Equity in health care: Theory to practice

Stephen Duckett, La Trobe University

Rosamond Rhodes, Margaret P. Battin, and Anita Silvers (eds.) Medicine and Social Justice: Essays on the Distribution of Health Care Oxford University Press, 2002 (488 pp). ISBN 0-195-14354-X (hard cover) RRP $135.00.

National Health and Medical Research Council Using Socioeconomic Evidence in Clinical Practice Guidelines Ausinfo, Canberra, 2003 (103 pp). [Online], Available: http://www.nhmrc.gov.au/publications/pdf/cp89.pdf.

A Fairer Medicare: Better Access, More Affordable, released by Prime Minister John Howard MP and Senator Kay Patterson, Minister for Health and Ageing, 28 April 2003. [Online], Available: http://www.health.gov.au/fairermedicare/overview.htm.

In a peculiar conjunction of timing, I recently received three works, ostensibly all related to equity in health care, across my desk. The first, a 488 page, 34-chapter book edited by Rhodes, Battin, and Silvers, comprehensively reviews justice in health care. The second, a report from the Health Advisory Committee of Australia’s National Health and Medical Research Council (NHMRC) provides advice on how to take socio-economic position into account in developing guidelines for clinical practice. The third is the government’s policy statement on changes to Medicare. The three are linked by their references to concepts of equity in health care. I array them here in order of their potential direct impact on consumers. At one polar extreme, the academic treatise will potentially influence thinking of students, researchers and practitioners (including policy makers and clinicians), the second will have, over time, an impact through the factors taken into account in formulating clinical guidelines, and the third could have a direct impact on access to care because policy changes affect financial incentives for general practitioners.

The differences between the three are manifold. The book is a weighty tome dealing with many different aspects of justice; the NHMRC publication is a slim volume of guidance supported by evidence; the policy statement is even slimmer—although long on rhetoric.

Equity (defined as low or no financial barriers to access) is only one element of a just health care system. In the introductory chapter of the book, Daniels, a leading American philosopher in this area, restates some principles for the design of a just health care system. He highlights (as he has done in previous works) the issues of procedural justice important for assessing the justice of rationing regimes. Daniels specifies four conditions for legitimising rationing and priority setting:

  • the publicity condition (that rationing criteria should be accessible);

  • the relevance condition (that the rationing criteria take into account relevant factors);

  • the appeals condition (essentially about natural justice: that people should be able to appeal against adverse rationing decisions);

  • the enforcement condition (that there is a system of public regulation to ensure that the preceding three conditions are implemented).

The debate on rationing is significant in the United States, where managed care organisations ration health services in secret, using ‘gag rules’ on doctors to prevent them disclosing to patients when managed care organisation policies may be impacting adversely on the choices and recommendations for treatment. Other peculiarities of the American health care system lead authors of several chapters of the book (including those by Menzel, and Hessler and Buchanan) to focus on the ethical basis of universality and just health care provision, issues that until recently we thought had been resolved in Australia for twenty years.

Questions of ethics and justice immediately draw attention to questions of politics. Vladeck and Fishman highlight the impact of American political culture and ideology on health care system design. The American Constitution seems to be designed to prevent a significant role for a public sector in the United States: power is divided between Congress and the Administration, and the Constitution both strengthens countervailing forces (including the courts) and weakens the party system in Congress.

Justice in health care is much broader than simply ensuring financial access.

Americans are known to be amongst the most litigious people on Earth but an interesting chapter by Tur reviews recent court decisions in the United Kingdom where issues of justice and rationing were challenged before the courts. Tur attempts to disentangle the ethical basis of some of the judicial reasoning in these cases, arguing an ethic of ‘secular human rights’ reasoning is emerging in recent cases about access to resources and welfare rights. Increasingly, health authority decisions in the United Kingdom may be challenged because of the application of the European Convention of Human Rights.

The Rhodes et al. book makes clear that justice in health care is much broader than simply ensuring financial access. Justice in health care must also deal with cultural barriers to access (addressed in essays by Blustein and McGary), and with the way the health care system deals with different population groups (for example, children as discussed by Kopelman, the aged as discussed by Francis, and carers of people with ‘mental retardation’, as discussed by Kittay). Several essays also deal with the issue of the right to health care, addressing both the pros and cons of using ‘rights’ discourse in this policy area.

Other essays address justice in particular countries. Unfortunately, although Sheehan and Sheehan’s chapter title suggests it is about Australia, they include more data on health status of people in other countries than in Australia and relatively little on Australians’ access to health care.

Finally, several essays recognise that treatment decisions often involve questions of justice. Rhodes discusses organ allocation, Kamm has contributed a very interesting essay on discontinuing non-futile use of scarce resources, Bickenbach discusses disability, and Holzman assisted reproduction.

The NHMRC publication focuses on more practical elements of justice, in particular, the impact of socio-economic position in health care. The last decade has seen an increased emphasis on evaluating clinical practice and ensuring that treatment approaches are based on evidence. Clinicians cannot be expected to read the thousands of articles published every day and so evidence is synthesised by groups such as the Cochrane Collaboration and/or translated into evidence-based guidelines for practitioners by professional colleges and other groups. Guidelines are designed to provide advice to clinicians (and consumers) on best-practice approaches to diagnosis and treatment.

Guideline production is almost as prolific as article production.

