Expert answer:Compare and Contrast Elements of Pricing, Solvency
Expert answer:Week 3 – Assignment: Compare and Contrast Elements of Pricing, Solvency, and Profit in the Private and Public Sector InstructionsSince being signed into law in 2010, the Affordable Care Act has generated many questions from the healthcare community. Create a handout in the form of a brochure that addresses the following points for healthcare providers:Evaluate the public’s concern with the relationship of healthcare cost to prices and revenue determination. Provide specific examples from today’s current events in addition to your research.Justify the need for healthcare providers to negotiate profit-enhancing contracts with managed care organizations.Supplement your handout with any pertinent and related graphics, charts, or illustrations. For instance, you may include screen shots from current events depicted on reputable websites.Support your brochure with a minimum of three scholarly resources. In addition to these specified resources, other appropriate scholarly resources, including older articles, may be included.Length: 5-7 pages, not including title and reference pagesYour brochure should demonstrate thoughtful consideration of the ideas and concepts presented in the course by providing new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards where appropriateSearch website for additional information for help:Cubanski, J., & Boccuti, C. (2015). Medicare coverage, affordability and access.Health Reform Update: Wellness Is The Key presented by Ann Hawkins-Hood, fl. 2014; produced by Healthy Learning (Monterey, CA: Healthy Learning, 2014), 1 hour 3 mins
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Funding the Costs of
Disease Outbreaks Caused
by Non-Vaccination
Charlotte A. Moser, Dorit Reiss, and Robert L. Schwartz
Introduction
Preventable diseases not only cause suffering and
physical harm, they also impose financial costs on private individuals and public authorities. By disregarding evidence of the safety and effectiveness of vaccines
and choosing not to vaccinate their children, some
parents are increasing the risk of outbreaks and their
attendant costs. In a very real sense, since those families are not currently required to cover the full costs of
outbreaks, they are externalizing those costs onto others — individuals affected and society at large. Since
non-vaccinating can directly lead to costly outbreaks,
this paper argues that it is both fair and desirable to
impose those costs upon those making the choice not
to vaccinate. There are, in fact, strong policy reasons
to support doing so regardless of whether we use an
approach based on fault or a no-fault framework. Not
only can the decision not to vaccinate be seen as culpable, aside from the culpability consideration, it is
appropriate to compel those deciding not to vaccinate
to internalize the costs in order to prevent free riding
and to mitigate harms to others.
This article addresses the legal tools that can be
used to manage the costs associated with outbreaks,
focusing on those that do not require demonstrating
Charlotte A. Moser is the Assistant Director of the Vaccine
Education Center at The Children’s Hospital of Philadelphia.
Dorit Reiss, Ph.D., LL.B., is a Professor of Law at U.C. Hastings College of the Law. She earned her LL.B. from Hebrew
University of Jerusalem and Ph.D. in Jurisprudence and Social Policy from the University of California, Berkeley. Robert
L. Schwartz, J.D., is the Henry Weihofen Professor of Law at
the University of New Mexico School of Law (as of January
2010, emeritus) and a Professor of Pediatrics at the University
of New Mexico School of Medicine (by letter of academic appointment). He earned his J.D. from Harvard School of Law
and B.A. from Stanford University.
fault. In particular, the article considers the imposition of a fee or a tax on non-vaccinators so that those
who avoid immunization are required to internalize
the costs associated with their decisions.
Costs Associated with Non-Vaccination
Widespread use of vaccines has transformed the landscape of medicine. Diseases that were once significant causes of morbidity and mortality are, in some
cases, no longer suspected when patients report with
symptoms characteristic of these diseases.1 In fact,
according to a recent study by William van Panhuis and colleagues, vaccines have prevented about
103 million cases of disease since 1924.2 Despite the
unquestionable effectiveness and proven safety of vaccines, some parents are concerned enough about the
safety of vaccines that they choose not to have their
children vaccinated.3 While the number of completely
unvaccinated children — those who received none of
the recommended vaccines — remains low, pockets
of unimmunized individuals make some communities particularly susceptible to outbreaks.4 In recent
years, outbreaks of the most contagious diseases, such
as measles and pertussis, have started to reappear in
communities throughout the country.5 Recent examples include outbreaks of measles in New York, California, Washington, and Ohio; and one of mumps in
Ohio. A recent press announcement by the Centers for
Disease Control and Prevention (CDC) stated that the
number of measles cases in the United States in the
first half of 2014 was the highest since 1994.6
Outbreaks are more likely to occur where pockets of
susceptible people cause a breakdown in herd immunity. Herd immunity results when enough individuals
are immunized, so that the few who are not are still
afforded protection. In fact, data have shown that it is
genomic research results to a participant’s family • fall 2015
633
IND EPEND ENT
better to be an unimmunized person in a highly vaccinated community than to be an immunized person in
a community of susceptible people.7 The disease is less
likely to penetrate communities with high vaccination
rates, so it is less likely that an unimmunized person
will be infected. In contrast, an infectious agent will
spread more readily through a lesser-vaccinated population resulting in infections in both unimmunized
individuals as well as those for whom the vaccine was
not effective. When families choose not to immunize
themselves or their children, discussions often focus
on the health consequences that the breakdown in
herd immunity imposes on individuals and society.
