Is There an Ethical Obligation to Provide Health Care to All Children?

2. Is There an Ethical Obligation to Provide Health Care to All Children? Douglas S. Diekema, M.D., M.P.H. Professor of Pediatrics University of Washington School of Medicine Treuman Katz Center for Pediatric Bioethics Seattle Children’s Hospital

3. Health Care in the U.S. • Over 50 million Americans Uninsured • About a third of these are children • >70 million persons lack health insurance at least part of each year • 16% of Annual GDP in US • $7,000 per capita • Insurance Cost: • $8,400/year for a couple in their 50s • $9,400-10,500/year for a family • This represents 20% of median income

4. Initial Observation This is an ethical issue, not simply an economic one. The economic question distracts from the real issue The economic issue is not really about whether “we” pay, but how.

5. Questions Do children have a valid claim to the provision of health care? Whose responsibility is it to assure they receive that care? Are there limits?

7. Questions Do children have a valid claim to the provision of health care? Whose responsibility is it to assure they receive that care? Are there limits?

8. A Valid Claim? May be rooted in Justice or Fairness May be rooted in social beneficence (a good society will ensure certain basic needs) To a certain extent, Justice and Social Beneficence reflect community values

10. The Story of EMTALA Emergency Medical Treatment and Active Labor Act Federal Anti-dumping Law The Problem: “Patient Dumping”--Denial of care or transfer of patients based upon inability to pay “Economic Triage” Passed by Congress in 1985 and signed into law by Reagan on April 7, 1986 Purpose: prevent the transfer of unstable patients for economic reasons

11. Prior to 1980 Providers and Institutions provided charity care “Care in the form of unpredictable noblesse oblige.”--Reinhardt Relied upon provider charity, cost shifting, and a sense of mission/duty on the part of providers and institutions

12. Changes in the 80s Health care costs increase alarmingly Reimbursement Rates decrease For-Profit health care services replace not for profit Ability to“Cost-Shift” reduced The existence of public institutions for those without insurance minimizes sense of duty to deliver care

13. Health Care Becomes a Commodity Taylor, Washington Post, June 30, 1985; A14. “We don’t expect Safeway or A & P to give away free food for people who can’t afford it.” --Vice President of for-profit hospital chain

14. Dumping Becomes Epidemic Schiff RL. NEJM 1986; 314: 552-557. • Cook county Hospital • 1980-1985 • Greater than five-fold • Transferred patients were: • 98% Black or Hispanic • 81% Unemployed • 87% without adequate insurance

15. Patient“Dumping” Increases

16. EMTALA Medical Screening Examination No Emergency Medical Condition Emergency Medical Condition Treatment and Transfer Requirements Apply until Stable No Further Duty under EMTALA

17. EMTALA Today Provides essentially the only form of health care that can’t be refused in the U.S. Burden on hospitals: Unreimbursed care Closing of many Emergency Departments Overcrowding of Emergency Departments Perverse implications: Patients with chronic illnesses in need of treatment (diabetes, CRD) may only be able to get treatment when their condition becomes an “emergency”

18. A Right to Health Care? • Need • Fair Opportunity • Rawls and Veil of Ignorance

20. Questions Do children have a valid claim to the provision of health care? Whose responsibility is it to assure they receive that care? Are there limits?

21. EMTALA EMTALA was a congressional solution to the problem of lack of access to health care for those without (adequate) health insurance

22. …But it was also a copout: “This is a moral outrage. Somebody must bear responsibility. …But it’s not us.”

23. Incompatible Views No person should be denied medical (emergency) care The“goods”of the US health care system should be distributed according to a free market economy The means to ”purchase” health care should not be guaranteed to all citizens via funding with tax revenues

24. Social Beneficence? • Collective Social Protection • Obligation to protect the vulnerable • Obligation to provide protection against common threats • Fire • Crime • Pollution • Starvation/Water deprivation • Contagion (public health) • Health care is more like these things than iPads and SUVs and Mariner’s games…especially where children are involved

25. Social Responsibility • US policy reflects an individualism that isn’t tolerated by most of its population • EMTALA • Need to rescue • Common goods should not be left to the free market • Leaving common goods (defense, health care, roads, national parks) to the “free market” rejects community goods and values along with those individuals who have no capital

27. Questions Do children have a valid claim to the provision of health care? Whose responsibility is it to assure they receive that care? Are there limits?

29. What is the Scope of the Right? • Can’t apply to everything: Recognizing a right to health care does not require recognizing a right to all available medical treatment • All societies limit health care • Some more than others • Some more fairly than others

30. Question is Not Whether to Place Limits, but What principle should be used to distribute limited resources?

31. Starting Point A Decent Minimum? Multiple Tiers?

33. Some Common Objections toa Single Payer (Government)

34. Government Run Health Care is Bad Presumably the objection here is that the government would screw it up The Market has done a pretty good job of screwing it up VA system

35. Will Lead to Rationing • Yup! But so what? • We already ration: we do it by • insurance status and ability to pay • Deductibles and Co-pays • Exclusions for pre-existing conditions • Waiting time for certain services • Shortened hospital stays

36. The “Free Market” is the Most Efficient Way to Deliver Care There is no data to support this view Administrative costs of current system in US are higher compared to other countries Profit increases costs over non-profit Marketing, billing, executive compensation, risk stratification Profit Maximization leads to perverse incentives and decision-making leading to waste (everybody needs a heart center) and bad choices (if maximization of health is the goal)

37. “Socialized” Health Care We already have a significant portion of our health care system socialized: Medicare, Medicaid, VA system Simply labeling something as “socialized” is not an argument. What exactly is “wrong” with a “socialized” health care system?

38. Will Lead to Lines Like in Canada Where do you get your care? Look at ED visit waits in US Waits for specialty clinic visits, CT scans, surgery

39. All these arguments avoid the larger issue What level of public support for health care do all children deserve and what is the best system to accomplish that.

40. Two Final Observations

41. Taxes and Health Care • The notion that government spending is bad reflects ideology, but not much else • Employment • Public infrastructure • Social security • Social Benefit of healthy population • Everyone gets something in return

42. Human Wrongs: Attack and Flight Plantinga, Not the Way it’s Supposed to Be

43. An Example of Flight: Rather than dealing with the real issue (underinsured patients), Congress simply mandated universal access (via the ED) and side-stepped the issue of paying for it.

44. Rep. Pete Stark (California) “Patient dumping is but a symptom of a much larger problem. Thirty-seven million Americans are without health insurance. Low income sick people are finding it increasingly difficult to get needed health care, and the burden of caring for them is falling on fewer and fewer hospitals.”