Health Care Access

Introduction

Health care access is the ability to obtain healthcare services such as prevention, diagnosis, treatment, and management of diseases, illness, disorders, and other health-impacting conditions.  For healthcare to be accessible it must be affordable and convenient.

Many people do not have access to adequate healthcare.  This occurs widely enough in third-world countries but also in the United States, despite Medicare and Medicaid programs.

Healthcare professionals, institutions, and governments face controversial choices about providing adequate healthcare.  Inaccessibility to healthcare is a public policy issue and, many people claim, a moral issue. 

Three important themes in healthcare access are the problem of poverty, the many barriers to healthcare access, and the question of healthcare resource allocation. These themes generate controversies about the role and alleviation of poverty, how to overcome access barriers, and how to fairly allocate limited resources.

Poverty

Poverty can be thought of as not having enough of the resources needed for an adequate quality of life, resources such as food, clothing, shelter, education, and healthcare.  We usually obtain these resources by purchasing them, so poverty is often seen as an income and wealth issue.

Poverty exists in both a relative and an absolute sense.  The relative sense means someone is poorer than the norm (or some threshold) of a larger population.  So in a society of billionaires a millionaire is poor.  Unless everyone has the same income or wealth, relative poverty will always exist, but it is not necessarily something that needs to be addressed.

Absolute poverty occurs when someone has less income or wealth than some absolute standard or threshold without regard to what everyone else has.  So if everyone in a country lacks enough money to buy food, everyone is poor, even if no one is in relative poverty.

In concepts of both relative poverty and absolute poverty one may question what the proper threshold should be.  On most analyses, in reality the world contains many people who are relatively poor and absolutely poor.

Many causes of poverty have been suggested, with some focusing on the individual and some focusing on group or systemic factors.  Among the most common causes or factors cited:

• Lack of education
• Lack of job skills
• Lack of natural ability and intelligence
• Lack of a country’s natural resources
• Lack of scientific knowledge
• Racial, ethnic, sexual, and age discrimination in employment practices
• Lack of infrastructure (roads, communication lines, efficient government, healthcare facilities, education facilities)
• Corrupt or incompetent governments
• Warfare
• Natural disasters (floods, droughts, soil erosion, hurricanes, earthquakes, climate change)
• Poorly developed economy; lack of industrialization
• Inefficient or ineffective economic systems stemming from faulty theories
• Religious influences preventing attempts at alleviating – belief in fatalism, acceptance of natural disasters as divine punishment, belief that the political and economic system is “God’s will”
• Pollution (especially water)

Most thinkers believe healthcare access is somewhat inversely correlated with poverty.  Poor countries by and large have poor access to healthcare.  And within a country, if you have plenty of money you usually have better access to healthcare than others do.  You will be able to afford insurance or have enough money to pay for care privately.

In the United States Medicaid is a government sponsored program to help poor people pay for healthcare.  But Medicaid is poorly funded and not all healthcare providers are willing to accept its low rate of reimbursement for services.  Medicaid as administered in any particular state does not necessarily cover all needed services, such as bone marrow transplants. 

Poverty might be seen as an impediment to “health access” and not just “healthcare access.”  Low income levels (“socioeconomic” status) are correlated with factors such as poor health literacy, poor health habits, and poor lifestyle choices that negatively impact health: poor nutrition, eating too much high-fat fast food, substance abuse (drugs, alcohol, tobacco), lack of exercise, and sexual irresponsibility.  These factors limit access to good health, not healthcare.  Putting a free doctor nearby may not be enough to overcome poor health access factors.

Barriers to Access

One way to look at the problem of healthcare access is in terms of such factors as the following constituting “barriers” to access:

• Not enough donor organs for transplant
• Not enough primary care physicians
• Not enough medical schools
• Urban blight and rural poverty limiting desirability of those neighborhoods for medical practices
• No convenient and affordable transportation for poor patients to get to remote medical offices or hospitals
• Patients cannot get time off of work
• Patients cannot obtain affordable childcare
• Limited hours, long waiting times, and limited afterhours care
• Insurance not available at affordable rates to certain populations
• Prohibitive copayment fees for certain services
• Drug prices too high
• Patients already with high medical debts
• Low health literacy
• Low level of computer skill
• Low level of computer and Internet access
• Undocumented residents from foreign countries having disadvantaged legal status
• Native language of patient not available at local facilities
• Country lacks healthcare professionals and facilities
• Climate factors create disease factors that overwhelm limited healthcare resources in tropical countries
• Superstitions, suspicions, and cultural factors create prejudices against using Western medical techniques
• Overall poverty level of individuals, population segments, countries, and continents

The list of barriers shows that there are various reasons for limited access to healthcare.  Some healthcare resources are in scarce supply in particular regions or time periods: organs, primary care physicians, and advanced technologies, for instance.  Sometimes it is a distribution problem: resources are available but in the wrong location, for example in large cities but not rural areas.  Many times it is an affordability issue: some people are poor and uninsured or underinsured. 

