Health Disparities:Just and Unjust

Robert M. Veatch

Professor of Medical Ethics

Kennedy Institute of Ethics

Georgetown University

Deamonte Driver (deceased)

Cause of death: No dentist

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%

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

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

Unjust and Just Disparities

• Funding universal basic care requires setting limits

• Rationing of care is a logical necessity–Rationing by wallet–Cf. rational rationing

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)

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

Arizona Governor Jan Brewer

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

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

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

Monitorable Health Disparities

• Smoking• Alcohol (?)• Public skiing• Professional sports

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

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?

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”

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

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

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”

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

Thank you