Nurses Providing Health Access

Ethical Issues in Healthcare

Healthcare Access and Healthcare Rationing

Universal Healthcare Coverage

Issues with Unequal Access

Forms of Rationing

Alternative Solutions to Providing Access

Nursing, and healthcare in general, often gets negative publicity when the idea of rationing healthcare is presented. However, healthcare is a finite resource that must be distributed by some means and a different levels. Decisions about health care are made at multiple levels within the system: (a) the macro level where policy is established by governments, health authorities, insurance plans, etc.; (b) the meso level where organizational budgets are established by organizational administrators; and (c) the micro level where care is delivered by clinician providers (Jones, 2015). On a national level, the politics and the economy of a nation often dictate the healthcare system. While nearly all developed countries offer some form of universal coverage, the United States is only slowly progressing towards a more inclusive system that provides expanded access. By contrast, most developed nations view healthcare as a human right entitled to all citizens; similar to the way the U.S. guarantees an education. Thus most modern healthcare systems are more egalitarian in nature than a for-profit system and provide roughly equal health care resources to keep every individual healthy and to promote a healthy "quality of life" for all their citizens.

But it is not only on a national level that a healthcare system must determine how best to ethically distribute its resources and provide services. Hospitals and practitioners only have so much time and so many resources available to them and have to decide where their energies can best invested in an ethical manner on a day-to-day basis. Deciding what priorities are present in the face of limited resources can be an ethical challenge on a day-to-day basis and represents a situation that is more common than most people think. Doctors and nurses often make judgements about where best to allocate their time consistent with their professional values. This analysis will look at the rationing of healthcare from different levels from an ethical perspective. Furthermore, it will also look at some innovative ideas to address the problems related to healthcare access in the United States.

Universal Healthcare Coverage

One major initiative from the World Health Organization has been to improve global public health by improving access. The WHO has created a coalition calls for a (WHO, N.d.):

"A new global coalition of more than 500 leading health and development organizations worldwide is urging governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty. The coalition emphasises the importance of universal access to health services for saving lives, ending extreme poverty, building resilience against the health effects of climate change and ending deadly epidemics such as Ebola."

The statement calls something other than common conceptions of what is referred to as "universal healthcare" system. However, "access" to healthcare in most of the world is typically thought of along three dimensions (Evans, Hsu, & Boerma, 2013)

Physical accessibility - the availability of health services within reasonable reach of those who need them and when they need them.

Financial affordability - people's ability to pay for services without undue financial hardship which also takes into account not only the price of the health services but also indirect and opportunity costs (e.g. the costs of transportation and of taking time away from work). Affordability is determined by the wider health financing system as well as by household income.

Acceptability -- this can be thought of as a patient's willingness to seek services. Acceptability is low when patients perceive services to be ineffective or when they are perceived as inaccessible for a variety of different reasons.

It is important to note that the UN does not necessarily call for universal healthcare coverage as found in most modern nations. Rather, the UN focuses on providing reasonable access to care that all citizens can utilize without unduly burden to themselves or their families.

The justification for the ethical and equitable distribution of health care for citizens is often founded upon the utilitarianism principle and the theory of justice. These principles can be argued to ensure that an equitable distribution of health care is designed in the system and the policies are designed in a way in which the distribution of benefits are roughly the same for the citizens (Beauchamp & Childress, 2001). The utilitarian theory suggests that all actions should be attempted to achieve the greatest good for the greatest number of people (Best, 2006). Hence an equitable distribution of health care services should be provided to the largest number of patients and individuals possible based on their needs. Conversely, by excluding any group completely from the healthcare system could easily be construed as unethical.

Issues with Unequal Access

Despite spending close to three trillion dollars a year on healthcare, significantly more than any other country in total or per capita, the United States does exactly maintain a healthy population (comparatively speaking) (Lavizzo-Mourey, 2015). There have been many different ideas about how to make the system more efficient and effective, however there is significant resistance to change that must be overcome. In recent history the debate over whether healthcare should be considered a privilege or a right has regained momentum in politics; especially with the passage of the Affordable Care Act (ACA). Although these reforms do not expand healthcare universally, the series of reforms did make healthcare more accessible for millions of Americans and will hopefully drive the costs down.

However, millions individuals still do not have affordable access to care. These individuals are maintaining not only health risks, but also financial risk by not maintaining adequate health care insurance. For instance, the leading cause of personal bankruptcies in the country are primarily due to healthcare costs. Furthermore, many low-income individuals seek treatment at emergency care centers because this can be the only option available to them. When individuals use the ER for non-emergency services this can drive up the costs in the entire system. When a patient seeks emergency care then the emergency room cannot deny care based on their financial ability to pay for these services. Therefore many of the bills that result in emergency treatment go unpaid. The hospitals or treatment centers are forced to absorb the costs of the uncollected revenues and these debts are offset by raising the rates for all health care consumers.

