Mappes & DeGrazia, Chapter 10: Lecture Notes/Outline by Larry Hauser

Social Justice and Health-Care Policy

Introduction: the Health-Care Crisis

"No honest discussion of American health care can deny that our system is in crisis" (Mappes & Degrazia).
Symptoms as diagnosed by Dan E. Beauchamp

for the nation's poor's coverage had always been lacking
Threats to middle class health care coverage

"Never-ending increases in insurance costs crowd out wage increases."
"Employees fear changing jobs and losing their insurance . . . ."
"[E]mployers edgily seek to shift coverage costs to workers' shoulders." (554)

Red tape: defending against rising costs often swells administrative costs

insurers require doctors & hospitals to justify expensive procedures adding red tape to the system.e
Medicare's prospective payment system of price control requires a whole new layer of adminstrative personnel in many hospitals.
The U.S. spends more than twice what Canada does on administration.

Rising costs lead insurers to "seek ingenious ways to avoid sick people" (554)

"redlining" various trades as too costly to insure
reluctance to insure samll businesses

"Public programs are permanently destabilized." (554)

The urban poor, largly lacking primary care physicians "crowd hospital emergency rooms and out-patient clinics"
"Hospitals respond with costly, often long-delayed care."
Consequently, Medicaid and other players are hit with a new round increased claims for this care.
"The increases doom legislative plans to fund more primary care for poor neighborhoods, in part to ease hospital crowding." (554)

The major problems seem to be worsening (Mappes & DeGrazia)

Increasing costs of health care

1986: 10.9% of GNP
1994: 14%
2003: 20% (projected)

Non-expanding -- even contracting -- coverage

figures

1986: 37 million uninsured
1994: 39 million uninsured
2003: 43 million uninsured (projected)

doesn't figure in

increasing population: as a % of population uncovered, the numbers look less bad
decreasing quality of coverage among those still covered:

e.g., HMOs vs. fee for service (BC/BS) plans
suggesting things have gone worse than the numbers indicate

"The United States and South Africa are the only two industrialized nations not to provide health-care coverage to all of their citizens." (555)

Players and Politics of the Situation

The public

"are disadvantaged by these trends" (555)
support (public opinion polls suggest) for reform including

universal access to coverage
controlling health-care costs

Special-interest groups

with vested interests in the current system or a financial stake in proposed reforms
in particular

the insurance industry
drug companies
doctors & the AMA

these groups, among others, spearheaded the defeat of proposals for comprehensive-health care reform 1993-1994

invested millions of dollars and "extraordinary political muscle"
"in an effort to preserve the status quo or something relatively close to it" (555

Justice Rights and Societal Obligations

Questions

Does society have a moral obligation to insure that everyone has access to at least some level of health care?
If so, what level of care is the appropriate standard?

Universal access to all needed services "including the most exotic hospical care"?
Only basic -- or some other lower-level -- of care?

Justice, Liberty, Equality, and the Right to Health Care

Three conceptions of justice that "dominate in contemporary sociopolitical theory" (555)

libertarian
socialist
liberal

utility

"everyone agrees that efficiency and practicality are important values"
"utility does not decisively favor one of the three basic conceptions.

The Libertarian Conception of Justice

Basic individual rights of individuals which society must recognize and respect

life
liberty
property

Rights are conceived negatively

A has a right to X means
"no one should prevent A from pursuing X or deprive A of X." (555)

Role of government (consequently)

limited to protecting individuals life, liberty, and property "against force and fraud"
everything else in society is matter of individual responsibility

"Providing for the welfare of others who cannot or will not provide for themselves is not a morally justifiable function of government." (555)

to do this government would have to take from some against their will to give to others
such taking is an unjustifiable limitation on individual liberty

since individuals own their bodies and the labor they exert
"individuals have the right to whatever income or wealth their labor can earn in a free marketplace" (556)
and no one -- including the government -- is entitled to take part of that wealth or income to provide health care for others

The Socialist Conception of Justice

Equality recognized as an intrinsic value

an intrinsic value which may trump rights of property & liberty (at least)
limitations on individual liberty that are necessary to promote equality are justified

Against the primacy of liberty

directly defend the competing value of equality
attack the libertarian defense of negative rights as partial -- rights the haves have more than the have nots

If you're starving, what good is a right to life that doesn't entitle you to something to eat?
What good is a right to property is you have none, and no prospect for getting much?
What good are rights to liberties you lack the wherewithal to exercise?

e.g., the right to exchange goods freely if you have no goods to exchange
e.g., the right to work at any job you choose when none are available

Rights are conceived of positiveIy -- as rights to be provided with certain things

