E. HAAVIMORRHM
ACCESS WITHOUT EXCESS
£. Haavi Morreim, Ph.D., Department of Human Values and Ethics, College of Medicine, University of Tennessee, Memphis, TN 38163, U.S.A. The Journal of Medicine and Philosophy 17:1-6,1992 © 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
The United States' health care system has perhaps as many critics as supporters. Those who have access to it enjoy a level of health care available only to relatively few elsewhere in the world. And yet, millions of people are excluded entirely from that system. At least thirty million people have no insurance whatever, and many more have seriously inadequate coverage. The cost of care has risen in double-digit inflation for decades, and neither government nor business - the two largest payers for health care - have been able to do anything to stop it. To keep their own expenditures at least somewhat under control, these two major payers have often responded by cutting back on the number of people for whom they provide insurance coverage. State governments have tightened their Medicaid eligibility criteria, for example, while many businesses have reduced or eliminated their insurance benefits for employees. Accordingly, the number of un- and underinsured grows. Government and business are also cutting costs by buying less care wherever possible and by paying less for it. In response, providers such as hospitals and physicians are increasingly restive as their reimbursement rates and rules are continually changed. They have correspondingly become less able and willing to care for the uninsured and so the access problem grows worse still. The challenge to rectify this system, or to replace it with a better one, is as complex as it is enormous. We need to understand why the system has gone so badly awry, and who is adversely affected by it, in what ways. This challenge is both empirical and moral, for we need to know not only what has in fact happened, but to identify the criteria by which we call it problematic. These criteria will then be equally essential in helping us to compose any adequate resolution. We also need to understand that any plan to increase access to health care must also be a plan to limit that
2
E. Haavi Morreim
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
access. In our world of finite resources, we can not describe who will receive what without, at least implicitly, describing who will be denied what. And so we must discuss access in the same breath with rationing. We must also recognize political realities. A morally, medically, or even economically optimal theory will serve no one if it cannot be adopted and implemented in our heterogeneous and not always harmonious society. The articles in this issue address this range of issues, from analyses of why the U.S. has its unique access problem, to proposals both for increasing access while concomitantly rationing services, to real-politik projections about what sort of system is actually likely, in the end, to emerge. In the first article, Shelton and Janosi help us to understand why the problem of access is inseparable from our inability to contain the costs of providing health care. The problem is a vicious circle of sorts. Businesses, which are the major purchasers of health insurance for working Americans and their families, cannot afford to provide this benefit unless they can be competitive in the marketplace. This, in turn, requires that they be able to predict and control their costs, one of the largest of which is those very health care benefits they provide for their employees. Despite extensive efforts, businesses have been unable to control that cost. This is partly because the government, facing its own fiscal problems, continues to shift its health care costs onto the private sector by providing inadequate reimbursements, and partly because the structure of the U.S. health care system encourages a proliferation of services with neither competition nor regulation to control the ensuing rise in costs. Businesses' inability to control their outlays for health care benefits means, in turn, that many are forced either to reduce those benefits or to eliminate them altogether - which then, of course, increases the number of people who are under- or uninsured. The cycle repeats itself. The problem can not be solved by the private sector alone, Shelton and Janosi argue, because it has neither the leverage nor the necessary level of consensus. Rather, a concerted effort is needed, one that culminates in negotiated budgets, supply-side controls, and in general a national resolution to this national problem. Peter Budetti likewise focuses on the role of business in providing access to health care. The problems in this approach are substantial, he notes. Many uninsured people are neither employees nor dependents of employees, and many who do have
Access Without Excess
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
