Chapter 17 :   A Claim of a Right to Health Care

Section 4. Readings

READINGS:

Presidential Commission: An Ethical Framework for Access to Health Care

Access in an equitable fashion to everyone

moral obligation to provide everyone with access to adequate are

Aging and then Ends of Medicine by  Daniel Callahan:

rationing of health care is a necessity. Rationing according to age. Improve the quality of life for the elderly and not the quantity.

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 The Doctor as Double Agent by  Marcia Angell   Kennedy Institute of Ethics Journal, Vol. 3, no. 3 (1993), pp. 279-286. 

Physicians and health care providers should not act on interests of managed health care programs but only in the interest of those they serve: the patients

 Summary by Damali Joseph QCC (2002)

Before 1980 doctors were only concerned with his patients and acted only as an agent for their care.  But now times have changed.  Today doctors are obligated not only to the patient but also societyís needs as well.  Many people also believe in saving the resources for society such as economists, governmental officials, corporate executives, ethicists, and even some doctors.  Many ethicists think, keeping an eye on the price tag means saving scarce resources for other, more important uses.  Doctors are also expected to determine if the benefits of treatment to patients are worth the costs to society in turn they act as double agents.   

This change is believed to be due to financial and economic difficulties of the large third- party payers.  This change will require for health care to use a smaller amount of the economical finances.  In turn there may be other ways in which we can do this without destroying the ethical pathway of the doctorís patient-physician relationship.   

Historical Review 

Economics is surely a drive for the ethical view nowadays.  The history of economics in the United States is divided into three phases.  1) True Market- people were paying for their own medical care until World War II.  Premiums were still paid by patients using medical insurance starting in the 1930s.  Medical costs in those days were very reasonably priced.  2) Big business into the health care picture- big business started offering health insurance as a fringe benefit in order to evade the wage and price controls in effect during World War II.  The important effect of this action was that it insulated, protected patients form the expenses and costs of medical care.  The poor and the elderly were included in this epidemic in 1966 by the arrival of Medicaid and Medicare.  Third-party payers covered almost everyone in the end of the 1960s and this came an end to the true market.  Medical care became more expensive and more effective.  3) Health care costs were rising more rapidly than the GNP- There were no limits on the cost of health care because of insurance.  Expenditures for other social goods like education declined and health care rose- 6% of the GNP in 1965 to nearly 10% in 1980 to 13% in 1991.  There were no ways shown to stop the increase but they were ways shown to increase the increase.  Things such as the fee-for-service reimbursement system allowed doctors to act as providers and purchasing agents to recommend someone elseís service and also charged a fee for it.   

Cost Containment 

In the 1970s Americans were hit with the realization that our resources were limited.  The costs of health care began to cross the minds of some, even experts and policymakers.  But in the 1980s everyone became clear of these increased costs and vowed to find a solution, Cost Containment.  The major third parties such as the government and big business were leading and organizing in the efforts to lower costs but they were essentially only thinking of the budgetary problems instead of the moral problems.  They tried in a number of ungainly ways to use Cost Containment but health care costs continued to go skyrocket.  Costs continued to go even higher and it was thought that Cost Containment efforts influenced this effect.   

A new expensive and invasive system of government was introduced due to regulations by third parties such as managed care.  Efforts to encourage and further competition led to increased marketing, efforts to limit demand through higher deductibles and co-payments and efforts by insurers to shun risks shifted costs limited care mainly for the most susceptible.  Savings to one part of the system were costs to another part of the system.  The American health care consists of no system, just a set of arrangements.  Administrative costs such as billing, marketing, underwriting, claims processing, and utilization review uses more than 20 cents of the health dollar. 

When looking back on the history of the economic system of Americans you can really see how important it is to understand in what context doctors are being used to act as double agents.  The health care system is entrenched in a society that wastes billions of money on things such as tobacco, television ads, and makeup.  This non-system spends about 40% more per citizen on health care than the next most expensive health care system in the world and at least twice as much on administrative costs.  We are not shortage of resources; we are facing an abundant use of resources.    

Saving for Third Parties 

As a double agent doctors are supposed to cut care of patients in order to save money for third party companies.  HMOs require doctors to limit the amount of costs incurred by the patient and even rewards doctors directly when the HMOís outcome is good.  If there are too many referrals given and too many tests and procedures doctors are in risk of the HMO withholding the salary.  Doctors are encouraged to under treat patients just as the fee-for-service system encourages doctors to over treat patients.  There are other types of managed care that prevent doctors from offering care such as the ones that require utilization review.  Anyway you look at it doctors are withholding care from patients to save money for third party companies and themselves.  The phrase Cost Effective is just a sugar coating of the real deal: least expensive of two equally effective alternatives, or to the most effective of two equally costly ones is just a way to save money. 