Medical education, healthcare infrastructure, organ allocation and distribution systems, and the level of medical technology may be low or poorly developed or administered in a particular country or in certain areas of a country.  Distribution problems may mean no nearby doctor to treat an individual, or a region or country unable to provide access to large population segments.  And in limiting healthcare access, poverty affects whole countries as well as individuals.

Perhaps many of the above problems would disappear if everyone’s standard of living were drastically raised, but, short of that, many ethicists believe we must look for other ways of overcoming barriers and improving healthcare access for underserved populations.  Given limited funding resources for payment and limited healthcare resources per se, healthcare access quickly becomes an allocation issue.

Healthcare allocation questions arise in several different realms.  Similar to the way economics can be divided into macroeconomics and microeconomics, healthcare resource issues can be macroallocation issues, microallocation issues, or somewhere in-between.  When the decisions are about large-scale allocation within society or government they are macroallocation issues and when they are at the level of healthcare professionals allocating time to specific patients they are microallocation issues.

One broad macroallocation issue is what priority the government should place on healthcare amidst other areas competing for funding, laws, and policies, for example, defense, education, and commerce.  Slightly less broad issues concern how much to spend or focus on prevention, treatment, and research.  Narrowing still, to the level of individual institutions or healthcare systems, what spending decisions should a hospital make about various healthcare programs, building facilities, buying technology, outreach to the community, etc.?  Where should new clinics be stationed?  Or for organizations, what algorithms should be used to match organ donors with potential recipients if there are not enough organs for the number of recipients in need?

Microallocation issues arise in the delivery of healthcare from provider and staff to patient.  What patients should the practice focus on?  How many Medicare and Medicaid patients should be accepted?  What insurance plans should the practice participate in?  What new equipment should be purchased?  How much staffing should the practice have, and at what level?  For specific patients, how much time should the physicians and nurses spend in the exam room, in patient education, in obtaining tests?  How much continuing education should the staff pursue?  Should the staff spend large amounts of time on the phone with patients?  How long should each office visit (patient encounter) be?

Theoretical Approaches to Allocation

Healthcare services are not free and unlimited.  In considering the problem of allocation, societies face some fundamental decisions.  Two distinct questions are:

1. Does society have a moral obligation to provide healthcare to all?
2. What is the most efficient and effective system for providing healthcare?

1. On the first question, some people think (a) healthcare is like any other consumer product or service (blenders, oil changes, etc.) that some people can afford and some people can’t.  (b) A different perspective is that healthcare is a right that the government has a moral obligation to provide to the entire population.  (A follow-up question would be: what level of healthcare?).  (c) Somewhere in between is the view that healthcare is a social good like highways, education, and defense, and the government should distribute it more fairly than by letting it depend on ability to pay.

2. The second question focuses more on how to most efficiently provide healthcare.  The usual assumption is that those who think healthcare is not a right believe a free market mechanism is the best system and those who think healthcare is a right or a social good would go with a government provided distribution.  Thus two theoretical approaches usually identified are the “libertarian” position (free market) and the “liberal, social welfare, distributive justice” position (healthcare as a right).  But this is not absolute.  One may believe that healthcare is a right and yet believe a free market is the best overall mechanism to provide it (the government messing up everything it touches) or, in contrast, believe no one has a right to healthcare but believe it works in the most organized, coherent fashion if the government handles it rather than being left to the “chaos” of the market.

With that caveat, here are three traditional theoretical approaches.

Libertarianism:  Those with libertarian sympathies believe government should for the most part stay out of healthcare and let it operate as a free market.  Healthcare should be provided by private practices, private and publicly-owned (not government) corporate institutions, whether for-profit or not-for-profit, and perhaps with the involvement of private and publicly-owned insurance companies.  Individual patients should be able to buy insurance and healthcare services as they wish.  Healthcare should be allowed to operate according to free market principles of supply and demand.  The libertarian thinks the role of government is limited to such functions as maintaining order.  This view stems from their view of individual moral rights and obligations.  Morality basically tells us to stay out of each other’s way, to refrain from harming others, to allow each of us basic liberty, rather than forcing us to provide for others or telling us how to live.  Individuals have no moral obligation to pay for the healthcare of their neighbors – that’s the role of private charity.  Healthcare allocation becomes a function of the ability of free markets to provide it and the ability of individuals to pay for it.