employer-provided health care plans find them to be seriously deficient. Structural factors compound the problems, for example as insurers use an experience-based rating system to set premiums. The very high charges levied on those who consume most resources in effect excludes people with costly or chronic illnesses who cannot afford those higher premiums, and makes it economically difficult if not impossible for a small business with such an employee to continue to buy insurance for its workers. Government programs designed to fill the gaps in employerprovided insurance are also increasingly constrained by growing deficits. To resolve this problem Budetti sees three options: do nothing, reform the current system, and restructure the entire system. Realistically, the most likely actual course in the immediate future is no action in particular. As the problems of the current system lead us to a crisis situation, however, we are more likely to think seriously about reforms. Such reforms are likely to encounter opposition, however, from those such as small businesses that may perceive their fiancial survival to be threatened. Ultimately our most likely course, Budetti predicts, is for current problems to build into a crisis sometime during the next three to five years. Only then are we likely to have built the 'crisis mentality7 that seems, in our system, to be prerequisite to serious change. While the first two articles argue that major change is needed, Paul Menzel considers what form a new health care system might take, and how it might honor important values such as equity (both in providing services and in paying for them), efficiency, quality, economy, and autonomy. A wide range of systems can be conceived, from a purely market-driven approach to a completely nationalized system in which government is both the sole financier and the sole provider of health care. And yet these moral values, central though they be to any selection of a new health care system, can not tell us which particular system we must choose. Facts, more than values, must ultimately dictate just which plan will best honor the values we seek. Respect for citizens' autonomy, for example, does not mandate, and may even preclude across-the-board equality in a health care system. Similarly, given that people of different financial means may have profoundly differing preferences for spending their available resources, we must look instead to their actual or at least to their reasonably presumed preferences if we want to honor autonomy.
3
4
£. Haavi Morreim
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
Likewise, the medical and monetary efficiency of any proposed system can vary depending on what sort of efficiency we're looking for. In the end, although we may invoke moral values for basic guidance, they will not resolve some of the most vexing debates about which system we should choose. While Menzel invites us to recognize that almost any health care system has its possibilities, Margaret Battin reminds us that virtually any system will have its problems. In particular, she is concerned about the inevitability of standardization. It can lead to a dehumanizing uniformity of care in any national system that must care for everyone on a limited budget. Even now, far shy of universal health care, we see a strong movement toward monitoring outcomes, designing practice parameters, and seeking 'best buys' that can compromise medically optimal or personally preferred care in the name of resource efficiency. Such standardization, despite its hazards, has an important justification. A system that provides at least a Trest buy7 level of care to all (perhaps permitting those who can afford it to purchase 'besf care) is considerably more just than a system that functions by excluding some people from care altogether. Still, some kinds of care resist even an otherwise justifiable level of standardization. In particular, something so deeply personal as one's death ought to be shielded as best we can from a mechanical, even if efficient, uniformity. The final two articles discuss the problem that, once we decide to grant access to health care, we must also determine who will have access to what. It is the perennial problem of rationing. According to Nancy Jecker and Robert Pearlman, there exists a variety of ways in which we can ration limited health care resources. On the one hand, we could focus our rationing on qualities of the resources themselves, and perhaps (1) ration those services that are particularly high-cost or high-technology or, alternatively, (2) determine which services are basic and which are non-basic, rationing only those non-basic services that do not "prevent, cure or compensate for deficiencies in the normal opportunities persons enjoy at each life stage". On the other hand, instead of focusing on resources we could look at particular qualities of the persons toward whom our rationing is directed. We might (3) distribute fewer resources to those patients who will benefit from them the least, for example, or we might (4) ration those services that are not equally available to all patients.
