORG/ETHICS

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Goal of Todays 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?

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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

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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

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

• Identification of moral problem
• Identification of interests
• Need facts
• Values at issue
• Priority of values
• Alternatives evaluated in light priorities

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poll

• Is healthcare more valuable than other values?
• Why is healthcare valuable?

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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

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poll

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

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HC needs to be distributed equitably?

• Well being
• Opportunity
• Information
• Interpersonal significance

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Equitable means?

• Equality
• According to benefit or need
• Adequate level
• Excessive burdens
• Acceptable burdens

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Poll

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

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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 rightsfree of restrictions
• Entitlement rightsclaim on another

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poll

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

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Does personal responsibility limit access?

• Difficult to identify
• Voluntariness difficult to ascribe
• Institutionalization leads to discrimination
• Fair share of burden

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Who is responsible to assure ?

• Market?
• People cant plan to afford
• No all places have markets
• Lack of information
• Charity?
• Government?
• Subsidiarity
• Local, state, federal

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Home health Whats 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

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What is adequate?

• Professional judgment
• Average current use
• List of services
• Overall evaluation

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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

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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

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Ethics of Process

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

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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?

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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

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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

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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

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• 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?

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Conclusions

• Establishing why it is a right
• Rights are inviolable
• Allocation is a mix of fair process criteria