Liberal, “social welfare” conception:  The liberal social welfare conception supposedly stems from seeing healthcare as a social good or moral right that the government should provide so as to ensure that it is distributed fairly and no one is left out.  This view seems to involve the notion of distributive justice, which has to do with the fair distribution of goods and services in society.  Unfortunately there are competing interpretations of distributive justice.  Commonly quoted is the phrase traced back to Aristotle, “equals should be treated equally, and unequals unequally,” but that doesn’t seem to solve the matter.  “Everybody should get their fare share” likewise does not end the discussion.  Does fairness require everyone get an equal dollar amount to spend on healthcare (even if sicker people need more, and what about the person who lives longer than the rest, wouldn’t he need more?), that everyone get however much they want (so with limited resources the government still pays for anyone who wants a face-lift), or that each person gets enough to bring their health up to some standard of normalcy (and how to define normalcy)?  Or should people get an amount based on their value to society, how much they have contributed already, and should they get less if their illness was partly their fault (drug abuse, etc.)?

Efficiency:  Others think healthcare should be allocated for optimal efficiency, to get the most “bang for the buck.”  Presumably this can be taken to extremes so that no considerations of fairness enter into it.  Healthcare decisions are made on the basis of cost-benefit or cost-effectiveness.  A cost-benefit analysis considers alternatives with respect to how much they would cost and the benefit they would bring, with both cost and benefit stated in financial terms (in dollars, for instance).  On a larger scale, alternative healthcare systems would be evaluated on the basis of how much money they required, how many lives were extended, the increase in quality in those lives, etc.  The system with the greatest benefit per unit cost would be the desired alternative.  On an even larger scale one might try to compare government spending for healthcare, defense, education, etc. in the same fashion to determine how much should be spent on healthcare.  A cost-effectiveness analysis is similar except it does not try to compare costs and benefits in terms of the same financial units.  Benefits are not converted to financial unites but instead something such as “quality-adjusted life years” (QALY).  QALY is an attempt to account for years of life adjusted for the quality of life.

The theoretical underpinning of the efficiency approach is that of the ethical theory of utilitarianism, in which the right action is one which brings about the greatest happiness for the greatest number.

Common Healthcare Systems

Incorporating considerations from the above theoretical perspectives, but also disagreements among competing factions and historical developments in societies, countries have evolved a number of different healthcare systems.

A country’s healthcare system includes providers, patients, payers, research trials, programs, organizations, institutions, related businesses, laws, regulations, and policies.  Some countries have a mostly private system with healthcare available to those who can pay or afford insurance.  Others have a “universal,” or “socialized” healthcare system.  There are various ways this might work.  In a “national health system,” like in Great Britain, many healthcare professionals and institutions are government owned and administered, through private providers exist as well.  In a “national health insurance system,” such as Canada, most healthcare professionals are privately employed but get reimbursed by the government in a “single payer” system.  Healthcare funding is from government revenue.  In a system of “socialized health insurance,” as in Germany, healthcare workers are privately employed but the government requires employee contributions (payroll taxes) that go into private insurance (“sickness funds).  Healthcare funding is through distinct taxes.  The idea of all such systems, though, is that everyone be provided healthcare.

The United States has a mixed private/public system, with more privatization than most other developed countries.  Most healthcare providers do not work for the government, and most health insurance is private.  Many people who have insurance get it at discounted rates through their place of work.  Some healthcare is paid for by government programs such as Medicare and Medicaid which are funded by taxes and the general government revenue.

In developed countries the cost of healthcare has been rising, fueled by the cost of new technology, better and more extensive care for patients and treatment of diseases, sedentary lifestyles and poor nutrition, and aging populations.

In most countries healthcare is not an unlimited resource.  Trade-offs and compromises must be made.  Either some people do not get adequate healthcare, the cost of healthcare is high, there is a long wait to receive certain healthcare services, healthcare workers are relatively poorly compensated, or some combination of these occurs. 

Don’t Forget the Future

When allocating healthcare resources, present people matter -- those in the past are dead and gone and won’t benefit from current allocations.  But what about future people?  Do we who exist now owe an obligation to ensure provision of adequate healthcare to future generations?  What if the current generation bankrupted the system by exhausting services without ensuring there were enough clinicians being trained, buildings being built, and funds made available to service future generations?

It could be argued that healthcare needs of future generations merit attention in discussions of distributive justice.  Attention to future generations may imply the need for greater allocation for research and prevention programs that would significantly affect the healthcare of people who do not yet exist.