Access Without Excess
5
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
Rationing is particularly of concern where public money is involved. Both ethics and prudence argue that health care should be universally ensured but, since the public resources necessary for such universal access are limited, we can only ensure a floor if we also establish a ceiling. Further, if the public is required to provide health care, that requirement can not be unlimited, for there are other priorities for common resources. Therefore, it is morally acceptable to begin rationing by excluding non-basic care from any universal entitlement. This conclusion should not be read simplistically, however. We would not, for example, automatically exclude high technologies as 'non-basic7. Such technologies can, after all, eventually lead to the low-cost, routine care of the future. Further, although equality is to be pursued, we can also defend limiting those services that have small hope of benefitting a particular patient. Finally, we need not honor equality in a simplistic way. We ensure equal access to basic care, yet still permit individuals to introduce some inequalities through their own purchases of non-basic health care. It is one thing to argue that society can rightly restrict its publicly funded health care to 'basic' care. It is quite another, however, to determine just what care is basic. In the final paper, Robert Nelson and Theresa Drought examine one particular attempt to specify the minimum level of services to which citizens will be entitled. The Oregon Basic Health Services Act purports to provide access to health care for all citizens with incomes below the federal poverty line, and to do so roughly within its existing Medicaid budget. In accordance with the Act, the state's Health Services Commission has established a priority system for determining which services are most important to fund, based on the importance, cost, and effectiveness of various services. An actuarial accounting has next been undertaken for determining how much money each level of services can be expected to cost. Ultimately, a legislative vote is then required to establish how far down the priority list the state will choose to provide care for its indigent citizens. (Two other bills create ways in which nonindigent citizens are likewise to be guaranteed access to care.) In this way, the state's definition of 'basic care' is established, not substantively through some general definition of adequate care, but procedurally as whatever level of service the legislature chooses to fund during any given year. Though such a system will surely perpetuate certain ine-
6
E. Haavi Morreim
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
qualities, and could lead to a denial of some medically necessary care, Nelson and Drought believe that it is nevertheless defensible. They argue that the Oregon plan can recognize resource limits, preserve the physician-patient relationship, and, if properly implemented, give citizens a voice in how common resources are used. Admittedly, the actual procedures used in setting Oregon's priority system arguably have not adequately honored the needs and preferences of those most affected by it. Still, the attempt to find resource limits procedurally through open discussion and negotiation is a move in the right direction, even if the process is halting and imperfect. In the final analysis, the question whether Oregon has actually established an adequate system will depend largely on what levels of care are actually funded. In this point, Nelson and Drought echo Menzel's point that matters of fact will be at least as pivotal as moral values in determining the justice and adequacy of any proposed system for providing increased, even if not unlimited, access to health care.
ACCESS WITHOUT EXCESS
£. Haavi Morreim, Ph.D., Department of Human Values and Ethics, College of Medicine, University of Tennessee, Memphis, TN 38163, U.S.A. The Journal of Medicine and Philosophy 17:1-6,1992 © 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
The United States' health care system has perhaps as many critics as supporters. Those who have access to it enjoy a level of health care available only to relatively few elsewhere in the world. And yet, millions of people are excluded entirely from that system. At least thirty million people have no insurance whatever, and many more have seriously inadequate coverage. The cost of care has risen in double-digit inflation for decades, and neither government nor business - the two largest payers for health care - have been able to do anything to stop it. To keep their own expenditures at least somewhat under control, these two major payers have often responded by cutting back on the number of people for whom they provide insurance coverage. State governments have tightened their Medicaid eligibility criteria, for example, while many businesses have reduced or eliminated their insurance benefits for employees. Accordingly, the number of un- and underinsured grows. Government and business are also cutting costs by buying less care wherever possible and by paying less for it. In response, providers such as hospitals and physicians are increasingly restive as their reimbursement rates and rules are continually changed. They have correspondingly become less able and willing to care for the uninsured and so the access problem grows worse still. The challenge to rectify this system, or to replace it with a better one, is as complex as it is enormous. We need to understand why the system has gone so badly awry, and who is adversely affected by it, in what ways. This challenge is both empirical and moral, for we need to know not only what has in fact happened, but to identify the criteria by which we call it problematic. These criteria will then be equally essential in helping us to compose any adequate resolution. We also need to understand that any plan to increase access to health care must also be a plan to limit that
