JUSTICE AND HEALTH CARE ALLOCATION

1. JUSTICE AND HEALTH CARE ALLOCATION “Is Health Care a Good…A Right?” “What Responsibility Does the Profession (and Individuals Members Thereof) Have in Ensuring Access to a Reasonable Level of Oral Health Care for Others?”

2. Distinction Between Social Goods and Consumable Goods An Inquiry Into The Nature and Cause of the Wealth of Nations Adam Smith 1776 Argued that there are basic social goods upon which the “free market” for consumable goods is dependent, and that these should not be considered a part of the “market economy.”

3. Is health care a social good? or • Is health care a consumable good (a commodity), to be sold and purchased in the marketplace? *********** • Do illnesses of others affect us? • Does one’s health affect one’s ability to have “equal opportunity?”

4. Health Care Expenditures • The United States spends 17.2% of its gross domestic product on health care, $8,915/person. International average of industrialized countries is 9.3%. • Health care costs were approximately $2.8 trillion in 2012. • Health care costs have increased over 1,000% in the past fifty years. • Average premium for an employer in 2009 was $13,375 for family of four; $4,829 for an individual. • The United States is the only industrialized, developed country in the world that does have a basic, universal health care plan that covers all of its citizens. (Institute of Medicine) • In 2013 Bloomberg Report, US was ranked 46th out of 48 nations in efficiency of health care system. • One in six Americans lacks any basic health insurance coverage; currently 46 million people. Of these 25%, or 18 million are children. • Sixty percent of American bankruptcies caused by medical expenses. • All Americans over 65 have a decent, basic level of health care through Medicare. • In the population served by Medicare, it is estimated that almost 30% of the funds spent by the 6% of enrollees that died that year.

5. Health Status In America • According to a report by the World Health Organization, the United States ranks 37th of 191 countries the world in the overall quality of health care and 72 in overall health, while spending far more per capita than any other nation. • On many population health indicators e.g., premature births, infant death rates, immunization rates, etc. the U.S. ranks significantly below other industrialized countries. • U.S. is 26th in the world in infant mortality. • In UNICEF study of 25 “rich” countries in the world: U.S. first in childhood obesity; first in teen births, and last in child safety. • A recent report graded the U.S. 66 on a scale of 100—failing in a college course. • The U.S., according to the report, is very good at expensive, technologically sophisticated care, but poor at low cost preventive care in which other countries excel. • Clearly, if one individual has a need to be treated for a specific disease, the best technical treatment in the world is in the United States. • But, on population-based statistics of the overall health of the citizenry, we rank 37th. France is ranked number 1 in overall health. • Recently, 8,000 physicians signed on to a proposal, published in the Journal of the American Medical Association, in support of a universal (single payer) health care plan to cover all Americans.

6. Harris Poll Ninety percent (90%) of Americans agree with the statement, “everyone should have the right to get the best possible health care--as good as the treatment a millionaire gets.”

7. Tempering Human Value • While we frequently attest that humans have infinite value, we only have finite resources to devote to caring for human health; our resources are not limitless. • There are also other human goods to be provided for. • On utilitarian moral grounds we must ask the difficult question of cost versus benefit/value. • Limited resources require that we ask, and operationalize, what a “decent basic minimum” is and how much we can be afford.

8. In health care, what would constitute a ... “decent, basic minimum?” Daniel Callahan, a prominent bioethicist has defined a decent, basic minimum as “that level of care our society would cringe at the thought of someone not receiving.”

9. Age Discrimination? • Medicare grants an entitlement right to a decent, basic minimum of health care to all Americans over 65, regardless of income. • The only way to exclude yourself from the system is to die or return to 64! • Whereas our children, the country’s future, and our most vulnerable population, does not have a guarantee to a decent, basic minimum of health care. • Children do not vote; senior citizens do.

