ACA ruling is ethical landmark: Health care is "moral imperative"

But many will still lack access to care

The most important ethical implication of the Supreme Court's ruling upholding the Affordable Care Act is "the recognized national responsibility to provide medical care for all citizens," according to Neil S. Wenger, MD, MPH, director of the University of California--Los Angeles (UCLA) Health System Ethics Center and professor at UCLA's Division of General Internal Medicine.

"There is a collective responsibility to ensure that people receive the medical care that they need — both because this is respectful for individuals and because it is necessary for the nation as a whole," he says.

The Supreme Court's decision "moves us closer to satisfying what I see as the moral imperative to provide access to health care for all," says Jeffrey Kahn, PhD, MPH, professor of bioethics and public policy at Johns Hopkins University in Baltimore, MD.

Ruth Berggren, MD, professor and director of the Center for Medical Humanities & Ethics in the School of Medicine of the University of Texas Health Science Center at San Antonio, says that while the decision "does not solve the mismatch between our health needs and our health resources, it opens the door for our society to work towards a more equitable distribution of health, and by extension, to that most American of values, freedom."

Wise use of resources

"The nation will need to grapple with prioritization of use of resources, both the distribution between health and other societal programs, as well as within healthcare," says Wenger. "These are value-laden decisions, which means confronting the ethical choices inherent in prioritization." (See related story, below, on ethical considerations for clinicians when discussing this with patients.)

Because illness is expensive, patients must take greater responsibility for preventive measures and in caring for their own health, says Berggren.

"If we want to distribute health equitably in our society, we need to ask serious questions about where it is most just to invest the greater portion of our limited health care dollar," she says. "Is it early in life when preventive measures can still become habits or late in life when expensive heroics can only prolong the final weeks?"

The law has its underpinnings in the collective responsibility to ensure that all individuals have the opportunity to receive the medical care they need, which underscores the importance of using health care resources wisely, says Wenger.

"This means that health care professionals have the responsibility to use their knowledge and skills to steward resource use appropriately, and that individuals receiving medical care should similarly be prudent," he says.

Some may lack access

While more than 30 million uninsured individuals will get health coverage, according to some estimates, this still leaves more than 20 million without coverage, and those who are covered are not necessarily guaranteed access, says Berggren. "Thus, affirming the individual mandate is a positive but incomplete step toward the physician's obligation to support access to care for all," she says. (See related story, below, on ethical implications of the individual mandate.)

Virtually all patients in Washington state will have insurance or Medicaid coverage and "the promise of access to care" by 2014, says Doug Myers, MD, president of the Washington State Medical Association. Society has an obligation to make access to an adequate level of health care available to all its members regardless of ability to pay, he adds.

"Certainly, the ACA is a step towards accomplishing that endeavor," he says. Myers expects to see less inappropriate use of the emergency department due to fewer uninsured individuals — if solutions to the anticipated gaps between patient demand and physician supply can be bridged.1

"Our mission now is to make sure these patients develop a long-term, stable relationship with a physician to ensure that they get the care they need, when they need it, in an appropriate setting," he says.


  1. Ho V, Spetz J. Baker Institute Policy Report: Health reform and the health care workforce. Number 51, March 2012.


Jeffrey Kahn, PhD, MPH, Levi Professor of Bioethics and Public Policy, Johns Hopkins Berman Institute of Bioethics, Baltimore, MD. Phone: (410) 614-5679. E-mail:

Neil S. Wenger, MD, MPH, Professor, Division of General Internal Medicine, University of California, Los Angeles. Phone: (310) 794-2288. E-mail:

Individual mandate: "Right, not privilege"

The Supreme Court's decision to affirm the individual mandate moves the country toward the philosophy that health care is "a right, not a privilege," says Vivian Ho, PhD, Baker Institute Chair in Health Economics at Rice University and professor of medicine at Baylor College of Medicine, both in Houston, TX.

Up until now, patients who lacked the financial resources to pay for medical care have had to depend on a patchwork of publicly subsidized clinics and hospitals for health care, Ho explains.