2
E. Haavi Morreim
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
access. In our world of finite resources, we can not describe who will receive what without, at least implicitly, describing who will be denied what. And so we must discuss access in the same breath with rationing. We must also recognize political realities. A morally, medically, or even economically optimal theory will serve no one if it cannot be adopted and implemented in our heterogeneous and not always harmonious society. The articles in this issue address this range of issues, from analyses of why the U.S. has its unique access problem, to proposals both for increasing access while concomitantly rationing services, to real-politik projections about what sort of system is actually likely, in the end, to emerge. In the first article, Shelton and Janosi help us to understand why the problem of access is inseparable from our inability to contain the costs of providing health care. The problem is a vicious circle of sorts. Businesses, which are the major purchasers of health insurance for working Americans and their families, cannot afford to provide this benefit unless they can be competitive in the marketplace. This, in turn, requires that they be able to predict and control their costs, one of the largest of which is those very health care benefits they provide for their employees. Despite extensive efforts, businesses have been unable to control that cost. This is partly because the government, facing its own fiscal problems, continues to shift its health care costs onto the private sector by providing inadequate reimbursements, and partly because the structure of the U.S. health care system encourages a proliferation of services with neither competition nor regulation to control the ensuing rise in costs. Businesses' inability to control their outlays for health care benefits means, in turn, that many are forced either to reduce those benefits or to eliminate them altogether - which then, of course, increases the number of people who are under- or uninsured. The cycle repeats itself. The problem can not be solved by the private sector alone, Shelton and Janosi argue, because it has neither the leverage nor the necessary level of consensus. Rather, a concerted effort is needed, one that culminates in negotiated budgets, supply-side controls, and in general a national resolution to this national problem. Peter Budetti likewise focuses on the role of business in providing access to health care. The problems in this approach are substantial, he notes. Many uninsured people are neither employees nor dependents of employees, and many who do have
Access Without Excess
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
employer-provided health care plans find them to be seriously deficient. Structural factors compound the problems, for example as insurers use an experience-based rating system to set premiums. The very high charges levied on those who consume most resources in effect excludes people with costly or chronic illnesses who cannot afford those higher premiums, and makes it economically difficult if not impossible for a small business with such an employee to continue to buy insurance for its workers. Government programs designed to fill the gaps in employerprovided insurance are also increasingly constrained by growing deficits. To resolve this problem Budetti sees three options: do nothing, reform the current system, and restructure the entire system. Realistically, the most likely actual course in the immediate future is no action in particular. As the problems of the current system lead us to a crisis situation, however, we are more likely to think seriously about reforms. Such reforms are likely to encounter opposition, however, from those such as small businesses that may perceive their fiancial survival to be threatened. Ultimately our most likely course, Budetti predicts, is for current problems to build into a crisis sometime during the next three to five years. Only then are we likely to have built the 'crisis mentality7 that seems, in our system, to be prerequisite to serious change. While the first two articles argue that major change is needed, Paul Menzel considers what form a new health care system might take, and how it might honor important values such as equity (both in providing services and in paying for them), efficiency, quality, economy, and autonomy. A wide range of systems can be conceived, from a purely market-driven approach to a completely nationalized system in which government is both the sole financier and the sole provider of health care. And yet these moral values, central though they be to any selection of a new health care system, can not tell us which particular system we must choose. Facts, more than values, must ultimately dictate just which plan will best honor the values we seek. Respect for citizens' autonomy, for example, does not mandate, and may even preclude across-the-board equality in a health care system. Similarly, given that people of different financial means may have profoundly differing preferences for spending their available resources, we must look instead to their actual or at least to their reasonably presumed preferences if we want to honor autonomy.
