January 3, 2011 | Posted By Bruce D. White, DO, JD

The first page of the Sunday Business section of the January 2, 2011, New York Times carried an article by Andrew Pollack titled “Coupons for Patients, but Higher Bills for Insurers.” Click here for the article.

The gist is that patients somehow obtain discount coupons for a particular antibiotic for acne, they ask their physicians to prescribe the medicine, when they get their prescription filled they pay a token amount or smaller co-pay, and the insurer pays the balance. However, in this case, the name brand antibiotic is relatively expensive and there is a generic alternative available at a much lower cost. The insurer is stuck paying the greater cost, a cost that has to be distributed to other subscribers in higher premiums.

Less clear on its face is another health care justice dilemma that appeared inside the Front Page section: “But in recent months, Mr. Cuomo has vowed to shrink the number of state agencies by one-fifth and to make substantial cuts to the state’s Medicaid program, the most costly in the nation.” Take a look at the New York Times article on January 1, 2011 by Hakim and Confessore, “Cuomo Promises Emergency Plan on Finance Woes.”

A synopsis of the New York State Medicaid report may be found here.

The introductory paragraph under background reports:

New York Medicaid provides essential health insurance coverage to over 4.7 million New Yorkers including 1.8 million beneficiaries age 18 and under, 1.8 million adults without disabilities age 19 to 64 and 400,000 elderly and 700,000 disabled individuals. Enrollment by county is shown in Exhibit E. In 2010-11, Medicaid spending will exceed $52 billion including state, federal and local funds, or about one-third of the state’s all funds budget. Exhibit F details Medicaid spending by category of service for 2009. Additionally, New York’s Child Health Plus program, which is administered by the state, covers an additional 400,000 children up to 400 percent of the federal poverty level.

In digging more deeply into the statistics, one finds that a disproportionate share of the Medicaid dollars (2003 data) are allocated to the aged ($26,385 per person expenditure) and blind and disabled patients ($25,553 per person expenditure) compared to expenditures for children ($2,221 per person) and adults ($3954 per person). (Special needs children are included in the blind and disabled category.) See this link.

In some cases, families with disabled children who would not otherwise meet the “medically-needed.” Following is an explanation from a 2008 report from the Citizens Budget Commission, Medicaid in New York:

     Individuals with incomes above the federal poverty-related thresholds, who incur large medical expenses may subtract these expenses from their actual incomes to enable their adjusted incomes to fall below eligibility thresholds. Once the expenses reach this level, then all medical care expenses may be covered by Medicaid. Federal rules do not require states to provide eligibility to medically- needy individuals, and 15 states have no provision for this type of eligibility. For states opting for this part of the Medicaid program, the federal rules set limits on the maximum income and assets, and these criteria vary among types of individuals. States also are given latitude in the types of services they may cover for the medically-needy, with the requirements less comprehensive than for the other eligibility categories.
     In general, New York’s eligibility standards are generous. … Although New York State is home to 7.0 percent of the nation’s population living below the federal poverty threshold, it covers 8.5 percent of the nation’s Medicaid enrollees. In this sense, New York is more generous with respect to eligibility than the rest of the country.

There is no question that persons with acne and disabled adults and children need proper medical care. The justice questions arise when some “game the system” for personal advantage. Openness and transparency are the keys to managing justice concerns.

Allocation mechanisms involve justice when one person’s actions result in shifting financial obligations to others in the community. Resolving these justice problems will be extremely difficult but are critical if the system’s integrity is to be maintained for all.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.