A has a right to X means
society should enable A to pursue X successfully or else provide A with X

Deuling Conceptions

Libertarians criticize socialists for restaints on liberty.
Socialists criticize libertarians for "allowing gross inequalities among those who are `equally human'" (556)

The Liberal Conception of Justice

An intermediate position: Those who have more are morally required to help those who are in need.

agrees with the libertarian that various negative rights are to be recognized as of overriding importance

advocate institutions to ensure basic liberties (e.g., freedom of speech)
while providing for the basic needs of the disadvantaged

agrees with the socialist that certain extreme inqualities are unjust and immoral, e.g.,

failing to provide for the basic needs of those who
lack these through no fault of their own
when others enjoy benefits far above and beyond their basic needs

Disagreement about the extent of inequality that should be countenanced as just and permissable

Utilitarian liberalism: "inequalities are justified to the that they increase the total amount of good in society" (556)
Rawlsian liberalism: "the only justified inqualities in the distribution of primary social goods (e.g., income, opportunities) are those that will benefit everyone in society, especially the most disadvantaged" (556)

primary concern is not with the total amount of good in society
but with the good of the least advantaged
because the rational Rawlsian decision procedure is maxi-min

Theories of Justice and a Right to Health Care

Allen Buchanan's analysis

Libertarian conception

health care is is not a right possessed by individuals
society has no moral obligation to provide health care

Liberal positions

Rawls: unclear: depends on hard to determine empirical facts
Rule-Utilitarian: unclear: depends on hard to determine empirical facts

Defense of the Socialist Position (Kai Nielsen)

Liberty presupposes equality: "autonomy cannot be widespread or secure in a society which is not egalitarian" (572)
The fundamental egalitarian principle is impartiality, which means "the life of everyone matters and matters equally" (572)

thus everyone has an equal right to have their basic needs met
basic needs are for what (almost) all people "must have in order to function well" (574)

Application to health-care

basic medical treatment needs include treatment of conditions

which impede one's functioning well
which adversely affect one's well-being
which cause suffering

under "conditions of moderate abundance" such as in the U.S. (574)

everyone has a right to such treatment
and an equal right -- a multi-tiered system is grievously unjust
society has an obligation to equitably supply such basic treatment
only "a health care system firmly in the public sector (publicly owned and controlled)" (575) can do it

in the private sector the governing rationale must be profit
only government can make efficient, full, and equitable health care delivery job one.

Societal Obligations or Commitments to Provide Health Care

Some arguments supporting a societal obligation to provide health care do not base the obligation on a claimed individual right to health care

appeal to considerations of benificence
the specal nature of health-care needs

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research

Conclusion: "society has an obligation to ensure that each of its members has access to adequate care without being subject to excessive burdens" (557)
Supporting Considerations

the special moral significance of some health care
the fact that many health-care needs are undeserved
the implausibility of expecting everyone to be able to meet with their own resources health-care needs which are

unpredictable
costly unevenly distributed among people

Discussion: Comparison to Nielson

obligation to insure adequate level of care
no obligation to equal level of care: consistent with two-tier system

Another non-rights-based tack: appeal to virtue or care

Universal access to to health care (or lack thereof) says something about a society's moral character (or lack thereof)
Surely, "no decent and compassionate society could fail to provide health care to its members when it has the financial resources to do so" (557)
Appealing to virtues of decency and compassion
A similar appeal might be made to a societal obligation to care for its members.

Macroallocation Decisions and the Problem of Rationing

The Concept: Macroallocation v. Microallocation

Macroallocation refers to decisions regarding allocation of heath care resources by

legisatures and other governmental agencies
insurance companies
private foundations
etc.

Microallocation refers to decisions regarding allocation of health care resources to particular patients by

particular hospital staffs and
individual professionals

Two major issues concerning macroallocation

How much of our total economic resources should go for health care?

"questions must be asked about the importance of health care vis-à-vis othere goods"

e.g., should education receive less funding
to devote more to trying "to prolong individual lives as long as possible"?

rationing: "we may say that the American health-care system presently rations by the ability to pay" (558)

How should this total be divided up among specific areas such as: also involves rationing

crisis care
prevention
production of new equipment to be used in treatment and diagnosis

Rationing: if it is necessary or desirable, what should be the criteria for allocating available resources

Daniel Callahan: age

example of misuse of scarce medical resources: liver transplant for a 76-year old woman
whereas

medical resources are limited and
the elderly are consume a disproportionate and still increasing share

proposal: elderly individuals who have lived a natural life span should be

offered care that relieves suffering
denied expensive life-sustaining technologies

objections

Amatai Etzioni: age based rationing would lead to

intergenerational conflict and
a slippery slope leading to growing restrictions on health care for other groups

