ETHICAL/MORAL ANALYSIS HEALTHCARE DISPARITIES 1
Ethical and Moral Concerns of Healthcare Disparities in the United States
by
Nipa Patel
June 21, 2015
MPH-560- Public Health Ethics
Professor: Hollie Pavlica, DrPH
Concordia University, Nebraska
Ethical and Moral Concerns of Healthcare Disparities in the United States
Ethical and moral concerns arise when there is not a healthcare system treating people equally and with respect. People are seen differently due to race/ethnicity and socioeconomic status. These differences lead to healthcare inequalities. In an ideal society, it would only be ethical and moral to treat all equally and with respect regardless of their race/ethnicity and socioeconomic status. What is it about the healthcare system of the United States that leads to such healthcare disparities?
Healthcare in the United States
The United States does not have a universal healthcare system. Health insurance in the United States is offered through private marketplace or the government (Ridic, Gleason & Ridic, 2012). Private marketplace allows residents to seek their own insurance or from employers. The government offers two major types of insurance which are Medicare and Medicaid (Ridic, Gleason & Ridic, 2012). Medicare is a program for disabled residents as well as aged residents. Next, Medicaid gives health coverage to “economically disadvantaged groups.” It should also be considered that not all residents in the United States have health insurance.
The Patient Protection and Affordable Care Act (PPACA) was signed in 2010 “to reform the healthcare system by providing more Americans with affordable quality health insurance” and by reducing the healthcare spending (Obamacare Facts, 2015). This reform in the United States gives all Americans new benefits, rights, and protections through health insurance. This act also makes insurance more affordable and forms new competitive health insurance marketplace. The law limits ends discrimination on charges based on gender or health status (Obamacare Facts, 2015). Most importantly, this law requires all residents to have health insurance or face penalties.
Healthcare Disparities in the United States
The United States resides a wide range of population groups. This causes not everyone to receive the same type of healthcare leading to healthcare disparities. Healthcare disparities are the differences in healthcare between groups of people (Kaisher Family Foundation, 2012). This means there is a “difference between groups in health coverage, access to care, and quality of care.” Racial/ethnic minorities are more likely to be poor than Whites (United States Department of Health and Human Services, 2014). Also, these minority groups are less educated compared to Whites. In 2007, the United States had about 38.8 million African Americans, 45.5 million Latinos, 13.4 million Asians, 0.5 million Native Hawaiians and 2.9 million American Indians and Alaska Natives (United States Department of Health and Human Services, 2014). From these about 57% use Federal trust lands. It is estimated that by 2050, these minority groups will be about half of the United States population.
Disparities in access to care are common among these minorities. Blacks, Asians, Hispanics and poor people have worse access to healthcare than Whites (United States Department of Health and Human Services, 2014). Barriers to access healthcare include factors such as “race/ethnicity, income, education, availability of health insurance, limited English proficiency, and availability of usual source of care.”
There are various steps that a community can do to help reduce these healthcare disparities. State and local government can use rate to identify population that are at higher risk and work with them to implement policies and programs to improve their needs (United States Department of Health and Human Services, n.d). Next, employers can offer preventive screenings at workplace. In addition they can identify local resources to make health information available to their employees. Healthcare system can help reduce disparities by increasing their culture and communication level. They can train and hire more staff that represents minorities. Learning centers and schools can reduce disparities by conducting research to find new and effective policies to reduce disparities. Similar to employers, they can offer preventive services for all children. Non-profit and faith based organization can work with various professionals “to ensure that community health needs are identified” (United States Department of Health and Human Services, n.d). In addition, they can work to ensure prevention strategies are within the understanding of a community. These organizations can also provide internet access to help others find health information and services. Lastly to reduce healthcare disparities, individuals and families should participate in community based prevention efforts. They should also use resources such as libraries and literacy programs to improve their understandings (United States Department of Health and Human Services, n.d).
PPACA to Reduce Healthcare Disparities
The new health reform has provisions to reduce healthcare disparities. The Medicaid expansion is said to reduce disparities by increasing the number of people eligible for the program. Since January 2014, individuals who are at 133 percent of federal poverty level can be eligible for Medicaid (National Conference of State Legislatures, n.d). Next, the act prohibits insurance companies todeny coverage or increase premiums to those who have pre-existing conditions (National Conference of State Legislatures, n.d). This is very beneficial for minorities in obtaining insurance since they face many disorders such as diabetes, heart diseases, cancer and other diseases. The PPACA also plays an important role in focusing on prevention and wellness exams. The law requires insurances to cover these exams without co-payments and deductibles (National Conference of State Legislatures, n.d).