However, society must also absorb some of the financial burden related to cases of infectious diseases.
these are significantly higher and ultimately absorbed
by society.
Costs Associated with Permanent Harm
While most infectious diseases can lead to permanent harm, rubella and meningococcal disease may
cause the worst personal devastation. For example, a
pregnant woman infected with rubella may miscarry,
deliver early, suffer a spontaneous abortion or stillbirth,
or have a child born with congenital rubella syndrome
(CRS). Children affected by CRS can suffer deafness,
heart or eye damage, mental retardation, skeletal damage, autism, or some combination of these. If the child
survives, the cost to care for the child over his or her
lifetime is estimated to be about $143,000.9 Likewise,
Lee and Pichichero studied costs to families during a pertussis outbreak in
New York during 1995-96 and found costs to families were $181 per ill adult,
$254 per ill adolescent, $308 per ill child, or $2,822 per ill infant. In 2014
USD, these costs would range from $278 — $4,331. While these costs could
seem exorbitant to individual families, they are minor when compared with
the lifetime medical costs for an individual who is permanently harmed as
well as the costs associated with stopping the spread of an infectious disease.
Both of these are significantly higher and ultimately absorbed by society.
When an individual contracts a preventable disease, the costs are typically covered by the individual
or family, their insurance company or, if they lack private insurance, a federally funded program, such as
Medicare or Medicaid. Individual costs are incurred
for medications (over-the-counter or prescription),
co-pays and uncovered procedures or treatments,
and loss of productivity (time at doctor visits or not
at work). Several variables affect these costs, including who in the family is ill, which disease they have,
the severity of illness, and the extent of their private
or public medical coverage. Lee and Pichichero studied costs to families during a pertussis outbreak in
New York during 1995-96 and found costs to families were $181 per ill adult, $254 per ill adolescent,
$308 per ill child, or $2,822 per ill infant.8 In 2014
USD, these costs would range from $278 — $4,331.
While these costs could seem exorbitant to individual families, they are minor when compared with the
lifetime medical costs for an individual who is permanently harmed as well as the costs associated with
stopping the spread of an infectious disease. Both of
634
about 10-20 percent of the people who survive meningococcal infection, which can cause bloodstream
infection (sepsis) or meningitis, will have permanent
consequences such as deafness, limb amputations, or
neurologic disabilities. Costs associated with acute disease and lifetime medical costs for these individuals
have been estimated to range from $87,261 for deafness to $253,723 for someone with multiple amputations.10 Most of the costs associated with permanent
harm caused by an infectious disease are absorbed by
the family and its insurer. Because private insurers
base their fee structures on calculated risks, costs associated with permanent harm are passed on to insureds
through premiums. For those insured through public
programs, such as Medicare or Medicaid, costs associated with permanent harm are absorbed by tax payers.
Costs Associated with Containment Measures
When an infectious disease is identified, one of the
most pressing concerns becomes stopping the spread
to others. Containment measures include limiting
exposure of infected individuals to others who may
be susceptible; identifying those who were exposed;
journal of law, medicine & ethics
Moser, Reiss, and Schwartz
monitoring for additional cases; establishing diagnostic testing and preventive or treatment measures, such
as vaccination clinics; alerting and updating health
care providers and the CDC; and addressing the public and the media.11 A measles outbreak in 2005 showcases the complexities:
When an unvaccinated six year old was hospitalized with measles in Illinois, public health
officials in that state traced the child’s exposure
to a church gathering of 500 people two weeks
prior — in Indiana. When the Indiana health
department began investigating, they identified
the source case as an unvaccinated teenager who
had returned from a church-mission trip. Despite
symptoms of illness, she attended the church
gathering where she not only directly infected
the hospitalized child, but also seventeen others
attending the gathering and one other person
during a visit with a neighbor (19 first generation infections). In addition, thirteen additional
people were infected by close (household) contact
with the 19 directly infected individuals (second
generation infections). Public health officials
attempted to contact the 500 picnic attendees as
well as anyone in contact with what ultimately
became 34 people infected over three generations
of spread. Workers had to ascertain vaccination
status of attendees, attempt to identify additional
cases, and try to get unvaccinated individuals vaccinated. Containment activities involved
“ninety-nine public health officers and infectioncontrol personnel working in 12 health departments and health care facilities…”(p.449). These
personnel reported 3,650 hours of work, 4,800
telephone calls, 5,500 miles driven, and 550 lab
samples to contain the outbreak started by a single unvaccinated teen returning from travel.12
The cost of containment for public health authorities
was $62,216. The total cost of the outbreak was over
two hundred thousand dollars. While the aforementioned outbreak started at a church gathering, outbreaks can begin anywhere that people gather. Table 1
lists articles detailing additional outbreaks in a variety
of situations.13
Because each situation is different, the extent of and
need for containment measures varies. In addition,
the responsibility for and distribution of the financial burden associated with containment may also
vary. For example, in 2008 a measles-infected traveler
visited a hospital resulting in an additional 13 cases,
