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

2. 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?

3. 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

5. 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

6. 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

7. poll Is healthcare more valuable than other values? Why is healthcare valuable?

8. 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

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

11. HC needs to be distributed equitably? Well being Opportunity Information Interpersonal significance

12. Equitable means? Equality According to benefit or need Adequate level –Excessive burdens –Acceptable burdens

13. Poll Is it a social obligation? –Why? Is a social obligation the same thing as a right?

14. 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

15. poll If it is a social obligation, can people forfeit the claim?

16. Does personal responsibility limit access? Difficult to identify –Voluntariness difficult to ascribe Institutionalization leads to discrimination Fair share of burden

17. 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

18. 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

20. What is adequate? Professional judgment Average current use List of services Overall evaluation

21. 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

22. 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

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

24. 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?

25. 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

26. 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

27. 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

28. 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?

29. Conclusions Establishing why it is a right Rights are inviolable Allocation is a mix of fair process & criteria