1. Health Disparities: Just and Unjust Robert M. Veatch Professor of Medical Ethics Kennedy Institute of Ethics Georgetown University

2. Deamonte Driver (deceased) Cause of death: No dentist

3. 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%

4. 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

5. 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

6. Unjust and Just Disparities Funding universal basic care requires setting limits Rationing of care is a logical necessity –Rationing by wallet –Cf. rational rationing

7. 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)

8. 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

9. Arizona Governor Jan Brewer

11. The Irrationality of Maximizing Ones 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

12. 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 Drivers tooth ache, we need to separate the costs of voluntarily (fairly) chosen health risks Need to separate two kinds of fair health disparities

13. 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

14. Monitorable Health Disparities Smoking Alcohol (?) Public skiing Professional sports

15. 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

16. 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 dont try diet and exercise first or dont try it seriously enough Is it just that insurers pay for these statins?

17. 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

18. Statins and Just Disparities T hose 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

19. 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

20. 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

21. 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

22. Thank you