On Thursday, March 23, the U.S. House of Representatives will vote on the American Health Care Act of 2017 (AHCA)—the proposed replacement for the Patient Protection and Affordable Care Act (PPACA). Response to the AHCA has come from many sectors, often with partisan bias. One perspective that is notably lacking from the debate—and the one we present here—is a nonpartisan ethical analysis of the proposed law. We are limiting our analysis to the micro level—the level of the individual. Analysis at the macro level is valuable and deserving of its own discussion, but we believe our micro analysis alone presents compelling reasons that core characteristics of AHCA are unethical.
There is a global consensus that modern societies have an obligation to provide essential health services to all of their members, thus our purpose is not to provide ethical justification for provision of these services. Americans value the highest-quality care, the greatest freedom of choice, the greatest affordability, and the most widely accessible healthcare; however, governmental resources will always fall short of what is required. This creates a need to identify and define priorities in health coverage (“priority setting”). As a result of priority setting, there must inevitably be tradeoffs—the deliberate decisions to allocate resources to certain areas of healthcare provision over others. There must be some ethical structure by which to assess the priorities. We analyze the proposal using the ethical principles of impartiality and justice, and we identify what we believe to be ethically unacceptable tradeoffs within this construct.
Extrapolating from the core principles of impartiality and justice, one can discern values around which to prioritize healthcare coverage. The first of these is cost effectiveness of healthcare, that is, the financial burden of the provision of healthcare relative to the benefits they confer. Second is priority to the worst off, accounting for socio-economic status, health status, and access to care. Access is particularly important given the growing scarcity of medical resources in the rural areas of the United States. The last is financial risk protection. On the micro level, a citizen should not have to suffer financial ruin in order to access adequate healthcare.
The cost effectiveness of prevention and public health is well established. Among the ten essential health benefits covered under the AHCA, only preventive services exempts cost sharing (co-pay or deductible). This might suggest prioritization on the basis of cost effectiveness, but none of the other nine essential benefits are prioritized on that basis. Moreover, if the AHCA truly prioritized cost effectiveness, it would not eliminate the Prevention and Public Health Fund, which provides evidence-based and innovative grants to improve the health of Americans. There is no mechanism in the AHCA for analyzing individual healthcare provisions on the basis of cost effectiveness. One could argue that until the cost effectiveness of healthcare is considered and prioritized, the gap between what the government can provide and what its people need will continue to increase.
Priority to the Worst Off
The second ethical criteria on which to assess the AHCA is priority to the worst off. The worst off can be defined by economics (poorer more so than wealthier), health status (sicker more so than the well), and geography (rural more so than urban). Pre-existing conditions are one surrogate marker for health status, and the AHCA provides coverage of pre-existing conditions. Thus, it succeeds at prioritizing the worst off, at least as defined by this particular marker of health status. The AHCA fails, however, to prioritize care for the worst off in several other important ways.
As mentioned previously, the AHCA ensures ten essential health benefits to everyone covered. Tax credits, calculated linearly based on age, indirectly subsidize healthcare coverage. There is also provision for a 5:1 ratio age rating, meaning that insurance providers are allowed to charge older citizens up to five times more for coverage than younger people, for the same level of coverage. According to a Milliman study, the impact of a 5:1 ratio is a significant premium increase for older people, who often have a limited, fixed income. The AHCA also significantly cuts funding for Medicaid, a program that provides care to the poorest, the sickest, and those with the most limitations to access. In these respects, the AHCA clearly does not prioritize the worst off.
Financial protection should be prioritized to assure that healthcare costs do not impoverish citizens, particularly in acute or catastrophic settings. The AHCA excels in that citizens covered can reasonably rely on protection from financial ruin. For instance, it prohibits lifetime and annual dollar maximums. However, those not covered are remarkably vulnerable to significant financial hardship, even for relatively routine care.
The nonpartisan Congressional Budget Office estimates that in 2018, an additional 14 million would be uninsured, increasing to 24 million in 2026. By increasing the number of uninsured so drastically, the AHCA fails to provide financial protection to the people of the United States on the whole. Consider instead a policy that ranked the same ten essential health benefits by cost effectiveness and eliminated the lowest ranked one. That reduction in individual coverage could in turn be used to cover more people, providing them with fewer but higher priority services.
The previous example calls for a distinction between ethically acceptable tradeoffs in the prioritization of healthcare benefits and unacceptable ones. Coverage of low or medium priority services before there is consistent coverage of high priority services is an unacceptable tradeoff. This brings us once again to consider prioritization, potentially on the basis of cost effectiveness, of the ten essential health benefits. The AHCA has sacrificed coverage of more people for higher individual levels of care. Those covered enjoy high quality and ready access without a maximum limit, coverage of pre-existing conditions, choice in provider and delivery. However, this robust level of individual services necessarily limits the number of people with coverage. This tradeoff is ethically unacceptable under the principles of impartiality and justice.
Another unacceptable tradeoff in prioritization is expansion of benefits for well off groups before doing so for worse off groups. As detailed previously, the increased number of uninsured, the cuts to Medicaid, and the increased premium expenses to older citizens allow for expansion of benefits to well off groups and in many cases excludes worse off groups—the elderly, the poor, the sick, and those with limited access. Again, this is an ethically unacceptable tradeoff.
Recognizing the necessity of priority setting in healthcare provision, an ethical framework based on impartiality and justice is necessary. It thus follows that coverage should be primarily based on need and not on ability to pay or political power. The AHCA is to be applauded in that it does not directly exclude or place exceptions to coverage on certain groups of citizens based on considerations of race, ethnicity, religion, gender, political beliefs, or sexual orientation. It also nominally acknowledges the value of cost effectiveness, ensures the coverage of those with pre-existing conditions, and provides financial protection in the form of prohibiting lifetime and annual maximums. However, it fails to consistently apply standards for cost effectiveness, it neglects the worst off as measured by access and economic status, and it provides no financial protection for the great number of people who will become (or remain) uninsured. Based on these shortcomings, the AHCA fails to meet the ethical standards for government-supported healthcare.