10. Kentucky Medicaid • In 2009, Kentucky spent $5.1 billion dollars in public funds for Medicaid; an increase from $3.3 billion since 1999. Medicaid funds are both federal and state dollars. Federal dollars match state dollars at a ratio of $3.25 federal for every $1.00 state. • 800,000 Kentuckians are covered by Medicaid (18%), with 300,000 more eligible as a result of recent Medicaid expansion (25%). • In 2014, federal poverty level (100%) is $11,940/year for one person, and $23,550 for a family of four; and is a reference point for calculating eligibility for most social welfare programs. • Medicaid eligibility is 150% of poverty and below, and S-CHIP eligibility is up to 200% of poverty. • Approximately 50% of the Medicaid budget is spent on long term and nursing home care for the elderly, many of whose families “spend down” their family resources in order to qualify for Medicaid. • In contrast to popular opinion, much of the Medicaid budget is spent on “middle class” individuals living in nursing homes during their last years of life. Your family?

11. State Children’s Insurance Program: S-CHIP • A federally mandated and funded program (1996) to provide health care for low income children, who would not ordinarily qualify for Medicaid. • In Kentucky is called K-CHIP. • Covers all children in Kentucky whose families are between 150% and 200% of poverty level (up to $47,000 for a family of four. • In Kentucky the program is integrated with Medicaid. K-CHIP families receive a Medicaid card and dentists (and physicians) are reimbursed at Medicaid fees. • Kentucky has 723,225 school children. 64.7% (468,133) are eligible for Medicaid or K-CHIP support.

12. Epidemiology of Oral Disease in the U.S.(Children Only) • Dental care is the most prevalent unmet need of U.S. children. • Dental caries is the nation’s most common childhood disease, affecting 58.6% of our 5-17 year olds. It is five times more common than asthma and seven times more common than hay fever. • Children lose 52 million hours of school time each year due to dental problems. • Children from poor families experience 12 times as many restricted activity days as children from advantaged families. • Toothaches are the most significant health problem encountered by primary school teachers. • 80% of dental disease is found in 20-25% of children (18 million), and these are children from African-American, Hispanic, Native American and low income families. • 79% of Native American children ages 2-5 have tooth decay, and 68% of it untreated. • The prevalence and severity of dental disease are linked to socio-economic status across all age groups.

13. Access to Dental CareFor Children • Children without dental insurance are 2 ½ times less likely than insured children to receive dental care. • Children with no dental insurance are 3 times more likely to have unmet dental needs than their counterparts with either private or public insurance. • Children from families at 200% of poverty or below are three times more likely to have unmet needs as children from families above that level. Nationally, one in four children (25%) are born into such a family. In Kentucky 64.7% of children are. • Nearly 25% of U.S. children are eligible for public financing of their care, yet fewer than one in five of these received a dental visit in the previous 12 months, according to a recent study. • One in four children have never seen a dentist prior to entering kindergarten. • 74% of poor children receive all of their immunizations, but only 22% of children under age 6 receive any dental care. • The percentage of Anglo-American children who have fissure sealants is 3 times that of African-American and Latino-American children. • 43% of Kentucky children ages 2-5 have untreated caries; 31% have severe early childhood caries; 44% have a history of parents abusing the baby bottle/sippy cup..

14. Student Dentist Survey(One School)

15. In oral health care (dentistry), what would constitute a … “decent basic minimum?”

16. Kentucky’s Medicaid Program in Dentistry • The services for which Kentucky Medicaid will reimburse dentists constitutes a practical definition of what is currently considered a decent, basic minimum in Kentucky. • The Medicaid dental fee schedule was upgraded in September of 2006; approximately a 30% increase. The handout shows current fees. • Private dental insurance companies vary greatly in what percent of the usual, customary and reasonable fee (UCR) they will pay, from 50-80% of UCR , depending on the patient’s insurance plan. Increasingly, private insurance companies are moving to fixed fee schedules, such as Medicaid uses, and abandoning the UCR approach. • Insurance companies maintain a record of UCR fees by zip code area. They then average the fees from a particular zip code to use as the benchmark for determining what constitutes 50-80% of UCR fee for that area.

17. Kentucky’s Medicaid Program in Dentistry • Medicaid is a fixed fee program. • While Medicaid pays a fixed fee for a procedure, calculating the percentage of UCR that Medicaid pays would depend on the area of Kentucky in which one practiced. For example, the UCR fee for an extraction in the Nicholasville Road zip code area would be higher than the UCR fee in Jenkins—in southeastern Kentucky. Medicaid pays $49.40 for a an extraction. The fee for an extraction in Lexington might be $100, thus Medicaid pays 50% of the UCR. Whereas in Jenkins, the UCR fee for an extraction may be $50, thus Medicaid would be paying essentially 100% of the UCR. • Our UK faculty practice UCR fee for a stainless steel crown is $188; Medicaid pays $119.60—which is approximately 65% of UCR. UK Dental Care, the College’s dental insurance program pays $129, or approximately 68% of the UCR. The most paid by other private plans would be $150 (80%), with many paying less. • An analysis of 20 procedures covered by Medicaid in relation to College of Dentistry faculty fees (which some indicate are high, even for Lexington) indicates that on average, Medicaid pays 62% of the UCR faculty fee.

