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8/14/2019 Health Care Reform on the Nation's Agenda
1/28
Health Care Reform on theNation's Agenda:
Ethical Foundations, Policy
Goals, and How to Get There
Robert M. Sade, MD
Department of SurgeryInstitute of Human Values in Health Care
Medical University of South Carolina
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My talk
Current trends Problems with 1 social emphasis
Myths re socialized medicine Dangers of fidelity to society (the state)
Ethical basis of 1 fidelity to patients
Current systemic problems in U.S. Presidential politics: views on health care
reform
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If you think health care is expensive now,wait until you see what it costs when its
free.
--P.J. ORourke
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Medical student attitudes
ACGME mandated H.O. work hours STS data: HOs benefit, pts suffer
AMA Code of Ethics
VIII.A physician shall, while caring for a patient, regard
responsibility to the patient as paramount.IX.
A physician shall support access to medical carefor all people.
Current Trends in Medicine
Favor Social Goals
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Problems with 1 social emphasis Myths re National Health Care Services.
Under NHCS: people have a right to HC
all have equal access to HC care given for need, not ability to pay
people get higher quality HC
administrative costs are lower
resources allocated to maximize impact
preventive HC is more available
racial minorities fare better
JC Goodman, GL Musgrave, DM Herrick. Lives at Risk. Rowman&Littlefield, 2004SC Pipes. Miracle Cure. Pacific Research Institute, 2004
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Central controlsubversion by self-interest
spectacular collapse of socialist states produced disaster in U.S. HC financing
Efficient market mechanisms precluded
Problems with 1 social emphasis
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The Evolution of HC Insurance
1929: The Baylor Hospital Plan 1932: Blue Cross begun
exempted from taxes and reserve reqs encouraged front end coverage covered services: prepayment, not indemnity
1940s: Federal policy (wage-price controls) IRS: HCI deductible for employers NLRB: HCI noncash benefit, bargaining chip
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The Evolution of HC Insurance
Reimbursement hospitals--cost-plus physicians--UCR
Perverse incentives of cost-plus Hospitals: cost income employer pays first dollar coverage
physicians set fees w/o market forces HCI does not spread risks
tax avoidance for medical expenses
demand prices
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Central Problem of HC Financing
When people buy health care,they do not have the perceptionthat they are spending their ownmoney.
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0
500
1000
1500
2000
2500
1980 1990 1995 2000 2004 2008
National Health Expenditures in CurrentDollars (Billions)
Deloitte & Touche
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Health Care Problems Unsustainable rise in cost of HC
Failed policiesunanticip consequences
NLRB, IRS, CON, DRG, RVS in M&M,mandated benefits, CMS regs Smothering bureaucr requirements (pub/priv)
Unfunded mandates
Strangulating paperwork Unwarranted 3rd party intrusions in HC
Diminished access to HC Uninsured (47M and rising, predicted)
Health disparities
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Politics is the art of looking for trouble,finding it everywhere, diagnosing it
incorrectly, and applying the wrongremedies.