Justification for Double Agents 

The thought of being able to withhold care for a patient is unbearable and should not be allowed.  But people in these positions offer justifications and ethical justifications, too.  They give three justifications for their actions.  1) The will of the society is expected to be followed by doctors in giving care to the patient.  They do whatever they are expected to do by the body politic and in doing so they neglect patients in need of care.  2) Third parties who pay for the medical care would like to run the show in deciding the limits of care given.  Many forget that while working that everyone pays taxes and those taxes are supposed to be of a benefit to you when you canít work.  Some forget that.  So you are actually using the monies you put in.  And 3) as a good citizen doctors should limit supplies to be of use to pay for others, lesser treatment or things such as education.  Dan Callahan believes and shares the belief that Americans have overvalued health care compared with other social goods.   

Arguments Against Double Agents 

Regardless of the justifications given there are five serious tribulations with the outlook that doctors should act to control expenses when caring for individual patients.  1) Resources in our health care system are not scarce but plentiful.  In 1990 the United States spent at least $2,566 on each individual while Canada only spent $1,770.  This leads us to believe that we have enough resources to go around.  Both Canada and the United States have no distinction in the outcome, so we must come to a conclusion that maybe the system is just not efficient enough and should be rebuilt so it becomes more efficient.  2) Funds not used will be used for others medically.  In the United States there isnít a system that allows funds to be taken out form one part of health care and put into another.  Resources saved by denying health care recipients are not being used for others in need of medical care but for other sectors in the economy such as education, defense, farm subsidies, or personal savings.  Even if saved funds were to remain in the health care system they might go to hospitalís public relations office or to higher wages for administrators.  The solution to this problem is to create limits for everyone. 3) Doctors should not be asked to play the role of a double agent.  Doctors are there to preserve our lives and it is essential for humans to survive, so therefore doctors have the right to act in the best interests of the human right.  People put up with many things like lower income just to protect their rights.  The public poll supports this view of we is not spending too much on health care but that we are not getting our moneyís worth.  4) Doctors acting as double agents act on their own prejudices.  They make the decision on if the medical service costs too much.  This judgment is not a medical judgment but a political or philosophical one and therefore is not a professional one.  Another doctor may make a different judgment.  This is no way to run the health care system.  And, 5) Doctors are not honest.  We as patients expect them to have no other obligation than to heal us.  Anything short of full efforts to heal the individual patient, then, must involve a hidden agenda-an ethically indefensible position. 

Conclusion

Ethics should be based on basic moral principles leading our behavior and obligations toward one another.  Doctors are supposed to be ethically committed to care for us because they are health care providers.  If doctorís best interest is to care for the health of the patient then nothing should get in the way of this not even money.  Doctors should still continue to care for patients while trying to change a system that defies that.   

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Wanted: A Clearly Articulated Social Ethic for American HealthCare by  Uwe E. Reinhardt   JAMA, November 5, 1997- Vol. 278, no. 17, pp.1446-1447

Should policy be bases on maximizing wealth or maximizing utility?

summary by Jason Chirichigno,  SCCC 2005

In this article Reinhardt explores the status of the US healthcare system and in particular, poses a very important question, "As a matter of national policy, and to the extent that a nation's healthcare system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?" (p. 849). For Reinhardt, the answer to this question is a resounding "yes" and he points out that the same holds true for all other developed nations in the world, except in the United States, where the answer is a resounding, "no". Reinhardt then explores the uninsured statistics in the United States. "At any moment, over 40 million Americans find themselves without health insurance, among them some 10 million children younger than 18 years of age" (p. 849). According to Reinhardt, US policy makers are not at all phased by these statistics, as they claim that a lack of insurance does not equate with an absolute lack of care. However, the status of one's insurance does relate to the quality of care that one receives.

"It is known that other socioeconomic factors (such as income, family status, location, and so on,) being equal, uninsured Americans receive, on average, only about 60% of the health services received by equally situated insured Americans" (p. 850). People without insurance in the United States , have to rely on the emergency room as their primary mode of obtaining care, sometimes waiting many hours, sometimes to the point where the wait is so long they leave and do not receive any care. It is for these reasons that, "uninsured Americans tend to die in hospitals from the same illness at up to triple the rate of insured Americans (p. 850).