3
4
£. Haavi Morreim
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
Likewise, the medical and monetary efficiency of any proposed system can vary depending on what sort of efficiency we're looking for. In the end, although we may invoke moral values for basic guidance, they will not resolve some of the most vexing debates about which system we should choose. While Menzel invites us to recognize that almost any health care system has its possibilities, Margaret Battin reminds us that virtually any system will have its problems. In particular, she is concerned about the inevitability of standardization. It can lead to a dehumanizing uniformity of care in any national system that must care for everyone on a limited budget. Even now, far shy of universal health care, we see a strong movement toward monitoring outcomes, designing practice parameters, and seeking 'best buys' that can compromise medically optimal or personally preferred care in the name of resource efficiency. Such standardization, despite its hazards, has an important justification. A system that provides at least a Trest buy7 level of care to all (perhaps permitting those who can afford it to purchase 'besf care) is considerably more just than a system that functions by excluding some people from care altogether. Still, some kinds of care resist even an otherwise justifiable level of standardization. In particular, something so deeply personal as one's death ought to be shielded as best we can from a mechanical, even if efficient, uniformity. The final two articles discuss the problem that, once we decide to grant access to health care, we must also determine who will have access to what. It is the perennial problem of rationing. According to Nancy Jecker and Robert Pearlman, there exists a variety of ways in which we can ration limited health care resources. On the one hand, we could focus our rationing on qualities of the resources themselves, and perhaps (1) ration those services that are particularly high-cost or high-technology or, alternatively, (2) determine which services are basic and which are non-basic, rationing only those non-basic services that do not "prevent, cure or compensate for deficiencies in the normal opportunities persons enjoy at each life stage". On the other hand, instead of focusing on resources we could look at particular qualities of the persons toward whom our rationing is directed. We might (3) distribute fewer resources to those patients who will benefit from them the least, for example, or we might (4) ration those services that are not equally available to all patients.
Access Without Excess
5
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
Rationing is particularly of concern where public money is involved. Both ethics and prudence argue that health care should be universally ensured but, since the public resources necessary for such universal access are limited, we can only ensure a floor if we also establish a ceiling. Further, if the public is required to provide health care, that requirement can not be unlimited, for there are other priorities for common resources. Therefore, it is morally acceptable to begin rationing by excluding non-basic care from any universal entitlement. This conclusion should not be read simplistically, however. We would not, for example, automatically exclude high technologies as 'non-basic7. Such technologies can, after all, eventually lead to the low-cost, routine care of the future. Further, although equality is to be pursued, we can also defend limiting those services that have small hope of benefitting a particular patient. Finally, we need not honor equality in a simplistic way. We ensure equal access to basic care, yet still permit individuals to introduce some inequalities through their own purchases of non-basic health care. It is one thing to argue that society can rightly restrict its publicly funded health care to 'basic' care. It is quite another, however, to determine just what care is basic. In the final paper, Robert Nelson and Theresa Drought examine one particular attempt to specify the minimum level of services to which citizens will be entitled. The Oregon Basic Health Services Act purports to provide access to health care for all citizens with incomes below the federal poverty line, and to do so roughly within its existing Medicaid budget. In accordance with the Act, the state's Health Services Commission has established a priority system for determining which services are most important to fund, based on the importance, cost, and effectiveness of various services. An actuarial accounting has next been undertaken for determining how much money each level of services can be expected to cost. Ultimately, a legislative vote is then required to establish how far down the priority list the state will choose to provide care for its indigent citizens. (Two other bills create ways in which nonindigent citizens are likewise to be guaranteed access to care.) In this way, the state's definition of 'basic care' is established, not substantively through some general definition of adequate care, but procedurally as whatever level of service the legislature chooses to fund during any given year. Though such a system will surely perpetuate certain ine-
6
E. Haavi Morreim
Downloaded from http://jmp.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
qualities, and could lead to a denial of some medically necessary care, Nelson and Drought believe that it is nevertheless defensible. They argue that the Oregon plan can recognize resource limits, preserve the physician-patient relationship, and, if properly implemented, give citizens a voice in how common resources are used. Admittedly, the actual procedures used in setting Oregon's priority system arguably have not adequately honored the needs and preferences of those most affected by it. Still, the attempt to find resource limits procedurally through open discussion and negotiation is a move in the right direction, even if the process is halting and imperfect. In the final analysis, the question whether Oregon has actually established an adequate system will depend largely on what levels of care are actually funded. In this point, Nelson and Drought echo Menzel's point that matters of fact will be at least as pivotal as moral values in determining the justice and adequacy of any proposed system for providing increased, even if not unlimited, access to health care.
