Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform

As the American system of health care delivery strains under the weight of erratic coverage, inefficiency, and uncertain quality, proposals for how it should be reformed have proliferated. (1) Some proposals focus primarily on improving quality, others on restraining costs; all, directly or indirectly, address access to health care. (2) We present a consensus framework for evaluating how well a proposal addresses the issue. While access is affected by a number of factors (geography, distribution of providers, and so on), for this essay we focus primarily on ethical issues in access to health care coverage. The framework emerges from the work of the multi-stakeholder Ethical Force Program, which uses a standardized process derived from well-accepted methods for generating consensus on clinical practice guidelines and measuring quality in health care. (3) The program is a collaborative initiative led by the Institute for Ethics at the American Medical Association. It was established in 1997 "to improve health care by advancing ethical behavior among all participants." (4) It is motivated by the beliefs that ethical standards are fundamental to health care systems that are effective and trusted, that all stakeholders in health care should be accountable for their ethics, and that stakeholders must work together to ensure that shared ethical standards are widely promoted, understood, and followed. (5) The program functions as a national quality improvement organization for health care ethics. As such, it produces an array of reports and tools that all stakeholders can use to assess and improve the ethical environment of health care. The method by which it produces consensus statements has been described in detail elsewhere. (6) In brief, it runs as follows. An oversight body provides guidance on all programmatic activities. (For a list of the members, see the accompanying box.) The oversight body comprises a diverse group of leaders from all aspects of health care delivery, including clinicians, patients, provider organizations, purchasers, and others. The AMA holds two seats on the oversight body; the Agency for Health Care Research and Quality, the American Hospital Association, The Joint Commission, and the National Committee for Quality Assurance also hold permanent seats. The remaining seats are filled to three-year terms by vote of the oversight body, which seeks to ensure diverse perspectives and involvement. To determine consensus on recommendations, the oversight body votes on whether members support each recommendation using a one to ten scale. A statement is rejected if it fails to achieve an average score of greater than seven or if any member gives it a vote of less than three. We used this consensus process to come to agreement on four core ethical obligations for health system reforms that aim to improve access to care. We present these obligations with a number of more specific consensus recommendations that follow from taking the four ethical obligations seriously. Access to Health Care as an Ethical Issue As the number of Americans without health care coverage continues to increase, access to care is a major political, economic, and policy problem. Unequal access to health care is also an ethical issue. Most Americans understand this: 72 percent think our society should ensure universal access to health care, and 60 percent consider it to be a moral rather than a strictly political or economic issue. (7) We hold that three core American values are at stake: equality of opportunity, justice, and compassion. Equality of opportunity is essential for each of us to fulfill the American promise of life, liberty, and the pursuit of happiness, and personal health is an essential ingredient to ensure opportunity. (8) Equality of opportunity is compromised whenever identifiable subpopulations of American society are disproportionately affected by limited access to care. For instance, it belies the American ideal that all are created equal when disparities in access to care lead to consistently poorer health outcomes for specific racial and ethnic groups. …