Access to health-care providers is a matter of justice. Justice is a core Christian value and the cornerstone of the United States’ political system. Yet, it is clear that whatever measures of justice in health-care one claims, our system is not meeting those standards.

Recent Institute of Medicine reports have documented that quality is sometimes dangerous (number of deaths attributable to medical errors) and that access and quality are differentiated in racially identifiable ways. Now the institute is publishing a series of reports on the consequences of being uninsured.
The core ethical dimension of this public health issue is access to health-care providers. Both justice and quality must be considered.
Access to health-care providers is a matter of justice. Justice is a core Christian value and the cornerstone of the United States’ political system. Yet, it is clear that whatever measures of justice in health-care one claims, our system is not meeting those standards.

  1. Justice may mean that all have equal access to the most and the best of every treatment.
  2. Justice may mean that all have access to basic medical services while those with resources buy more.
  3. Justice may mean that medical care is a commodity like all others, and justice occurs best when there is free and unrestricted governance by market forces.

Whichever definition of justice is claimed, the United States system does not meet that definition.
The primary determiners of access are employer-sponsored private insurance or being a citizen over 65 years old (Medicare). During 2000, 25.9 percent of those under 65 were uninsured for part of the year, while 13.3 percent were uninsured for the entire year.
While those over 65 years have Medicare coverage, continuing cutbacks in levels of reimbursement to physicians and hospitals are limiting their access to providers. Furthermore, the absence of prescription drug coverage thorough Medicare limits access of the poor to this essential aspect of modern medicine.
Access to health-care providers impacts the health status of an individual and communities. There are consequences to being uninsured.

  1. Recommended preventative care is not received. Thus, uninsured are less likely to be involved in weight loss and smoking prevention programs. Screenings, such as cholesterol evaluations or mammograms, seldom occur. Dental diseases are also common among the uninsured.
  2. Chronic conditions are untreated or under-treated. For example, complications from diabetes are extremely high among the uninsured.
  3. Developing diseases such as cancer, heart disease and HIV infection are diagnosed later when treatments are more costly and less effective.
  4. Acute diseases or trauma are less aggressively treated in the uninsured. People with heart attacks are less likely to receive recommended angioplasty. Trauma victims die more often.

To be without health insurance is to be at great risk of disabling and terminal disease.
Who are the most vulnerable? Racial and ethnic minorities, rural residents and Medicaid recipients are most likely to suffer adverse health consequences. These groups tend toward hospital emergency departments as their points of entry into the medical system. Most frequently the conditions for which they seek treatment in these settings are not conditions the emergency departments are constructed to treat. Further, emergency medicine certainly does not allow for continuity of care.
Also, the hospitals who primarily serve these patients, so-called “safety net hospitals,” are under severe strain. Whether these are urban or rural public hospitals, urban teaching hospitals or charitable hospitals dedicated to “treating all without regard for ability to pay,” they are financially and humanly struggling.
As federal and state budgets are limited by “red ink,” health-care cutbacks, especially for Medicaid programs, are rampant. Many states have diverted the substantial proceeds from tobacco company lawsuits away from medical issues and into their general coffers.
Are there proposals for ethically addressing concerns of justice and quality?
An informed debate in the public forum is long past due. The optimal balance for health-care financing between government, private insurance, employer and individual responsibility should be resolved.
Choices regarding the cost-benefit expectations of technology, pharmaceuticals, “heroic interventions” and preventative-primary care must be considered. Our citizens pay the most of any nation for health care (percentage of GNP). We also receive the most services and the most advanced technology of any nation. But our outcomes never reach the benchmarks set by other industrialized nations. Our choices may not be optimal.
The health-care system as it now exists is not a rational system by any standard: economic, scientific, medical, human. Priorities for care and systems of care should be reconsidered in light of current knowledge and needs.
Finally, congregations and groups of congregations must join the conversation about health, health-care and our responsibilities to each other and our communities. The issues are complex. The problems are thorny. The results will likely be messy. What better place for Christian voices to struggle with this core dimension of being human in God’s world?
Steve Ivy
is vice president for values, ethics, social responsibility, and pastoral services of Clarian Health Partners in Indianapolis, Ind.

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