Nora Kizer Bell: age based rationing morally troubling due to its

bordering on involuntary passive euthanasia
sexist implications given the preponderance of women among the elderly

Oregon Plan

explicitly rejects "the rationing system that predominates in the United States" which "excludes whole categories of the poor and near-poor from access to public insurance"

denying coverage to people
rather than to low-priority services

explicitly accepts the following principles (593)

"there is a social obligation to guarantee universal access to a basic level of health-care"
"reasonable or necessary limits on resources mean that not every beneficial service can be included in the basic level"
"a public process, involving consideration of social values, is required to determine what services will be included"

Medicaid coverage determined according to a system of ranking services from most to least important

taking into account both the expense and the their likely effects on quality of life

prenatal examinations: high
soft tissue transplants: low

denying coverage for treatments below a certain point on the list

a point determined by available funds
given the number of Oregonians "at or below the federal poverty line" (558) to be covered

Norman Daniels discusses the fairness, or justice, of this plan.

Daniel Wikler's discussion of rationing

Distinction: trimming v. cutting

cutting: "the limiting or exclusion of services that few people want and no one needs (e.g., ineffective treatments)"

"not really controversial"
it would even be "irresponsible not to engage in this form of rationing" (559)

cutting or "hard rationing": the limiting or exclusion of services that are both wanted and needed

Argues against "the common assumption" that cutting "is necessitated by exploding medical costs"

these hard choices could be avoided
by appropriate reforms to our health care system

Health-Care-Delivery Systems

The Current U.S. System: a mix of public and private elements

a large percentage of Americans have some form of private health insurance

often paid for partly or entirely by employers

Medicare provides federally funded coverage to people over 65.
Medicaid provides government funded coverage to the poor

those below a certain income level
this cutoff level varies from state to state

special groups are directly cared for in government operated hospitals

veterans
those suffering from certain diseases, e.g., tuberculosis

extent of coverage: 1994

85% of Americans have medical coverage through private insurance companies or governmentally funded programs
15% have no coverage: 39 million Americans

Discussion

"Assuming some type of health-care reform in the United States is morally imperative" (559)
Question that arises: "[W]hat sorts of reforms should be sought."
Desiderata the critics agree on:

universal coverage
controlling costs

Two types of proposals

mixed public and private sector systems
entirely publically funded or "single payer" systems

"Mixed" Health-Care-Delivery Systems

Seek "to restructure both public and private elements of our present system" to better meet the desiderata

extending access
containing costs

Inefficiencies of current system

uncovered individuals end up in ERs

where health care services are most expensive
and law requires that they be treated regardless of inability to pay

fee-for-service wherein

physicians and hospitals are reimbursed by insurers for specific services rendered
and neither patients or physicians have any incentive to be cost-conscious
only insurers have an incentive to be cost conscious but insurance company micromanagement of treatment seems particularly ill-advised

due to lack of expertise (regarding the particulars of the case)
due to serious conflict of interest

Managed competition approach (Alain Enthoven & Richard Kronick)

restructure the system so financial incentives lead to managed care
HMOs exemplify managed care

HMOs are paid a lump sum on a periodic basis
giving them an incentive to be cost-conscious

by emphasizing preventative care over "crisis" and specialty care
controlling [i.e., restricting (LH)] access to treatment

The Single-Payer Option

All payments made by a single "insurer", the government, like Canada.
Administratively simpler

Administrative vices of U.S. system

U. S. has more than 1,500 different payers
private sector payers have many extraneous costs

advertising
their own peculiar red tape
profit

Bottom line

25¢ on every U. S. health-care dollar goes to administration
13¢ on every Canadian health-care dollar

Produces better social outcomes

universal coverage
with "high-quality care"

"achieves health indexes that are at least comparable to those of the United States"
without Oregon-style rationing

Criticisms of the Canadian system & Replies

Objection: a national health would be bureaucratic & inefficient

Reply: it's the current system that's inefficient

25¢ on every U. S. health-care dollar goes to administration
Congressional Budget Office assessment

of various planns submitted to congress and studied by the CBO
the single-payer plan was the only one projected

to achieve universal coverage
while saving money (billions per year)

Objection: Canadians have to wait in line for needed services

Replies

interest groups opposed to national health exaggerate these waits
waits are generally for elective services
seriously ill patients are prioritized

Canadian feelings

a majority of Canadians would not trade their health-care system for ours
some weathly Canadians seek high-technology services in the U.S. rather than wait for them in Canada