18. Dentist Participation • Of Kentucky’s 2,200 dentists, fewer than 1,000 are registered to receive Medicaid patients, and fewer than 500 treat such patients as a regular and routine component of their practices, that is, bill Medicaid for more than $10,000/year. • This figure is a little less than 25% of Kentucky dentists; the national average participation is just over 10%. • Such a low percentage presents significant access to care issues for those needing dental treatment the most. • For example, we know that 80% of dental caries in children is found in 25% of the population; and that 25% is primarily those children covered by Medicaid and the S-CHIP program. Our failure to treat these children means that we are ignoring the major focus of oral disease and in our vulnerable children. • Is such morally justified?

19. KentuckyDental Medicaid • Of the total Kentucky Medicaid expenditures in 2005, $65 million was spent for dental care, or approximately 1.4 % of the total. • However, this does figure does not include hospital-based emergency room dental care or dental treatment under general anesthesia in hospitals or surgery centers.

20. KentuckyDental Medicaid • If a dentist is a Medicaid “participating provider,” s/he must accept the fixed fee paid by Medicaid. No additional fee can be charged the patient for a covered service. • If the dentist has not signed a Medicaid “participating provider” contract, s/he can see a Medicaid patient and charge the usual and customary fee. • A “participating provider” can provide care not covered by Medicaid and charge the patient the regular fee for the procedure. For example, complete dentures are not covered. A dentist may bill Medicaid for the necessary extractions, and then charge the Medicaid patient the usual and customary fee for the dentures. • A “participating provider” may limit the number of Medicaid patients s/he treats; however, cannot do so in such a manner that discriminated against a protected class of citizen.

21. Professional Duty • We have said throughout the curriculum that professional ethics is based on the moral rule…”do your duty.” • In this course on social justice, we are attempting to better understand the nature of that duty. • Society has granted dentistry a virtual monopoly to practice in order to ensure that society benefits by gaining the best quality in oral health care. • Kentucky citizens will have invested approximately $250-300,000 in the education of each student dentist in the class by graduation. • Life guard has a duty to rescue regardless of personal consequences to self. • What does society (Kentucky taxpayers) expect of Kentucky dentists as to “doing your duty?” Is there an expectation to care for the “dentally ill” in Kentucky, regardless of personal consequences?

22. Ethical Values of a Just Health Care System • Liberty • Equality • Fairness • Community

23. Equality • Nation founded on the belief that all deserve equal opportunity. • By providing a decent basic minimum of health care for all we move toward this ideal. • Pain and suffering, disability and limitation of function, and premature loss of life all restrict opportunities. • Education available to all as we realized lack of education had a fundamental impact on equality of opportunity. • In different way, health care is at least as important as education is securing equal opportunity.

24. Fairness • Theories of justice differ on what goods a society should secure for all its citizens. Nevertheless, all imply that it is a serious injustice when individuals suffer preventable loss of opportunity, pain and suffering, or loss of life for want of health care. • While theories (and people) disagree about how much inequality of wealth is fair, there is widespread agreement that fairness requires that the contributions of individuals to a basic social good, such as education and common defense, be based on their ability to pay; this should be true of health care as well.

25. Liberty • Constitution enshrines the value of personal choice and tolerance of diversity. • Health care system must be such as to respect the principle of individual choice. • A proper concern of liberty recognizes that with liberty comes personal responsibility for our own health. • Sometimes we must limit liberty to control health care costs, but our commitment to individual liberty requires that we do so minimally.

26. Community • While we are a diverse Nation, we are joined in a single national community. • Fundamental to our sense of community is a shared concern and responsibility for one’s fellow members, especially those suffering misfortune and in need of help. • A health care system that serves and cares for us all will also help bind us together as a national community.