| (cont)
III. Adequate Health Care for the Poor?
The second challenge which
the consistent ethic poses concerns "contemporary"
social justice issues related to health care systems.
The primary question is: How does the gospel's preferential
option or love for the poor shape health care today?
Some regard the problem
as basically financial: How do we effectively allocate
limited resources? A serious difficulty today is the
fact that many persons are left without basic health
care while large sums of money are invested in the
treatment of a few by means of exceptional, expensive
measures. While technology has provided the industry
with many diagnostic and therapeutic tools, their
inaccessibility, cost and sophistication often prevent
their wide distribution and use.
Government regulations
and restrictions, cut-backs in health programs, and
the maldistribution of personnel to provide adequate
services are but a few of the factors which contribute
to the reality that—unless we change attitudes, policies,
and programs—many persons probably will not receive
the kind of basic care that nurtures life.
A significant factor
impacting health in the U.S. today is the lack of
medical insurance. The American Hospital Association
estimates that nearly 33 million persons have no medical
insurance. They include the 60% of low-income persons
who are ineligible for Medicaid; nearly half of the
"working poor"; the unemployed, seasonally employed,
or self-employed; and middle-income individuals denied
coverage because of chronic illnesses. They include
disproportionate numbers of young adults, minorities,
women, and children.
According to the most
recent federal data, only one-third of the officially
poor are eligible for the "safety net" of Medicaid.
The Children's Defense Fund estimates that two-thirds
of poor or near-poor children are never insured or
insured for only part of the year. It is shocking,
but not surprising in light of what I have just said,
that the U.S. infant mortality rate is the same as
that of Guatemala! Forty thousand infants die each
year in the U.S. and others are kept alive by surgery
and technology—only to die in their second year of
life. The principal causes are well known: poverty
and lack of adequate medical care. Moreover, many
argue that the situation worsens as hospitals become
more competitive and prospective pricing holds down
the reimbursement rate.
I assume that we all
share a deep concern in regard to adequate health
care for the poor, but we also recognize that providing
this is much easier said than done. Between 1980 and
1982 the number of poor and near-poor people without
health insurance increased by 21%. During the same
period, free hospital care increased by less than
4%.
A related concern is
sometimes referred to as "dumping." An article in
a recent issue of the New England Journal of Medicine
reported the results of a study of 467 patients transferred
to Cook County Hospital in Chicago in a 42-day period
in late 1983. The conclusions were disturbing for
a number of reasons. First, the primary reason for
a majority of the transfers was economic rather than
medical. Second, at least one-fourth of these patients
were judged to be in an unstable condition at the
time of transfer.
In addition, only 6%
of the patients had given written informed consent
for transfer. Thirteen percent of the patients transferred
were not informed beforehand about the transfer. When
the reason for the transfer was given, there was,
at times, a serious discrepancy between the reason
given to the patient and that given to the resident
physician at Cook County Hospital during the transfer-request
phone call.
The problems facing
Chicago hospitals are by no means unique. They can
be found across the nation. Another article in the
same issue of the journal described the Texas attempt
to eliminate "dumping" of patients without valid medical
reason. However, the same article summarized the ongoing
dilemma which continues to face all segments of our
society: "Who will pay for the medical care of the
poor?"
Although each hospital
must examine its own policies and practices in regard
to uncompensated care of the poor, some recent studies
suggest that such care of itself may not be an effective
substitute for public insurance. Arizona, as you may
know, is the only state without Medicaid. Recent studies
reveal that the proportion of poor Arizona residents
refused care for financial reasons was about double
that in states with Medicaid programs. On the other
hand, poor elderly Arizona residents—covered by Medicare—were
found to have access to health care comparable to
that of other states.
These facts are disturbing
to anyone who espouses the sacredness and value of
human life. The fundamental human right is to life—from
the moment of conception until natural death. It is
the source of all other rights, including the right
to health care. The consistent ethic of life poses
a series of questions and challenges to Catholic health
care facilities. Let me enumerate just a few.
-
Should a Catholic hospital transfer
an indigent patient to another institution unless
superior care is available there?
-
Should a Catholic nursing home
transfer a patient to a state institution when
his or her insurance runs out?
-
hould a Catholic hospital give
staff privileges to a physician who won't accept
Medicaid or uninsured patients?
If
Catholic hospitals and other institutions take the
consistent ethic seriously, then a number of responses
follow. All Catholic hospitals will have outpatient
programs to serve the needs of the poor. Catholic
hospitals and other Church institutions will document
the need for comprehensive prenatal programs and lead
legislative efforts to get them enacted by state and
national government. Catholic medical schools will
teach students that medical ethics includes care for
the poor—not merely an occasional charity case, but
a commitment to see that adequate care is available.
If they take the consistent ethic seriously, Catholic
institutions will lead efforts for adequate Medicaid
coverage and reimbursement policies. They will lobby
for preventive health programs for the poor.
My point in raising
these issues is not to suggest simplistic answers
to complex and difficult questions. I am a realist,
and I know the difficulties faced by our Catholic
institutions. Nonetheless, the consistent ethic does
raise these questions which present serious challenges
to health care in this nation—and specifically to
Catholic health care systems.
To face these challenges
successfully, Catholic health care institutions, together
with the dioceses in which they are located, will
have to cooperate with each other in new and creative
ways—ways which might have been considered impossible
or undesirable before. No longer can we all be "lone
rangers." I know what you have done (and are doing)
here in the Brooklyn diocese to maximize the effectiveness
and outreach of your hospitals and other health care
institutions. I commend you for this. In the very
near future the Archdiocese of Chicago and its Catholic
hospitals hope to announce the establishment of a
new network which will provide a structure for joint
action aimed at the hospitals' market competitive
position, promoting governance continuity, and ensuring
maximum mission effectiveness.
In short, today's agenda
for Catholic health care facilities is new. The context
in which we face this agenda is also new because,
unlike the past, the Catholic health care system today
confronts issues of survival and of purpose. How shall
we survive? For what purpose? The consistent ethic
helps us answer these questions. It is primarily a
theological concept, derived from biblical and ecclesial
tradition about the sacredness of human life, about
our responsibilities to protect, defend, nurture and
enhance this gift of God. It provides us with a framework
within which we can make a moral analysis of the various
cultural and technological factors impacting human
life. Its comprehensiveness and consistency in application
will give us both guidance and credibility and win
support for our efforts. The challenge to witness
to the dignity and sacredness of human life is before
us. With God's help and our own determination, I am
confident that we will be equal to it.
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