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Children’s Access to Health Care: The Puzzling U.S. Attitude. April 11, 2008 Healthcare, Ethics and Law Institute, Samford University Loretta M. Kopelman, Ph.D . Overview. 1. Thesis 2. What do we get for our money? 3. Is the US allocation fair to children? 4. What is the puzzle?.

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children s access to health care the puzzling u s attitude

Children’s Access to Health Care: The Puzzling U.S. Attitude

April 11, 2008

Healthcare, Ethics and Law Institute,

Samford University

Loretta M. Kopelman, Ph.D.



1. Thesis

2. What do we get for our money?

3. Is the US allocation fair to children?

4. What is the puzzle?

1 thesis

1. Thesis

The current US healthcare system is unfair in its allocation of benefits to children.


2. What do we get for our money? The US:

  • Spends over $2 trillion or 16% of its GDP on health care; per capita spending $6,401.* -picks up about 50% of healthcare costs
  • Leads in innovative care & research.
  • Provides comprehensive “socialized” medicine for some: the elderly (Medicare), federal employees, congress, military, the poor (Medicaid), veterans.
  • *Oberlander N Engl J Med 357:17 2007

ACCESS: 47 million (15.8%) US citizens lack insurance (= not one day of/year).*

    • -9-11 million children lack healthcare insurance.
    • -State Children’s Health Insurance Program (SCHIP) expansion to cover more children was vetoed in 2007**
    • OUTCOMES: Growing health care disparities exist among rich and poor and white and non-white.
  • *Oberlander N Engl J Med 357:17 2007
    • **Rosenbaum N Engl J Med 358:2 2008

Most OECD countries provide basic health care to all for 8-11% of their GDP, viewing it like basic education.*

    • “The US health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just six percent of gross domestic product (GDP) on health services, ranks 18th.”*
  • Ranking the US as 37th reflects disapproval of the large numbers of uninsured, high infant mortality & health disparities.
  • * (WHO: Office for Economic Co-operation and Development)

Despite great outlays of public funds millions of children have unmet health care needs:* **

Children’s most common problems include vision impairments, hearing loss, dental pathology, allergies, and asthma.

Lack of vaccinations, preventive care and early treatment can cause life-long impairment.

*Starfield B JAMA 28(4) 2000 483.

**Newachecket, PW et al Pediatrics 105(4) 2000: 989-997.


Effective interventions in childhood:

 are often inexpensive: education about exercise,

diet, alcohol, tobacco, harmful drugs, and

prevention of teenage pregnancy.

 can prevent death, disabilities, and a lifetime of

chronic illnesses.

 affect near and long term health status and function.

poor children
Poor children:
  • get sick more often and stay sick longer
  • are three-to-four times as likely to become seriously ill and get multiple illnesses when they do get sick
  • are two to three times
    • to be of low birth weight,
    • to get asthma and bacterial meningitis,
    • to have delayed immunizations, and
    • to suffer from lead poisoning.

3. Is the US Healthcare System fair to


Fair systems require giving people their due:

(a) Similar cases are treated similarly, different cases

differently, and the differences and similarities are


E.G.: racial and gender biases in Medicare allocations are formally unfair and undermine confidence in the system.*

*Gornick, ME. et al.NEJM Vol 335:11 (1996), pp791-799.


(b) And assurances that allocations meet the

particular society’s justifiable needs and

values. The US population want to



-equality of opportunity

-social utility

-help for vulnerable people

These values can conflict and different theories of justice rank these values differently when they conflict.


Overview: Three important theories of justice rank these values differently but all show the US allocation is unfair to children:

- Libertarianism

- Utilitarianism

- Egalitarianism


Libertarians hold people have rights to control their fairly obtained property and this shapes the role of the state and social interactions.

- Competent adults should not be forced to do anything

unless it prevents fraud, harm to third parties, enforces

contracts, or protects the public.

- The state should provide protection and prevent harm

but not seize and redistribute people’s wealth to provide things like health care (or bailouts).

- People should take responsibility for themselves and

their family including about health care and insurance



- LIBERTY should be maximized.

- EQUALITY OF OPPORTUNITY is best served when

people use their resources as they wish.

- SOCIAL UTILITY and efficiency, including in health care,

are best promoted by personal choice and market forces.

- VULNERABLE PEOPLE such as children are best helped

by giving their guardians/parents responsibility to care

for them.

Moderate libertarians permit safety nets for children with irresponsible guardians.



