Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform (Essays‪)‬

As the American system of health care delivery strains under the weight of erratic coverage, inefficiency, and uncertain quality, proposals for how it should be reformed have proliferated. (1) Some proposals focus primarily on improving quality, others on restraining costs; all, directly or indirectly, address access to health care. (2) We present a consensus framework for evaluating how well a proposal addresses the issue. While access is affected by a number of factors (geography, distribution of providers, and so on), for this essay we focus primarily on ethical issues in access to health care coverage. The framework emerges from the work of the multi-stakeholder Ethical Force Program, which uses a standardized process derived from well-accepted methods for generating consensus on clinical practice guidelines and measuring quality in health care. (3) The program is a collaborative initiative led by the Institute for Ethics at the American Medical Association. It was established in 1997 "to improve health care by advancing ethical behavior among all participants." (4) It is motivated by the beliefs that ethical standards are fundamental to health care systems that are effective and trusted, that all stakeholders in health care should be accountable for their ethics, and that stakeholders must work together to ensure that shared ethical standards are widely promoted, understood, and followed. (5) The program functions as a national quality improvement organization for health care ethics. As such, it produces an array of reports and tools that all stakeholders can use to assess and improve the ethical environment of health care.