There are also indirect costs to this trend. If an individual does not seek early treatment because they do not have access to primary healthcare, their conditions can escalate to the point in which they do need emergency treatment. Many of the cases that end up in emergency treatment centers could be treated less expensively if treated earlier on. Instead of treating this conditions when they are relatively inexpensive to treat, those without access to affordable care will allow the conditions to worsen to the point in which they can no longer ignore. In this case, when the conditions worsen the related health care costs also rise substantially. Therefore, it is not only an ethical consideration present, but there is also an economic inefficiencies that are created by individuals not having access to basic healthcare services.

Forms of Rationing

One of the arguments against providing universal access has always been that it will require some level of healthcare rationing. However, recent studies into nursing care rationing indicate that nurses always ration their time and care, resulting to serious threats to the quality of care and patient safety; for example patient mobilization, hygiene, feeding, communication, patient support, teaching and discharge planning, surveillance and care documentation are regularly lacking or omitted (Papastavrou, The ethical complexities of nursing care rationing, 2013). Healthcare rationing stems for the simple fact that organizations have scarcity in resources. Thus resources are inevitably either explicitly or implicitly rationed, even if this process is not consciously considered. Healthcare rationing has been extensively discussed in the medical profession and is understood as withholding beneficial interventions, mainly for cost-effectiveness reasons that occur at all levels and in all healthcare systems around the world (Papastavrou, Andreou, & Vryonides, 2014).

Yet, because healthcare rationing is often charged issue in the United States, it can be difficult to study and the benefits of effective rationing are not well-understood. One study conducted in Texas found that some degree of rationing on at least one of the nursing care activities was reported by almost all of the respondents and most rationed multiple activities; also rationing preference patterns favor completion of activities directed to meet immediate physiological needs over other activities (Jones, 2015). Implicit rationing of nursing care is the withholding of or failure to carry out all necessary nursing measures due to lack of resources; there is evidence supporting a link between rationing of nursing care, nurses' perceptions of their professional environment, negative patient outcomes, and placing patient safety at risk (Papastavrou, Panayiota, Hartini, & Anastasios, 2014). Thus rationing simply by a nurse's deciding what their highest priorities are.

It seems that the idea of rationing becomes more controversial in healthcare when these decisions are made at higher levels. Decisions about health care are made at multiple levels within the system: (a) the macro level where policy is established by governments, health authorities, insurance plans, etc.; (b) the meso level where organizational budgets are established by organizational administrators; and (c) the micro level where care is delivered by clinician providers (Jones, 2015). Although a form of rationing occurs when a nurse makes a judgement about where to best use their time, the forms of rationing that are based on a higher-level decision made by executives, managers, and administrators are often meet with hostility; yet even determining staffing levels can be considered a form of rationing.

Nurses' decisions to ration care may be influenced by hospital organizational attributes and the nurse practice environment, and researchers have developed a rationing measurement instrument, the Basel Extent of Rationing of Nursing Care (BERNCA), which has produced reports that rationing was significantly associated with staffing and work environment conditions (Schubert, Glass, Clarke, Aiken, & Sloan, 2008). Such metrics can explore the association between implicit rationing of nursing care and selected patient outcomes in hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing (Schubert, Glass, Clarke, Aiken, & Sloan, 2008). Thus understanding how rationing on this level can be used to improve health outcomes on the micro level just as it could also be used ethically on a meso level.

Alternative Solutions to Providing Access

Although the United States may not be politically ready to adopt some form of universal healthcare system, there are many other alternatives to expand access in regards to how the UN defines it. For example, nurse managed care has many potential benefits and could help relieve the reliance on the crowded emergency department by many segments of the population such as the homeless and low-income individuals often rely on the ED as their primary health care source. One proposed solution to such overcrowding in the ED, is to promote nurse managed lower cost clinics that can assist a majority of this populations non-emergency needs as well as help them to access additional community resources that they may need to treat their specific conditions (Savage, Lindsell, Gillespie, Lee, & Corbin, 2008).

There are many different benefits associated with such a proposal. Not only can it more ethically distribute healthcare resources, but it could also help train and provide experience for nurses. Another benefit could be that the quality of care provided to those most marginalized could be substantially improved. For example, if a homeless person goes to the emergency department with a minor condition they will probably not receive the best care for that condition. For example, they will likely be treated and released as soon as possible to ration for more serious conditions.

By contrast, a nurse-based clinic could essentially spend more time with patient to diagnose deeper health issues (such as drug use) as well as refer them to additional community resources such as social services. The nurse could treat the patient more comprehensively so that they could receive care that could substantially lead to better outcomes. There would also be the possibility for nurses to coordinate services as well as provide follow-up care to homeless patients.