Making healthcare affordable is one of the major challenges we face today as a society. Health never used to be expensive, as it is today, in the history of humankind. However, with the advent of modern medical technologies and drugs, we got into the business of improving and even extending human life. This forced us to put a dollar value to human life- which is the fundamental behind the pricing of healthcare services and drugs. The end result: ever increasing healthcare costs that is in sync with healthcare advancement. Capitalistic free market concept made the situation worse. The market players are constantly trying to come up with the next innovation that can extend or improve human lives in order to make money. The policy makers and government are facing one of the most challenging questions to answer: How much is the value of human life and quality of life? And who should pay for it? And, how to pay for it?
Consumers pay from their pocket for most consumer needs. Usually, these needs are at its peak during the money earning years of consumers. However, when it comes to health, spending usually happens when money is not earned or when it the earning is not enough. According to a National Institute of Health (NIH) published study1, even with private insurance coverage, avoidance of care due to cost remained a concern for people under 200% of federal poverty limit. When people age usually they need more care and earn less income. This means someone else other than the consumer (patient) needs to pay for healthcare. This is the main reason why government basically ends up paying for healthcare especially as people age. Even in the US where we have a system where it is almost required to have a job to have health insurance, government end up paying for people who need most care. Tying health coverage to jobs also is a problem. When people lose jobs due to sickness, the insurance goes away as well, forcing the government to pick up the costs. When government budgets cannot handle such high costs or when private insurers increase premiums to their insurance customers, health care become unaffordable to the individuals. This is the situation in which we started looking for ways to make healthcare affordable. This situation is going to be even worse as we go into future. According to US census bureau2, the largest increase in population between 2012 and 2016 is expected for the age group of 65+. This means further possibility of increased healthcare costs and less affordability.
Making healthcare affordable is more than just a matter of finding the money to pay for healthcare. It is a substantial ethical challenge as well. The problem roots from what we discussed above regarding the fact that heavy users of healthcare resources are not necessarily contributing to the society as much as a healthy individual (purely from an economics perspective). In that case, how do we allocate scares resources ethically? According to a study published by Medsurg Nursing Journal3, since 1986, hospitals are prohibited from denying care to any individual who could not afford to pay. Consequently, $100 billion of care annually is cost shifted to those who can afford to pay. This shift raises the average healthcare premium of those who can afford the insurance by $1000.00 per year. This is a lack of distributive justice, which is a major ethical concern. On the other side, US is the only developed nation in the world that does not guarantee health coverage. This is also an ethical issue in a country that relies on health insurance coverage for health care provision. This paper also depicts the different viewpoints on Liberal Egalitarians and Free Market advocates when it comes to distributive justice of healthcare coverage.
One of the problems of insurances in general is that, in order to work properly, insurance companies need to make sure the insurance is brought by healthy people as well. Otherwise, insurances cannot stay in business. There is no free-market mechanism that can ensure healthy people will buy insurance when they believe they don’t need care. Due to this, the government made it mandatory for everyone to buy health insurance (through Accountable Care Act). By doing this, US, for the first time, made it a requirement to buy a product or service as a condition for lawful residence in the country4. For a country that touts freedom and liberty, is it ethical to force a citizen to buy a product or service?. It is definitely against the libertarian principle5 of ethics where it is important for the individuals to have maximum equal empirical liberty when it comes to choosing what they want and what they don’t want.
According to a study published by American College of Emergency physicians6, we strive for four fundamental goals and desires when it comes to healthcare. First, we want high quality care. Second, we want the freedom to choose. Third, we want healthcare to be affordable and Fourth, we want our fellow citizens to share the benefits of healthcare. This used to work when we had limited healthcare options and less cost of care. However, it has become impossible or at least impractical to balance these four desires or goals. According to this paper, our fundamental goals have become incompatible. This leads to several questions centered around ethics. Is there anything wrong in spending too much on healthcare? In other words, are we throwing money at healthcare to stop or slow the natural fate of humans? How much money need to be spent on someone’s health? In order to answer these questions, we may have to invoke an ethical principle. Even if we take the common tool used to justify money related matters- namely, Utilitarian principle, we face another scary question. How much is the money value of human life? (or the value of an additional day of life). Clinical trial researchers have tried to answer this by the concept of Quality Adjusted Life Years (QALY). Even in this case, QALY needs to be compared to a dollar value to make is measurable and make decisions based on QUALY.
Affordability of healthcare is probably a nucleus of an ethical dilemma. As we saw above, the discussion quickly leads to several other ethical questions. And, fundamentally, it all comes down to how much dollar value we are going to stick on each human life (may be for each additional day of life). This is an intimidating concept- again for reasons that are moral and ethical. We haven’t found a solution to the problem yet, however, further development in healthcare and especially if the technological advancements in healthcare at a larger scale can become cheap, may offer us a solution to this difficult question.
REFERENCES
[1] Who Can't Pay for Health Care?
Robin M Weinick, PhD,1,2 Sepheen C Byron, MHS,1 and Arlene S Bierman, MD, MS3
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490134/
[3] Ethical Challenges in the era of Healthcare Reform, Vicki D Lachman, Published by Medsurg Nursing Journal July-August 2012, Volume 21/No 4 (http://www.nursingworld.org/mainmenucategories/ethicsstandards/resources/ethical-challenges-in-the-era-of-health-care-reform.pdf)
[4]Ethical Challenges in the era of Healthcare Reform, Vicki D Lachman, Published by Medsurg Nursing Journal July-August 2012, Volume 21/No 4 (http://www.nursingworld.org/mainmenucategories/ethicsstandards/resources/ethical-challenges-in-the-era-of-health-care-reform.pdf)
[5] Source: https://plato.stanford.edu/entries/libertarianism/
[7]Ethical Challenges in the era of Healthcare Reform, Vicki D Lachman, Published by Medsurg Nursing Journal July-August 2012, Volume 21/No 4 (http://www.nursingworld.org/mainmenucategories/ethicsstandards/resources/ethical-challenges-in-the-era-of-health-care-reform.pdf)