In United States, a very high standard of health care, inflationary rises in cost due to increased demands for services and the use of expensive life-extending technology threaten to overwhelm the system. In 1997, we were spending about 14 cents out of every dollar of the gross national product on health care, and the trend indicates increases in foreseeable future. These cost have escalated, even in the face of massive governmental intervention by way of prospective payment. The end result of our seeming inability to contain costs has been to place an ever-increasing number of our citizens outside our health care system, without money to purchase care, insurance, or health benefits to cover costs. A recent study highlights the problems our system is facing. Uninsured infants, while having more severe medical problems, received fewer medical services than those provided to babies who were privately insured or cared for under Medicaid. This decline in in quality of health care afforded to uninsured Americans seems pervasive across the whole system. A feeling of crisis permeates the nation in regard to health care as we struggle to decide to what and who is to pay.
National discussions in regard to the micro and macro allocation of health care resources have entered around the principle of justice. Proponents of egalitarian, libertarian, and utilitarian theories of justice have put forward a variety of rationing schemes, and is outline in three approaches;
- Private Market Approach – this approach seeks to build upon our existing system by encouraging everyone to buy health insurance with the assistance of tax credits, tax deductions, and redeemable vouchers. Some citizen would receive health insurance through purchasing it, others through their employers, and low income individuals would receive tax credit/vouchers that would make health insurance affordable and available.
- Government-based Approach – this approach calls for a national health insurance provided by the government. Everyone would receive access to a guaranteed basic hospital and physician coverage. Employers would no longer be required to provide coverage for employees but would contribute financially to the universal health plan. Private health insurance companies would play no part in the plan, but might provide additional coverage through supplemental insurance.
- Employer-based Approach – Sometimes called the “pay or play” approach, this plan calls for employers to either ‘play’ by providing health insurance for employers, or ‘pay’ a tax that provides coverage through a public plan. Either way, everyone receives health insurance, either from an employer or the government. Medicare would still be in place for older citizens and those handicapped.
The options available range over the full spectrum of political philosophy. There are those who argue for a pure capitalist approach, whereby costs are contained by the invisible hands of a free market. Others see the need for a utilitarian system, with government distributing care so as to provide the best for the most by restricting access of certain therapies to selected patient groups. Still others admire egalitarian proposals, by which everyone has equal access to all the care available consistent with resources.
Several mixed models for the macro allocation of health resources have been put forward. They call for a two-tiered system that provides a decent minimum level of basic and catastrophic care available to those who can afford to purchase it. The concept of a two-tiered system, providing a decent minimum care, forms the basis of the system in Oregon.
On the micro allocation level, groups have struggled with the allocation of such diverse resources as mechanical hearts, fresh organs, and intensive-care beds. Several system have been put forward, looking at a variety of triage schemes, with criteria based on such concepts as social and medical utility, ability to pay, first come first serve, and the lottery. Whatever system is finally selected, to be ethically sound of it must not fall more heavily upon the socially disadvantaged or those incapacitated by illness. The weighing of one class of treatments or technologies against another must take place in a closed system. When beneficial care is denied to one group it must be because there is a better use of those resources elsewhere in the system. The criteria for making decisions of what constitutes “better use” should be in accordance with the principle of material justice, and the fair opportunity rule.