treuman katz center for pediatric bioethics seventh annual pediatric bioethics conference july...

Treuman Katz Center for Pediatric Bioethics


Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011

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 MedicineTreuman Katz Center for Pediatric Bioethics

Seattle Children’s Hospital



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:

o $8,400/year for a couple in their 50so $9,400-10,500/year for a familyo This represents 20% of median income



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.



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?






Questions



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



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



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



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



Health Care Becomes a Commodity

“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

Taylor, Washington Post, June 30, 1985; A14.



Dumping Becomes Epidemic

• Cook county Hospital• 1980-1985• Greater than five-fold• Transferred patients were:

o 98% Black or Hispanico 81% Unemployedo 87% without adequate insurance

Schiff RL. NEJM 1986; 314: 552-557.



Patient “Dumping” Increases

0

1000

2000

3000

4000

5000

6000

1980 1981 1982 1984 1985

DC

Dallas

Chicago



EMTALA

Medical Screening Examination

Emergency Medical Condition

No EmergencyMedicalCondition

No Further Dutyunder EMTALA

Treatment andTransfer Requirements

Apply until Stable



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”



A Right to Health Care?

• Need

• Fair Opportunity

• Rawls and Veil of Ignorance



Questions






EMTALA

EMTALA was a congressional solution to the problem of lack of access

to health carefor those without (adequate) health insurance



…But it was also a copout:

“This is a moral outrage. Somebody must bear responsibility.

…But it’s not us.”



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



Social Beneficence?

• Collective Social Protectiono Obligation to protect the vulnerableo Obligation to provide protection against common threats

• Fire• Crime• Pollution• Starvation/Water deprivation• Contagion (public health)

o Health care is more like these things than iPads and SUVs and Mariner’s games…especially where children are involved



Social Responsibility

• US policy reflects an individualism that isn’t tolerated by most of its populationo EMTALAo 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



Questions






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 careo Some more than otherso Some more fairly than others



Question is Not Whether to Place Limits, butWhat principle should be used to

distribute limited resources?



Starting Point

• A Decent Minimum?

• Multiple Tiers?



Some Common Objections toa Single Payer (Government)



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



Will Lead to Rationing

• Yup! But so what?

• We already ration: we do it by o insurance status and ability to payo Deductibles and Co-payso Exclusions for pre-existing conditionso Waiting time for certain serviceso Shortened hospital stays



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)



“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?



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



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.



Two Final Observations



Taxes and Health Care

• The notion that government spending is bad reflects ideology, but not much elseo Employmento Public infrastructureo Social security

• Social Benefit of healthy population• Everyone gets something in return



Human Wrongs: Attack and Flight

Plantinga, Not the Way it’s Supposed to Be



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.



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.”

treuman katz center for pediatric bioethics seventh annual pediatric bioethics conference july...

Documents

charity care care

annual gdp

provision of health

denial of care

s health care costs

median income slide

economic issue

economic reasons