    • conclude the current US system is unfair because many competent and even wealthy people get state subsidized health care (e.g., Medicare recipients).
    • moderates hold basic health care (safety nets) can be provided for children when their guardians cannot provide it.

Utilitarians hold that just allocations of state funds should provide the greatest good for the greatest number of people.

State health care expenditures should provide the most cost-effective programs for the most people:

- some of least costly programs are most beneficial.

- preventive care & primary care are often highly cost effective.

- develop and use fewer expensive technologies that help the few if they jeopardize care for the many.


- LIBERTY: Access to health care make it possible to develop one’s potential & become autonomous. Basic rights have great social utility and are rarely negotiable for the common good.

-EQUALITY OF OPPORTUNITY is served because

everyone’s interests or needs are counted equally.

-SOCIAL UTILITY is served since efficiency in the use of

state monies, including for health care, is best achieved

by maximizing benefit to the greatest number.

-VULNERABLE PEOPLE: It is cost effective to give children basic health because it prevents later costly illnesses, provides longer benefits and results in a healthier work force.


Utilitarians conclude:

-The current US health care system is

unjust because great outlays of public funds leaves millions without basic, effective and often inexpensive health care. The market is ill suited to enhance efficiency in health care.

- Basic health care should be provided to

all children because it is extremely cost

effective giving long years of benefit,

preventing later costly illnesses and having a healthier population.


Egalitarians hold that access to health care should be provided to people on the same basis to:

- demonstrate their value to society

- maximize equality of opportunity and

- maximize people’s objective net value or well-being by targeting those most in need.

-Some favor having one system for everyone.

-Moderates permit some inequalities based upon ability to pay once a baseline of good care exists for all.


- LIBERTY and responsibility mean little without the opportunities or means to choose. Access to health care and good health make it possible for people to develop their potential.

-Moderate egalitarians will not sacrifice basic liberties to achieve equality.

- EQUALITY OF OPPORTUNITY: Equality is promoted by targeting those most in need.

- SOCIAL UTILITY is important but we need to direct resources to where needs are greatest.

- VULNERABLE PEOPLE: access to health care should be provided to people on the same basis & people who have the greatest needs should get the greatest help.


Egalitarians conclude:

  • The US health care is unfair. Despite huge outlays of state monetary, it leaves millions without basic health care. We should focus on providing care for all on the same basis and helping the least well off.
  • - Basic health care should be provided to all children to foster equality of opportunity and demonstrate their value in society.

To Summarize: Providing basic health care to children

  • promotes key values of liberty, social utility, equality of opportunity and help for vulnerable people.
  • - live more fulfilling live.
  • - be healthy citizens, now and later,
  • - prevention of later costly illnesses,
  • - be a healthier work force, and
  • - efficient: For the cost, longer benefits to children.
  • - compete as equals
  • - compassionate
  • - can be justified by three important theories of justice*
  • Libertarianism, Utilitarianism, Egalitarianism
  • *LM Kopelman & MG Palumbo, “The U.S. Health Delivery System: Inefficient and Unfair to Children,” Am J of Law and Medicine, XXIII: 2-3 (1997), pp. 319-337
  • *LM. Kopelman. “Children’s Right to Health Care: A Modest Proposal,” in Medicine and Social Justice: Essays on the Distribution of Health Care, Rosamond Rhodes, M. Battin, A. Silvers, (eds.), Oxford University Press: New York, 2002, pp. 259-277
  • *LM Kopelman. "Children/III. Health Care and Research Issues," Encyclopedia ofBioethics, 3rd MacMillan 2004, pp. 387-399.

4. What is the puzzle? Why doesn’t the US provide all children basic health care?

- Refusal to select one theory of justice and use it consistently?

- All three theories justify basic health care for children in societies that can afford it.

- The lack of a consistent theory of justice for allocation results in a lack of a sense of one’s fair share.


Potential criticism: Too Narrow a View?

  • Other important perspectives exist beside philosophical ethics on this and other topics in bioethics.
  • Bioethics is a second order discipline (it has a teachable subject matter; it is composed of many disciplines but not reducible to any one field due to the complexity of problems associated with bioethics); none could be experts in all areas *
      • *Kopelman, L.M. (2006). “Bioethics as a Second-Order Discipline: Who is not a Bioethicist?” The Journal of Philosophy and Medicine 31:601-628.

Can the failure to provide basic health care for children in the US be justified from other perspectives?



Kids Don’t vote?


Most children are healthy?

More important community goals?




The current US healthcare system is unfair in its allocation of benefits to children.