Guideline production is now almost as prolific as article production and one role of the NHMRC is to give its imprimatur to guidelines developed by other organisations. NHMRC endorsement carries weight amongst health professionals and accordingly, the NHMRC has developed a ‘toolkit’ series to assist guideline developers to understand how the NHMRC evaluates the externally developed guidelines it endorses. Most well known of the criteria the NHMRC uses is that the guidelines should be evidence-based rather than simply the collective wisdom of wise old men sitting in rooms which are no longer smoke filled. Previous guidelines for guidelines publications have highlighted the importance of incorporating economic evaluation into guideline development. This latest publication places the issue of socio-economic position firmly on the policy agenda. Socio-economic position can influence health care at any point of the treatment process including access to care, the diagnostic process, the treatment process, rehabilitation and so on. The booklet notes several examples where access (for example) is impacted by socio-economic position:

  • activities that modify cardiac risk factors—such as recreational exercise—may not be available in disadvantaged areas;

  • people in rural areas or urban areas of disadvantage are less likely to have breast-conserving surgery;

  • higher rates of childhood asthma are associated with poorly maintained housing;

  • different ethnic groups may have different levels of knowledge/understanding of diabetes.

The booklet incorporates excellent literature reviews and illustrative case studies of how socio-economic position could be taken into account in several national health priority areas.

However, the NHMRC is a rather toothless tiger and its policy decision-making processes are somewhat opaque. The booklet does not make clear when new guidelines for endorsement will be required to explicitly consider socio-economic position. If guidelines did include socio-economic analysis, and clinicians were required to be cognizant of the impact and effect of socio-economic position on treatment decision-making, this booklet would have contributed in an important way to reshaping the experience of disadvantaged groups seeking health care in Australia.

If a policy is called ‘a fairer Medicare’, people may believe that is what it is trying to achieve.

The third contemporary publication purportedly dealing with justice and equity in health care is the policy statement and associated publicity released as part of the government’s proposed changes to Medicare. In the best Orwellian tradition, this publication presents the big lie. If a policy is called ‘a fairer Medicare’, people may believe that is what it is trying to achieve. This publication, of course, does not sit well with either of the others I’ve discussed. You will look in vain for any evidence (of the kind the NHMRC might demand) underpinning the policy proposals. You will also look in vain for any explicit consideration of the conception of justice that underpins the policy. The government has used words like equity and fairness in connection with this policy. But it is a peculiar conception of equity that is likely to restrict access to health care, with financial barriers for a significant proportion of the Australian population.

The ostensible problem the government addresses with these changes is the decline in bulk billing. Bulk billing rates have fallen from a peak of around 80 per cent shortly after the government came to office to under 70 per cent at the end of 2002. The new government initiative is expected to cost about $1 billion, mostly funded by a cut of about that amount from the forward estimates for public hospital funding. The equity effects of how the government proposes to pay for their Medicare package have not received much public airing, possibly because there is no discussion in the public documentation about the source of the funding.

The government’s policy contains some admirable elements (for example, more doctors to be trained and more of these to be trained as general practitioners) but the bulk of the policy initiative has been extensively criticised and probably will not see the light of day. The initiative appears to have been designed to implement the philosophical principles of the pre-Whitlam health care system rather than reflecting Australia’s post-Medibank and Medicare social consensus of an inclusive society with universal access to protection against the costs of access to health care.

The policy aims to provide incentives for general practitioners to bulk bill a specifically defined and means-tested group within the population. Paradoxically, these incentives are aimed at promoting bulk billing in the group that probably achieves a bulk billing rate of over 80 per cent at present, namely pensioners and Health Care card holders. These incentives are therefore probably wasted and will achieve little change in practice patterns.

There is little of fairness in this policy.

One of the design principles of Medicare was universality: that all people have the right to be treated equally by government policy and financial assistance schemes. It is true that, as it has turned out, general practitioners did not treat all people equally. General practitioners in rural areas traditionally had a lower rate of bulk billing, probably reflecting the market power and lack of competition. Bulk billing was also low in areas of high socio-economic status. But the struggling Aussie battler in outer suburban cities often was able to access bulk billing for their care and the care of their children. This group has been affected most significantly by changes to the rate of bulk billing in the last few years. This group, through pressure on local members of parliament, has probably stimulated the government to action. Interestingly, however, it is this group that the government has excised from consideration in terms of direct incentives on GPs to bill the working poor. Those not entitled to Health Care cards are not going to be assisted by this package. Those with Health Care cards may feel that they are getting care only because of the beneficence of the doctor and this stigmatisation may create alienation.

For the middle class, the government is proposing that out-of-pocket costs in excess of $1,000 in any one year can be covered by health insurance funds. Because health insurance is subsidised by government, there is a cost to government through the increased subsidy. Fifty-five per cent of the population do not have health insurance; those that do are generally wealthier than those that don’t. So this element of the policy also leaves the middle class, especially the poorer middle class without any real assistance. There is thus little of fairness in this policy.

A policy which espouses principles of justice and equity along the lines outlined in the Rhodes et al. book would not have as a central element stigmatisation and targeting, but would rather reinforce universality. Financial incentives to increase levels of bulk billing are required, but these should be implemented in a way which moves us towards a more just society, rather than away from that goal.

Stephen Duckett is Professor of Health Policy at La Trobe University and a former senior bureaucrat in both the Commonwealth and Victorian health authorities/departments.