Discussion 6

Chapter Eleven
A New Era of Health Care: The Ethics of Health Care Reform

1

2

Health Care Reform in the U.S.
HR 3590 and HR 4872 signed into law in 2010 (PPACA) by President Obama.
PPACA represents a century of efforts to provide access to high quality, affordable health care.
Access, cost, and quality are the triumvirate mantra of health care reform.
3

Health Care Reform in the U.S.
There are three ways to provide universal coverage for populations:
The Bismarck Model.
The Beveridge or National Health Service Model.
The National Health Insurance Model.
4

A Bit of History
Otto von Bismarck introduced universal healthcare insurance in Germany in 1883.
Other European countries provided universal health care for a variety of variations and reasons.
European plans evolved from wage protection motives to providing medical and hospital coverage.
5

A Bit of History for the U.S.
Theodore Roosevelt was the first to support universal health care insurance.
His ideas were not supported by labor, medical societies, the insurance business, and business interests.
Universal coverage was excluded from the Social Security Act of 1935.
6

A Bit of History for the U.S.
In 1939-1943, attempts were made to create national health insurance, but they were not successful.
In 1948, President Truman campaigned strongly for national health insurance.
71% of Americans were in favor of universal coverage, but it never passed in Congress.
7

7

A Bit of History for the U.S.
In 1960, there was a new effort to address the healthcare coverage of the elderly through Medicare.
President Johnson’s political skills assisted in the passage of Medicare in 1965.
Medicaid, designed to provide care for needy children, was also passed in 1965.
8

8

A Bit of History for the U.S.
In 1971, President Nixon proposed a plan for compulsory employment-based health insurance that died a quick death.
The Clinton administration attempted health care reform with the Clinton National Health Security Plan.
This plan died in committee.
Health policy legislation is not easy.
9

9

What contributed to PPACA?
The percentage of the population without insurance reached 16%
Shortages of professionals lead to compromised access to care.
Costs for health care continued to rise and quality lapses continued.
Health care reform sought to: increase access, improve quality, and control costs.
10

Key Areas of PPACA
All Americans and legal immigrants must have health insurance or pay a penalty. Exceptions exist.
Businesses must provide health insurance.
Medicaid eligibility was extended.
Medicare benefits were improved.
11

Key Areas of PPACA
Insurance reform was extensive.
No lifetime limits were allowed.
Preventive care must be provided with no copays.
Minimum loss ratios were required.
States received assistance to set up insurance exchanges.

12

Key Areas of PPACA
The Act supported quality efforts.
It supported research on quality and other areas.
Coordination and integration of services was required.
Incentives and disincentives were based on quality efforts.
13

Key Areas of PPACA
The Act was concerned with adequate workforce and coverage for underserved areas.
There were incentives to increase the number and balance of health care professionals.
The Act was funded by new taxes, savings, and penalties.
14

PPACA Is Phased In
The provisions of the Act will be phased in through stages beginning in 2010.
Note the changes by year given in the Chapter.
The Act will not be fully implemented until 2020.
15

REFORM and JUSTICE
PPACA has increased access through affordability and availability for approximately 50% of the uninsured.
It created incentives for quality.
It struggles to maintain choice.
16

REFORM and JUSTICE
Approximately 20 million people remain uninsured.
Uninsured include undocumented immigrants, exempt individuals, and eligible but not enrolled Medicaid patients.
Uninsured also includes those choosing to pay penalties.
17

REFORM and JUSTICE
PP ACA improved quality for Medicare.
Pay for value or performance (P4P) incentives/Disincentive are in place.
Most newly insured patients were satisfied with care.
Tax credits improved affordability for health insurance.
18

REFORM and JUSTICE
However, insurance companies are exiting the PPACA marketplaces.
Their actions are because of cost and the losses.
Consumer choice within these plans is decreasing.

19

REFORM and JUSTICE
PP ACA was designed to decrease healthcare spending.
In in 2010 through 2013, spending did decrease.
In 2014 to 2015, it increased because of enrollment.
Controlling healthcare cost remains a challenge.

20

Ethics Assumptions and Health Care Reform
Most societies and individuals conclude that there is fundamental right to health care.
Support also comes from WHO, The United Nations, The Organization of American States, and The U.S. Declaration of Independence.
Religious traditions also support it.
21

Ethics Assumptions and Health Care Reform
Health care is a social good.
Therefore, there is a social contract concerning the good of individuals.
The good of individuals benefit society as a whole.
Therefore, providing universal access to healthcare is ethical.
22

Ethics Assumptions and Health Care Reform
The Rawlsian view of social justice support subsidized insurance plans. Under the difference principle, there is a ethical duty to improve the life of those worse off in a society.
Therefore, providing access to healthcare through social programs meets the categorical imperative.
23

Ethics Assumptions and Health Care Reform
Under the ACA states can refuse to expand Medicaid services.
Individuals can refuse to have health care insurance and pay fine.
These actions are in keeping with the libertarian view of ethics and market justice.
24

Ethics Assumptions and Health Care Reform
The political environment shows conflicts between Rawlsian ethics, and market forces (libertarian ethics).
The complexity of the issue and competing ethical views make healthcare reform difficult.

25

Is Health Care Reformed?
Given the need for addressing the three areas of access, costs, and quality, PPACA will continue to be a work in progress.
The healthcare system will continue to be refined and reformed in the years to come.

26

Is Health Care Reformed?
Given the need for improving access, costs, and quality, reforming health care is an ongoing issue.
The fate of PPACA could be repeal, replace, or repair.
Whatever its fate, healthcare policy will continue include ethics issues in the future.

27

In Summary…
28

28