treuman katz center for pediatric bioethics seventh annual pediatric bioethics conference july...
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Treuman Katz Center for Pediatric Bioethics
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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.
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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?
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
• 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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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.
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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.
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Patient “Dumping” Increases
0
1000
2000
3000
4000
5000
6000
1980 1981 1982 1984 1985
DC
Dallas
Chicago
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
EMTALA
Medical Screening Examination
Emergency Medical Condition
No EmergencyMedicalCondition
No Further Dutyunder EMTALA
Treatment andTransfer Requirements
Apply until Stable
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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”
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
A Right to Health Care?
• Need
• Fair Opportunity
• Rawls and Veil of Ignorance
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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?
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
EMTALA
EMTALA was a congressional solution to the problem of lack of access
to health carefor those without (adequate) health insurance
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
…But it was also a copout:
“This is a moral outrage. Somebody must bear responsibility.
…But it’s not us.”
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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?
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Question is Not Whether to Place Limits, butWhat principle should be used to
distribute limited resources?
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Starting Point
• A Decent Minimum?
• Multiple Tiers?
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Some Common Objections toa Single Payer (Government)
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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)
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
“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?
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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.
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Two Final Observations
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
Human Wrongs: Attack and Flight
Plantinga, Not the Way it’s Supposed to Be
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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.
Treuman Katz Center for Pediatric Bioethics
Seventh Annual Pediatric Bioethics ConferenceJuly 22-23, 2011
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 ConferenceJuly 22-23, 2011