Health Disparities: Just and Unjust

1. Health Disparities:Just and Unjust Robert M. Veatch Professor of Medical Ethics Kennedy Institute of Ethics Georgetown University

2. Deamonte Driver (deceased) Cause of death: No dentist

3. Medicaid Pediatric Dental Access Disparity • Maryland: Medicaid children • less than one in three receive dental service • 16% had access to restorative services • D.C.: 29% • Virginia: 23%

4. Primary Care Access Disparity • Gentleman without primary care • Calls 911 whenever he feels sick • Knows EMS service must respond and transport him to a hospital • Knows ER will look at his sore throat

5. Unjust disparities and Universal Basic Healthcare Access • Unconscionable lack of basic healthcare coverage in the United States • Cost not necessarily the limit • Better dental care for Deamonte would have been cheaper and more humane • The ER is not the cost-efficient way to deliver primary care • Universal access to just basic care is a right

6. Unjust and Just Disparities • Funding universal basic care requires setting limits • Rationing of care is a logical necessity • Rationing by wallet • Cf. rational rationing

7. Rational Rationing Exclusions • Treatments not established to be effective • Treatments for trivial problems • Cosmetic surgery • Minor aches and pains • Morally controversial interventions • Voluntarily assumed risks (the problem of justified health disparities)

8. Just (Justified) Health Disparities • Some health risks are voluntarily and intentionally undertaken • Ethically suspect to impose the resulting health costs on the basic health plans of other people • We have to confront the rationality of voluntarily choosing less than maximal health

9. Arizona Governor Jan Brewer

11. The Irrationality of Maximizing One’s Health • The goal of maximizing health conflicts with the goal of maximizing well-being • Implication: People are voluntarily less healthy than they might be • Intentionally • Rationally • Different people deviate from maximal health by different amounts • Health disparity that is not unjust

12. Implications for Health Insurance • Unfair for insurance to pay indiscriminately for both just and unjust health disparities • To have the resources to pay for Deamonte Driver’s tooth ache, we need to separate the costs of voluntarily (fairly) chosen health risks • Need to separate two kinds of fair health disparities

13. Monitorable Health Disparity Costs • Smoking • Monitorable • Behavior in the public nexus (purchasing) • Linear dose-response correlation • Clearly not worthy of public subsidy (cf. fire-fighting) • Health fee calculated to reimburse insurance system

14. Monitorable Health Disparities • Smoking • Alcohol (?) • Public skiing • Professional sports

15. Nonmonitorable Health Disparity Costs • Obesity and hypercholesterolemia • High cholesterol medically bad and costly • Two plausible approaches: • Diet and exercise • Statins • Standard recommendation: diet and exercise first • Statins as a backup

16. Statins • 25 million Americans take a statin • Cost: $11/month or more • Aggregate cost: $26-34 billion/year • “Diet and exercise first” can be questioned • Some people don’t try diet and exercise first or don’t try it seriously enough • Is it “just” that insurers pay for these statins?

17. Problems in expecting people to pay for their own statins • Diet and exercise are not monitorable • Relation of cholesterol to diet and exercise not linear • No reason why it is rational to expect maximum use of diet and exercise before statins • Statin use may be rational alternative • = a “just disparity”

18. Statins and Just Disparities • Those with high cholesterol who have not adequately tried diet and exercise are different from those who have • Many statin users are free-riders • They have a health disparity that is not unjust

19. The Problem of Just Disparities • Those with high cholesterol who have not maximized diet and exercise have “just disparities” • In theory they should pay their own way • Impossible to enforce • Must resort to ethical appeal

20. Ethical appeal and just disparity • Some with high cholesterol have not tried diet and exercise • No one should be expected to eliminate all voluntary health risk • Rational people will not have ideal cholersterol level without statins • Resulting disparities not “unjust”

21. Ethical appeal and just disparity • People should make a “reasonable” effort • Insurance should not pay to treat voluntary (just) disparities • Place health fees on monitorable risks (tobacco) • Try to transfer nonmonitorable health costs • At least appeal to ethical duty • Attempt to develop valid monitoring • Such policies necessary to be able to pay to cover Deamonte Driver and others with unjust disparities

22. Thank you