The second part of Reinhardt's article is a critique of the policy set forth by Richard Epstein in his article, "Mortal Peril: Our Inalienable Right to Healthcare?". Epstein states in his article, "We could do better with less regulation and less subsidy, scarcity matters even in healthcare" (p. 850). For Reinhardt, this is the exact ideology that is contributing to the lack of care for children and the lack of concern for the uninsured. Epstein attaches more value to the dollar than he does to human life, this is the crux of the problem for Reinhardt, and that Epstein has the luxury of feeling this way because, "everyone who shares Epstein's distributive ethic tends to be rather comfortably ensconced in the upper tiers of the nation's income distribution" (p. 851). Reinhardt cites this as another example of the rich opposing measures to help the poor and until this is a national priority, the uninsured will continue to receive sub par healthcare.

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The Case for a Single Payer Approach by Jim McDermott:

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"The Benefits of Privatization" by   Victor Dirnfeld  in  Canadian Medical Association Journal, August 15,1966: 155(4), 407-410, 1996

Canadian universal coverage should be supplemented by a private not-for-profit system of insurance.

Summary by Justin Cortes, SCCC, 2007

In Canada the Medical Care Act of 1966 introduced Canada to the bold and initiative system of Medicare. This system was designed to give all the citizens of Canada essential medical coverage. Nowadays this system has started to fall into disservice as it, like many other social programs has begun to get too large to be funded by the tax paying public. Since April of 1996 until the time of the articleís publication the funding that the Canadian federal government gives to the provincial governments has been decelerating in growth. Along with the deceleration in transfer payments the provincial governments have gained debt that has forced them into cut backs. Now because of these cut backs there are closed hospitals or hospital beds and the elimination or reduction of hospital programs. Now patients donít have access to the care they need or in some cases they are not receiving adequate care form properly trained nurses. All of this has had its mark on the people of Canada who in a recent polls expressed their attitude towards the decline in health care.

All of this has raised a solution: a parallel, private system of medical care funded by a not-for-profit, regulated system of insurance. This was the type of insurance scheme that was used all throughout Canada prior to the Medical Care Act of 1966. The fact that it would be regulated means that they would have to accept applications for all coverage. This means that they canít just accept low risk clients. The overall goal is a system with affordable premiums that most wage earners can afford. Paring a universal public health care system with a paralleled private regulated system is in place in most western countries, baring the United States and Canada. A benefit of having these two paralleled systems is that the private option can take people off of the public health care system thereby decreasing waiting lists and allowing greater access to care. The way the system is now it isnít geared toward the consumers but rather to the amount of funding the government can give. At certain times that can mean that the government may ration or decrease the quality of care. A private system would be more cost effective. It was demonstrated that it would be half as expensive to perform a procedure in a private hospital than in a public one. One point against a private system however, is the lack of available nurses and doctors who would be willing to move from a public system to a private system. They claim that there isnít enough work in a private sector to support them. This is however countered by Canadaís claims that they have a surplus of nurses and doctors. If this were true then the lack of willing professionals wouldnít be such a problem. Other problems pointed out are usually horror stories about people who end up under-insured, or locked into jobs just to be able to afford health care. Another argument against a private system would be that only the rich would have access to the best care. This of course is not true seeing as it is a regulated system that would allow coverage to all wage earners.

All in all the privatization of Health care in Canada has more good evidence than bad. Because of only deriving their funding from the government, hospitals must force patients to wait on long waiting lists for care, and that only negatively impacts the people. The people are in fact for a private health care system, because overall it helps the people.

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Title of Article: "The Forgotten Domestic Crisis" By Marcia Angell in Paying for Health Care, Chapter 8, Page 549

Summary by Jason Weissler, SCCC, 2007

 Marcia Angell points out several weaknesses in the current healthcare system. She describes one of the fatal flaws as being the fact that in the United States we treat healthcare as a commodity with the criteria for receiving healthcare based on the ability to pay. As a great deal of healthcare dollars is not directed to the healthcare professionals or medical services and administrative costs continue to rise, the money available to pay fort treatment diminishes. As healthcare is a business with its is basis in making a profit, insurance companies aim toward increasing the number of people willing to pay for the insurance. Her perspective is that the system needs an overall change in its approach. By eliminating unnecessary administrative costs, a more efficient system would result and waste would be reduced. Her suggestion includes paying for healthcare through an income tax, utilizing a single-payer system that is more loosely regulated and not controlled by the private insurance industry. The result of her suggestions could be available medical care for all individuals benefiting the US population while reducing financial waste.

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Reading: Overseas, Under the Knife

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