"Even with this public safety net, these patients have experienced long wait times and denial of care. Uninsured patients suffer lower health status and consume less health care, relative to those with health insurance," she says.

The Affordable Care Act provides individuals in families earning up to 133% of the poverty level with Medicaid coverage, and partial subsidies to purchase health insurance for families up to 400% of the poverty level. "These subsidies will allow many more individuals to have health insurance coverage, regardless of their income level," says Ho.

Research suggests that approximately 9% of households in the United States that can afford to purchase health insurance choose not to.1 When these individuals become seriously ill, federal law requires that most hospitals provide care to these people, regardless of their ability to pay, says Ho.

"The cost of this uncompensated care is born by the taxpayer," she adds. "Therefore, the individual mandate prevents those who can afford to buy health insurance from free-riding on the taxpayer."


  1. MK Bundorf, Pauly MV. Is health insurance affordable for the uninsured?, Journal of Health Economics 2006;25(4): 650-673.


Vivian Ho, PhD, Professor, Department of Economics, Rice University, Houston, TX. Phone: (713) 348-2195. E-mail:

Patients likely unprepared for difficult new choices

Physicians incentives are ethical issue

"We offered this treatment previously largely because we were incentivized to do so, but that is no longer the case." This may be a truthful statement in light of the changes resulting from the Affordable Care Act (ACA), but it's unlikely a clinician would say this to a patient, according to Paul Helft, MD, director of the Charles Warren Fairbanks Center for Medical Ethics and associate professor in the Department of Medicine at the Indiana University School of Medicine, both in Indianapolis.

The ACA is going to put some clinicians in a difficult ethical position at the bedside — one they are largely unprepared to deal with, he predicts.

"The way the law is constructed is clearly to incentivize hospital systems — which are no more than an amalgamation of individual physicians — to make choices about what treatments we do and do not provide to a population of patients," says Helft.

Patients haven't changed

Currently, when clinicians offer a cost-ineffective treatment to patients, the physician gets paid for providing the treatment, and the cost comes out of the pocket of the government insurance agency or private insurer — not the hospital system, notes Helft.

"That's not going to be the case now. The law, shrewdly in a sense, has re-incentivized us to limit cost-ineffective treatments," he says. "The problem is that patients are not any different after the law than they were before the law."

Patients are likely to expect that they'll be the ones to decide whether to receive a $500,000 treatment that might add a marginal amount of survival, for instance, and clinicians will be put in the uncomfortable position of disavowing patients of this notion.

"It's not going to be people sitting in offices that are going to have to talk to patients and families about this. It's going to be clinicians and nursing," Helft says.

This raises the ethical question of how much physicians should reveal about the role of incentives. "Patients may say, 'How am I ever going trust somebody who is incentivized financially not to spend money on my mother?' This will radically alter our relationship with patients," he says.

Pathways and treatment algorithms that are meant to maximize the cost-effectiveness of a given set of diseases "only makes sense," says Helft. "We should be making these choices. But we are very much unprepared to do it at the level of the interaction of patients and families. And patients are very unprepared for this."

Public won't accept limits

"If there is a treatment out there, no matter how theoretically cost-ineffective that treatment is, some people are going to want it," Helft says. If the family of a critically ill intensive care unit patient with a poor prognosis is told there is a 1% chance of survival with a given treatment, some families may expect the treatment to be offered if they decide they want the 1% chance, for instance.

"For the last 30 years, that is what we have been doing. Under the ACA, physicians are going to be in a position of saying, 'We did that a year ago, but well, we've reconsidered that. We're not sure that a month of life is worth the tens of thousands of dollars that it's going to cost to provide this treatment,'" he says.

The populace of other countries "is more accepting that we don't just spend money on hopeless treatments, just for the one in a million chance that there will be another month of life," says Helft. "In the U.S, the general public, in the end, is unlikely to accept limitations. They will not accept Accountable Care Organizations saying, 'There are certain treatments we will no longer provide.'"


Paul Helft, MD, Director, Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis. Phone: (317) 962-9258. E-mail: