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Posted on March 13, 2018 at 12:22 PM

A new article in The Hastings Center Report, by Nir Eyal, Paul Romain, and Christopher Robertson, asks whether it is ethical to ration healthcare by inconvenience and red tape?  In other words, given that all societies must ration health care in one way or another, is it ever ethical to push people away from an unpreferred healthcare option by making it more inconvenient?  For example, what if physicians had to go through a very long process to prescribe a nongeneric drug, or if ERs had really onerous check-in procedures for patients without medical emergencies? This came at an interesting time for me, because I was recently asked to provide informal support for a low-income woman I will call Millie, who was moving from her home in New York State to my community in Pennsylvania.  Despite my fairly extensive reading on what it means to be poor in America today, I was blown away by the sheer inconvenience of Millie’s daily existence (and awed by the way she navigated bureaucracies that would have reduced me to gibbering idiocy).

Millie is in her 50s, dependent on public assistance, and with a number of health problems (e.g., diabetes, hepatitis C). She had spent her last dollars to hire the truck to move her possessions to her new home; she had moved to live with distant relatives who had been persistent in inviting her, but turned out to be interested only in her disability paycheck.  The household was chaotic and unsafe, and everyone smoked.  Millie’s immediate problems were to find new Section 8 housing and a way to move her stuff; to get her many medical prescriptions transferred to her new state; to find new doctors and get her medical care back on track.  She had to do this with no car, no credit card, and no checking account.

In addition to the hours that Millie spent dealing with those problems, her daily life presented its own inconveniences. Living miles from a decent grocery store, she tended to shop at the local bodega, whose meager offerings were not ideal from the standpoint of her diabetes.   Without a car, or the money to call an Uber, shopping by public transport would have eaten up a big chunk of her day.  Picking up prescriptions presented parallel problems.

In short, what I learned from Millie was how time-consuming and inconvenient it is to be poor.  Being poor is virtually a full-time job.  Being poor with chronic illness is two full-time jobs.

This is especially concerning because of a theory, promulgated by Schilbach, Schofield and Mullainathan at the Wharton School of Business, that poor people are often so preoccupied with the challenges of daily living that they have less “bandwidth” with which to make good choices.   Of course, the authors of the Hastings Center article do not ignore this question.  They are concerned that any rationing process not be regressive, that is, that it not disadvantage those who are poor.  But they believe that rationing through inconvenience is less regressive than, e.g., rationing through cost-sharing.   “[All] people have twenty-four hours in a day, a limited attention span, and a body that can be in only one place at a time.”  The authors do acknowledge that rationing through inconvenience must be used thoughtfully, but some of their solutions seem merely to generate more onerous paperwork:  “In some instances, a hardship waiver would be feasible and appropriate.”  Can you imagine how long it would take to fill out the application for that waiver?  Rationing through money can more easily be made less regressive by exempting people who have already done the paperwork to be eligible for Medicaid, SSI, and so on, and already have the card to prove it.

Eyal, Romain and Robertson are not targeting only patients in their paper; they hypothesize “negative nudges” that operate on all players in the healthcare system.  But because poor people already get poor healthcare, and live in less healthy environments, and because their lives are already burdened by inconvenience, we need to be very sure not to increase that inequality.


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