In March, the United States Supreme Court will hear arguments in an historic legal challenge to the new health law, the Patient Protection and Affordable Care Act (PPACA). An article by Jennifer Prah Ruger, associate professor of public health, has been cited by the Department of Health and Human Services (DHHS) in its brief supporting the law.
The health care reform law has been under increased scrutiny and its constitutionality has already been challenged in U.S. District Courts and U.S. Circuit Courts of Appeal.
The PPACA aims to improve the performance of the health care market by addressing costs, quality, and access to health care. To achieve this, the act requires that non-exempt taxpayers purchase a minimum level of health insurance or pay a penalty. In a Brief for Petitioners in the U.S. Supreme Court, the DHHS argues that the minimum coverage provision is a legitimate use of Congress’ commerce and taxing powers. DHHS asserts that because health care markets have near universal participation, the minimum coverage provision is needed to regulate the way that individuals pay for their participation in the health care market.
A key component of the DHHS argument is that health care markets are unique in that they fulfill needs that cannot be accurately predicted or budgeted for. The brief cites Ruger’s article “The Moral Foundations of Health Insurance” (Quarterly Journal of Medicine, 2007), in which she argues that health risks are uncertain in timing, magnitude, and frequency — making it difficult to predict when health care services will be needed and how much coverage will be necessary.
This uncertainty, Ruger argues, increases individual and community vulnerability, and economic and health insecurity. Universal health insurance is morally justified, she maintains, because it reduces, mitigates, and copes with risks of ill health and the resulting economic insecurity.
According to the DHHS, while lack of health insurance decreases access to medical care, “state and federal laws — reflecting deeply rooted societal values — have required emergency rooms to stabilize patients … and common-law and ethical duties restrict a physician’s ability to terminate a patient-physician relationship.
“The uninsured thus participate actively in the market for health care services, even if they cannot pay in full,” notes the DHHS.
When individuals cannot afford to pay for health care services, billions of dollars from uncompensated health care are shifted to private insurers who pass costs on to insured participants. DHHS notes that “Congress found that this cost-shifting increases the average premiums for insured families by more than $1,000 per year.” The department argues that minimum coverage provision prevents cost and risk shifting to others participating in the health care market and is a reasonable way to address the economic problems associated with uncompensated care.
“I’ve been following the coverage of the federal health law and health reform,” Ruger says. “An important perspective has been lacking and that is of the ethical underpinnings of the health care system and health policy. This point of view is essential for the ongoing and future debates over health reform.” Ruger offers an alternative moral framework for analyzing health insurance and health policy that is elaborated in her book, “Health and Social Justice” (Oxford University Press, 2010).
Ruger’s scholarship was cited in support of the PPACA during recent legal proceedings in California, Florida, Michigan, and Virginia. She is a member of the Ethics Subcommittee of the Advisory Committee to the Director of the Centers for Disease Control and Prevention and a Greenwall Faculty Scholar in Bioethics.