How to ethically and practically extend health care to all - STAT

The long-standing debate over whether health care is a right or a privilege seems particularly heartless during a global pandemic. Guided in part by aftereffects of the pandemic, we believe there is a straightforward way to equitably resolve this contentious issue.

The Affordable Care Act essentially claimed that health care is a right and should be accessible to everyone. Those who believe it is a privilege argue that while it may be beneficial, there is no moral wrong done if an individual does not have health care, and there is no obligation to help people obtain health care if they aren’t able to gain access to it by themselves.

How the Supreme Court rules in California v. Texas — the most recent attempt to nullify the ACA — won’t put to rest the debate over health care as a right or a privilege in the United States.

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Moral people recognize that needless human suffering and death should be avoided. Unfortunately, human suffering and death is all too often the direct result of inadequate medical care. This is not a new reality. Covid-19, however, has focused attention on long-known and often-ignored realities in health care, particularly racial health disparities. The pandemic may also show us a path forward.

The debate over whether health care is a right or a privilege is often based less on core beliefs and more on economic reality. Society has a finite amount of money available to allocate competing social needs, including health care.

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So how can the tension between humanity’s basic moral impulse to avoid needless pain and suffering and its finite economic resources be resolved? Where do ethics and economics find a common ground in this matter?

We believe that clearly defining this common ground can make an important contribution toward ensuring that all people have adequate, high-quality health care without increasing health care spending — and perhaps even lowering it.

We build on our collective experiences — one of us (C.E.B.) is a physician and bioethicist, the other (R.L.) is a health care executive and public health leader — to propose a straightforward model that aligns spending with the moral standard of improving the health of society: Reduce lower-value care to fund high-value care for everyone.

Our model eliminates spending on low-value care and its operational costs, which do not directly contribute to improving health. For example, procedures such as carotid artery screening among people without symptoms and cervical cancer screening for women over 65 years of age have not been shown to confer significant value in terms of improving health. In this approach, low-value procedures like those would be eliminated in favor of expanding access to high-value interventions such as prenatal care, childhood immunizations, and tobacco and substance use counseling.

Transitioning from low-value to high-value care applies not only to individual procedures but also to the way in which care is delivered. For instance, moving the point of care from the hospital to the home is often safer, more effective, and less expensive. Money saved by reducing or eliminating low-value care would be used to extend to everyone high-value care that has measurable benefits for health.

But questions remain: Can the health care system, which usually moves at a glacial pace, change fast enough? If so, how?

Covid-19 has shown us that the U.S. health care system can pivot quickly. Much of this innovation has occurred on the local level, which is where health care reform should begin. To improve the system, more attention must be paid to fast, customized regional solutions rather than waiting for slower, top-down government solutions. One example is a program developed at Dartmouth that evaluates low-cost, more-convenient medical interventions in rural communities, as well as integrated centers that provide holistic care for complex diseases such as cancer and diabetes.

To address local health care needs caused by Covid-19, resources were shifted away from low-value care and toward high-value care that emphasized public health. More home-based care and less hospital-based care reduced cost and improved patient satisfaction, while also reducing the possibility of Covid-19 transmission. Creating multidisciplinary teams consisting of psychosocial workers, navigators, and in-home caregivers can increase health care access to underserved parts of the population. The savings from these approaches can in turn be used to extend medical care to more people.

The system we propose uses a moral lens to assess the extent to which medical interventions themselves, and the manner in which they are delivered, improve the health of society. Framed this way, justice requires that everyone have equal access to interventions that can improve health. We believe it is an ethical obligation of providers, insurers, and the government to support spontaneously arising local efforts that make it economically feasible to provide high-value care to everyone.

Covid-19 has taught us this is possible.

Charles E. Binkley is a surgeon and director of bioethics at the Markkula Center for Applied Ethics at Santa Clara University. Richard Levy is the chair of the dean’s advisory board at the School of Public Health at the University of California, Berkeley; chair of the advisory board of the Markkula Center; retired CEO and chairman of Varian Medical Systems; and former chairman of the board of Sutter Health.

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How to ethically and practically extend health care to all - STAT
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