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Justice in Health Care Reform

People often lose their jobs (and their health insurance) when they get sick and are unable to continue working. I realized then that I could be one of those people.

By Deborah K. Cruze, Illustrations by Cagle Cartoons

Story Photo

Bill Schorr of Cagle Cartoons

I have a bias in favor of universal health care. Let me tell you why.


In the 1980s, my husband was diagnosed with cancer while I was pregnant with our third child. He worked in the aerospace industry at the time, and when he was in the hospital receiving chemotherapy, we had a visit from his company’s vice-president of human resources. He assured us that we didn’t have to worry, that my husband would keep his job. I hadn’t been worried—until then.

In that instance, everything turned out all right, but it could have gone a different way. People often lose their jobs (and their health insurance) when they get sick and are unable to continue working. I realized then that I could be one of those people.

The second experience that led me to support universal health care occurred 15 years later. My husband, now free of cancer, was laid off from his job. COBRA had come along by then so we were able to keep health insurance, but the cost was high—$1,200 a month for our family of five. We shopped around for a more affordable policy but found that we couldn’t get anything close to the coverage or price of the COBRA. Plus no one wanted to insure us because of the previous cancer.

Who are the uninsured? Some 49.9 million Americans lack health insurance, and of those, 81% are U.S. citizens. Let me share some other statistics. Half of all bankruptcies involve illness or medical debt. The uninsured die at a 25% higher rate than the insured. The uninsured rolls in Georgia include 1.9 million people, and the state is one of the top five states with the most premature deaths (1,161/year).

Why reform is necessary

As an ethicist, I have studied many theories of distributive justice that may apply to health care. For example, consider ethicist John Rawls’s theory of justice that views fairness as a social contract or obligation. It requires arrangements chosen by all members of society if each could choose freely and without bias. Rawls defines a "veil of ignorance" whereby rational people would choose to maximize the lot of the least well-off since that life might turn out to be their own.


 –Dave Granlund of Cagle Cartoons

Ethicist Norman Daniels also approaches questions of health care through an egalitarian lens. Daniels believes that social justice improves a society’s overall health while reducing health inequalities. Each person, irrespective of wealth or position, would have equal access to an adequate although not maximal level of health care. Daniels argues that people have a right to equal access to health care and a right to a "decent minimum" of health care. However, he accepts a two-tiered system, analogous to education. In other words, all Americans are entitled to a public school education but not necessarily a private school education. Likewise, everyone should have access to some sort of health care coverage even if it is not the premium coverage.

No matter the approach we use to analyze justice in health care, it is obvious that reform is necessary. Why? For starters, the United States is the only developed nation without universal coverage. We spend twice as much as the average of other developed countries on health care, and we are the only nation that treats health care as a commodity distributed based on ability to pay rather than as a social service distributed according to medical need. Our market-driven system creates a paradox of a health care system based on avoiding the sick.

Deborah Cruze
Deborah Cruze is a senior program associate in health sciences and ethics and co-director of the bioethics consultation service at the Emory Center for Ethics. A former assistant attorney general for Arizona and a city judge for Glendale, she also teaches in the masters program in bioethics.

Another reason for reform is a 2,000% or 20-fold increase in the number of health care administrators since 1970, paralleled by only a 2.5-fold increase in physicians. Finally, for-profit health care emphasizes the profit of the organization over patient care.

National Federation of Independent Business v. Sebelius

In 2010, President Obama and the U.S. Congress passed the Accountable Care Act to extend health coverage to more than 30 million people. Recently, the Republican-based House of Representatives voted for the 33rd time to repeal what has become dubbed as Obama-care. However, on June 28, the Supreme Court upheld the law, officially on its docket as National Federation of Independent Business v. Sebelius, including its controversial individual mandate.

The individual mandate, which goes into effect in 2014, requires that all Americans obtain health insurance or face a tax penalty. Exemptions apply to those with financial hardships, religious objections, American Indians, prisoners, and undocumented workers.


Excluding illegal immigrants from the law hurts hospitals that handle a large share of uninsured illegal immigrants such as Emory University Hospital and Grady Memorial Hospital, among others. Like their counterparts across the nation, they will go unpaid for providing care to illegal immigrants.

Nationally, the individual mandate will cover an additional 17 million people, and 650,000 additional Georgians will receive health insurance coverage as we go forward.

By allowing the individual mandate to stand intact, the Supreme Court spared itself the burden of determining which parts of the ACA could survive if they had struck down the mandate. However, the Court also determined that threatening the loss of all federal Medicaid funding to states who chose not to expand their coverage was too coercive and exceeded congressional authority to encourage states to regulate.

In other words, while the Court deemed that Congress couldn’t threaten to take all Medicaid funding if a state refused to expand its Medicaid coverage, it offered a compromise. States would be able to continue to receive current Medicaid funding but would lose new money from Medicaid if they chose not to insure everyone, thereby making adoption of universal coverage voluntary.

A number of governors have expressed their opposition to expanding health coverage in their states, including Rick Perry of Texas. Seven states and the District of Columbia have elected expansion of coverage. Georgia, along with many other states, is waiting for the outcome of the 2012 presidential election. If the Republicans win, the belief is that they will try to overturn the ACA.

How will a rejection of Medicaid expansion in Georgia affect Emory and other hospitals? In drafting the ACA, Congress had to get hospitals like Emory that treat a high percentage of uninsured patients to accept a reduction in disproportionate share hospital (DSH) payment. The assumption was that Medicaid reimbursements would increase, thanks to universal coverage provisions, thereby compensating for the DSH reductions. However, if a state’s governor decides not to expand coverage, these hospitals will not only receive lower DSH payments but also will fail to be compensated with additional Medicaid funding. This scenario, played out in Atlanta and across the nation, could wreak havoc on an already overburdened health system.


 –Larry Wright of Cagle Cartoons

Figures from 2008 put the cost of caring for the uninsured at $56 billion a year. Those numbers have continued to climb in the past four years, and without universal health coverage, it’s scary to think how far they could go.

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