--Groucho Marx
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Solving These Problems More Command and Control no answer My view:
Common men and women: competent to live own lives competent to know own interests and protect them dont need externally-imposed presuppositions re
interests (one law fits all)
Structure of society should: reflect needs of most (not least competent) most important need: space (personal freedom) provide safety net for most disadvantaged
Markets work well in U.S.; HC no exception
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A View of Ethics
Human beings living things, must maintain life Main tool is intelligence
Potentialities (generic-unique) can be actualized Goal: human flourishing
achieved only thru choices and actions of individuals
no instincts, but habits of mind (virtues) honesty, courage, rationality, justice
specific goals, needs (values) health, wealth, friendship
virtues and values require unique ranking
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The Need for Rights
Protect possibility of flourishing need personal territory: rights (negative)
freedoms of action guaranteed by government (constitution) expect errors, allow them (freedom/responsibility)
Central decision makers not free from error)
welfare rights (positive) impose unchosen obligations compromise possibility of flourishing
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Medical Ethics
Individual virtues goal of life
flourishing as human being MD virtues goal of medicine
good of the patient biological-medical good self-understood good
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MD Virtues Serving the Good(s)
Biological-medical good: scientific objectivity
maintaining medical competence conscientiousness in applying knowledge/skills
Patients perception of his own good: respecting pts self-determination benevolence in supporting pts goals honesty in disclosure
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Medical EthicsDistinguishing Characteristic
Intimacy and vulnerability of pts access to personal secrets
access to physical person Pts must trust that they will not be misused
Trust is and must be thefoundation of health care:serving the good of the pt
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The Ethical Core of Medicine
The pts good is paramount Effacement of narrow self-interest by MD
financial (fees, incentives, indigent care) own health (epidemics) inconveniences for pts needs
Obligations of secondary importance: colleagues, partnerships corporations society
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Markets and Freedom Markets: social expression of reason & choice
support right to pursue values for human living HC: right to seek care, accept or decline tx
voluntary trade everyone gains (not zero-sum) mandated terms unintended effects
Health health care (sanit. engineers vs MDs) health: nutrition, exercise, safe driving, hygiene,
Q: how money should be spent on health care-no! Q: how money should be spent on allhealth G&S best positioned: individuals living their own lives
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Markets vs Centralized Control
Myths HC market excludes non-players (poor) true only if charity not considered
MD (75%), private hospitals (60%) errors and omissions always present
not lower in public systems (collective vs individual)
Public institutions benevolent and wise politicians not less corrupt than businessmen public choice theory (powerful predictor)
political power used in self-interest
political decision making does not serve whole group
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HC System Problems Unsustainable rise in cost of HC Smothering bureaucr demands (pub/priv)
Unfunded mandates Strangulating paperwork Unwarranted 3rd party intrusions in HC
Diminished access to HC Uninsured (47M and rising, predicted) Health disparities
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Solving U.S. HC Problems Goal: affordable, safe, quality HC for all Administrations agenda: empower people
HSA (2003), need level tax field (employ-er-ee) consumer access accurate information, pricing
prudent buyers (few) quality, cost provider incentives to compete, innovate, risks
safety net: physical, mental, financ vulnerable children (no M-aid,S-CHIP): refundable tax cred community health centers: double in 10 yrs encourage AHPs (Association Health Plans) tort reform (comp injured pts, quality care)
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Blendon et al., Health Care in the 2008 Presidential Primaries. NEJM 2007;358:414-422
55
2058
94
7490
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1345
3913
7944
4121
7446
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14 32
23 6542 22
15 73
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McCains Reform Proposal HCI nationwide, not just in-state. HSA flexibility. HCI through any org or assoc or direct from insur co. Refundable tax credits $2,500 individual, $5,000
families (incentive to buy health coverage). Veterans use any provider (eg, electronic HC card). Support care delivery variety (eg, walkin clinic, retail
store). Develop routes for cheaper generic drugs to enter U.S.
market (including safe importation of drugs). Revamp Medicare payment:
Pay for diagnosis, prevention and care coordination. No pay for preventable medical errors or mismanagement.
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Reform Proposal Comparison McCain Clinton ObamaTax subsidies Replace regressive,
wasteful subsidieswith $2,500 ($5,000)refundable tax credit
No repeal, add moresubsidies No repeal, add moresubsidies
Household expense by $1,000 a year by $500 a yearNational Cost
(HSA flexibility)
Ideal: first dollarcoverage, no HSA,adds $1 trillion over10 yrs
Ideal: first dollarcoverage, no HSA,adds $$$$, < Clinton
Mandated insurance No Yes (but still notuniversal: 12 millionillegal immigrants
uncovered)
Yes (children only)
Access to care Use Medicaid/SCHIPto enroll people inprivate plans
Medicaid/SCHIP(move millions fromprivate broad accessto public limitedaccess).
Medicaid/SCHIP(move millions fromprivate broad accessto public limitedaccess).