Issues with the Healthcare in the United States
Has this new reform completely taken away healthcare disparities? The new reform in the United States is said to offer more opportunities for residents to access healthcare. Yet, does this change give equal opportunities to “all” people of the United States? As stated earlier, all residents are required to have health insurance, but is everyone getting health insurance?
A recent article by Kimberly Leonard mentioned about a yearlong study on 1,200 low income people in 10 states concluding “that people of color, families in rural communities and those with language and cultural barriers still struggle to get healthcare and pay for it” (2015). She states that the PPACA increased insurance availability by Medicaid expansion, but it is optional for the states to do so. Currently 22 states have not expanded the program (Leonard, 2015). This raises issues on inequality between states. In addition, having government insurance does not guarantee all types of healthcare coverage. For example, not all physicians and hospitals take patients with Medicaid. In 2011, 31% of physicians did not accept Medicaid patients (Decker, 2012). In addition, 17% were not accepting new Medicare patients. Each state varies on the percentage of Medicaid patients seen by doctors. New York had the lowest rate of 40% of doctors seeing patients with Medicaid (Galewitz, 2012). This is mainly because of the low reimbursement pay from the insurance. So what is the point of having such insurance where care is very limited? In addition, healthcare disparities arise since not every state has similar access to care. As stated earlier, New York held the lowest rate in the nation of seeing Medicaid patients. In comparison, Wyoming had the highest rate of 99% of physicians accepting Medicaid (Galewitz, 2012). Does this mean that people who are eligible for Medicaid must move to Wyoming for medical care?
For people who do not meet the requirements under Medicaid expansion and still have a low income can get insurance through healthcare marketplace. This is still very difficult for them since people are stuck with high premiums, copay and deductibles (Leonard, 2015). This is similar to not having insurance. Hence, some people rather pay the penalty in comparison to paying high premiums and deductibles. Some people find it cheaper to just pay the fine rather than the high premiums. For example in 2014, the penalty was $95 per adult or one percent of family income (CNN Money, 2013). A person who makes 50,000 would pay premiums of about $2,400 to $3,600 yearly. If this person declines insurance, he or she would only have to pay $400 at the end of the year which is way cheaper than paying monthly for insurance.
Another issue with the reform is technical access and language barrier. There are many ways to obtain health insurance such as by phone or online through marketplace. Many people and especially the low socioeconomic class find it difficult to access the internet to get coverage. In addition, some people find it difficult to enroll because they could not find their language. This means the opportunity to get health insurance is not equal. About 13.3 percent of Latinos, 22.2 percent Native Hawaiian or Asian-Pacific Islanders that did not speak English were not able to apply for insurance at home (Leonard, 2015). Limited English is a barrier to quality and access to healthcare. In 2007, 55.4 million Americans reported that they speak another language than English at home (U.S Department of Health and Human Services, 2014).
Furthermore, people who did sign up for insurance did not have enough knowledge about what plan they are picking and what financial support they have. However, the Marketplace does offer different types of methods to help customers such as, help by phone, in person, and insurance agents and brokers (Health Insurance Marketplace, 2015). Minorities are probably just not aware of such options.
Even after the PPACA law, the United States does not give equal opportunities to all. These issues of healthcare access in the United States relates to healthcare disparities among various groups of people leading to ethical and moral concerns.
Principles of Public Health Ethics
Public health ethics focuses on a whole community rather than an individual. The job of public health is to keep a community safe and healthy while avoiding ethical concerns. The goal of public health ethics is to “do no harm” or “do minimum harm” (Thomas, n.d). Public health ethics provide principles and values as a framework to make justified decisions (Center of Disease Control and Prevention, 2015). These actions are justified “based on ethical principles, values and beliefs of stakeholders, and scientific and other information.”
Kass (2001) mentions ethical framework in her article starting with: public health holds a value of maximizing individual liberties. Next, public health programs should decrease morbidity and mortality. In addition, these interventions should have minimized burdens. The interventions should also be made fair to minimize the existing social injustice.
Ethical Analysis of Healthcare Disparities
The existence of health disparities in the United States causes race and socioeconomic differences developingethical concerns. The ethics framework developed by Kass can be used to analyze ethical issues related to healthcare disparities.
