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Barriers to Health Care & Access to Care Philip Boyle, Ph.D. Vice President, Ethics

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

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Barriers to Health Care & Access to Care Philip Boyle, Ph.D. Vice President, Ethics

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  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

  4. 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

  5. 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

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

  7. 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

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

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

  10. Equitable means? • Equality • According to benefit or need • Adequate level • Excessive burdens • Acceptable burdens

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

  12. 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

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

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

  15. 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

  16. 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

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

  18. 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

  19. 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

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

  21. 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?

  22. 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

  23. 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

  24. 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

  25. 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?

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

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