Maximizing Individual Liberties
According to Meriam-Webster dictionary, individual liberty is defined as the freedom of exercising those rights that are not controlled by a government (2015). Ethically, public heath should maximize the individual liberty. With the new reform, people are criticizing the PPACA as a “government takeover” rather than a “public option” to get health insurance (American College of Emergency Physicians, n.d). Individual liberty is said to be violated because the government is mandating all to get covered. Yet, why are their healthcare disparities if all are required to get health insurance? This is because not everyone has access to the same type of insurance. This causes ethical concerns of healthcare disparities and violation of individual liberty. Next, there was also a controversy of the “death panel” which is an example of individual liberty in the health reform (American College of Emergency Physicians, n.d). People worried that the death panel would deny treatment to elder citizens (American College of Emergency Physicians, n.d). Many people faced ethical concern as they thought their individual liberty was at stake based on who the government chooses to get covered. Similarly, this led to healthcare disparities among elderly people.
Decrease Morbidity and Mortality
Public health strives to decrease death rates in a population by giving access to a better healthcare. It is ethical to build a society where all people live longer. Healthcare disparities in the United States causes increased rates of morbidity and mortality among certain groups of people. Even though science has evolved and treatment for many diseases exists, there are many racial and ethnic minorities that receive low quality of healthcare which leads to greater morbidity and mortality rates (Egede, 2006). Similarly, low socioeconomic status is also related to higher morbidity and mortality rates (Adler & Newman, n.d).
One factor that plays a role in receiving less care for these groups is the issue of prescription drugs not being covered by insurance plans. The PPACA does not include unlimited drug coverage which makes patients to pay out of pocket for some medications (Volsky, 2013). This can be very challenging for some minority groups who struggle for living due to limited income. Some people need medications for a lifetime and what happens if they cannot afford to pay the cost? They might choose to go without taking their prescriptions even though they know their diagnosis and dangers of not taking them. This can eventually lead to other diseases and/or death. This is a huge ethical concern because it is not right to have people suffer because of the “marketing business” between the government, pharmaceutical companies and insurance groups. It is only ethical to serve the community with cost effective prescriptions and especially to the most vulnerable. It is not fair that some people who can afford such costly medications have access to them, while another who similarly needs them cannot access them.
Minimized Burdens
It is ethical for public health to reduce burdens to decrease the gap of healthcare in the United States. Many minorities are burdened with various diseases due to the healthcare conditions (Baldwin, 2013). Barriers to healthcare such as lack of transportation and geographic location increase the burdens for minorities. Transportation barriers can cause missed appointments, delayed care or delayed medication access (Syed, Gerber & Sharp, 2013). The consequences of these can lead to negative health outcomes. Those with lower income suffer more from this barrier. To fix this problem it would be ethical to develop medical hospitals/clinics in rural areas. Development of these healthcare settings can decrease the barrier of geographic location. Healthcare disparities are formed in rural areas where minorities and low income residents resides. In the United States, rural areas face many obstacles in healthcare access. For example, only 10% of doctors practice in rural areas when about one-fourth of the population lives there (National Rural Health Association, n.d). Next, there are about 40 dentists for the 100,000 population in rural areas. The burden of diseases would be minimized for the minorities if more hospitals are built in these areas. This would also solve most of the transportation barrier if healthcare is in their local town. It is unethical to leave the ones who need the most care in an area with poor healthcare. This causes disparities between different societies.
Minimize the Existing Social Injustice
Social justice is the belief “that everyone deserves equal economic, political and social rights and opportunities” (National Association of Social Worker, n.d). It is important to maximize social justice to reduce healthcare disparities. Some factors that relate to social injustice are poverty, poor education, lack of health insurance, and limited access to medical care (Dilworth-Anderson, Pierre, & Hilliard, 2012).
The healthcare in the Unites States does not give equal healthcare rights to all residents leading to social injustice. People are able to access healthcare based on their social status. For example, the United States does not hold one universal health insurance that is available to both poor and rich. Each individual is provided insurance based on their social status. This raises ethical concerns since not everyone gets the same type of care. A person with Medicaid will be treated differently than a person with “good” insurance. For example a study was done in 2001 on children with asthma and hospital care for those who are covered by Medicaid to those covered by private insurance (Dayaratna, 2012). It was found that children with Medicaid had a longer length of stay as well as a poor outpatient care. In addition, it was found that Medicaid children lacked consistency in their outpatient care. This shows that these children will probably be making another trip to the hospital. Similar cases have been found in adult studies. In a 2010 study, the relationship between insurance type and “health outcomes for myocardial infraction, stroke, and pneumonia patients” was analyzed (Dayaratna, 2012). It concluded that patients with Medicaid have higher hospital mortality rates compared to privately insured patients. These types of social injustices open the gap of health disparities leading to ethical concerns.