most of which were acquired by others in the hospital
at that time or secondary cases related to those peo-
ple. Costs to that hospital were estimated to be around
$632,084 ($695,993 in 2014 U.S.); most of which was
related to wages and salaries of furloughed workers.14
In contrast, when a refugee entered the U.S. while
infected with measles in 2010, containment measures
were spearheaded by the state public health department, but also involved personnel from the local public health and refugee departments, CDC, and hospital personnel. While the containment succeeded in
stopping the spread of measles to others, the $25,000
($26,818 in 2014 US dollars) costs associated with this
single case fell completely to the government.15
Paying the Costs Associated with Infectious Diseases
While the government supports public health, the
annual budget does not typically garner large percentages of the whole. For example, of the $969.8 billion
health care dollars in the FY14 federal budget, only
$4.7 billion were earmarked for public health,16 and a
recent report by Trust for America’s Health called for
increases in core funding at all levels of public health
after presenting data showing that variability in health
statistics between states was related to variation in
funding.17 In addition, public health departments are
not funded for unexpected events, which means that
during an outbreak caused by an infectious disease,
departments may need to reassign staff and reallocate
funds to complete containment measures in a timely
manner.18 A 1995 outbreak in Minnesota is instructive:
Nine cases of invasive meningococcal disease
with one death and seven cases of streptococcal disease with four deaths occurred over a one
month period during the winter of 1995 in Minnesota. The cases occurred in two towns and
were coincident with influenza season thereby
complicating diagnoses in those presenting with
respiratory symptoms. Containment measures
included immunizing 30,000 residents; 26,000
of whom were vaccinated over a 4-day period.
Public health staff worked 18-hour days for more
than 23 days; in all, more than 600 people were
involved in the public health response. Costs of
vaccine alone were $1.2 million ($1.8 million
2014 US dollars). The state health department’s
budget for that year was $2.2 million ($3.4 million 2014 US dollars). While the state legislature
provided an emergency appropriation for vaccine
costs, the local hospital, which had to set up a
separate emergency area, was never reimbursed.19
Table 1 summarizes studies of costs associated with
investigating and containing recent cases and outbreaks of infectious diseases throughout the U.S.
genomic research results to a participant’s family • fall 2015
635
IND EPEND ENT
The Justification for Recouping Costs
Costs and Savings Associated with Vaccination
Whether it is appropriate to compel an individual to
Recently, researchers at the CDC compared the costs
bear the costs associated with the decision to not vacof the vaccination program with the costs savings
cinate is an important starting point to this discussion.
over the lifetime of a single birth cohort.20 Using the
It is especially important in terms of those costs gener2009 U.S. recommended immunization schedule and
ally imposed on the public purse and financed through
a hypothetical U.S. birth cohort of more than 4.2 miltaxation for the benefit of all. Sometimes, society does
lion children, the researchers calculated estimated
pay for problematic choices made by individuals. For
cases of disease and deaths as well as the direct and
example, individuals are generally not required to
societal costs associated with the diseases, immunizations, and net differences.
Direct costs included inpatient
and outpatient visits as well as
Unlike intentional torts, negligence does not
outbreak control; indirect costs
included loss of productivity and
require actual knowledge that one’s understanding
premature death. In addition to
of the risks is wrong or that one is making a risky
preventing about 42,000 deaths
choice. As long as the decision maker should have
and 20 million cases of disease,
vaccines were estimated to save
known that the decision was unreasonable, then the
about $14.7 billion (2014 U.S.
decision is negligent. Given the scientific consensus
dollars) in direct costs and $75
supporting vaccines, the abundant information
billion (2014 U.S. dollars) in
societal costs over the lifetime of
from reputable sources supporting immunization,
the cohort.
and the problematic sources relied upon by those
Costs of Outbreaks in the
Eyes of the Law
who choose not to vaccinate, it is easy to support the
claim that those who choose not to vaccinate should
know they are making an unreasonable choice.
The costs associated with outbreaks are unquestionably substantial and may constitute
legally compensable damages.
For example, direct costs of a tortious act are compensable and, in a case concerning a preventable infectious disease, may include the costs of treating current
cases and preventing further ones. In addition, when
an individual has been afflicted with an infectious disease, their costs may include lost earnings, future lost
earnings (losing the ability to work generally or to work
in specific types of jobs), physical and emotional pain
and suffering (as allowed by the particular state), and
subsequent decrease in life expectancy. Additional relevant costs are costs associated with inability to perform household tasks. If the afflicted individual dies as
a result of the disease, relatives of the individual can sue
for wrongful death, and for the harm they suffered as a
result of the loss, including economic contributions that
individual would have made, lost value of services, and
loss of companionship. Individuals may also recover for
pain and suffering, including physical pain and emotional harm accompanying a physical injury or illness
(though some states limit pain and suffering awards in
some or all contexts). In some rare cases, where behavior is especially culpable, for example, intentionally
exposing a child to chickenpox, punitive damages may
also be appropriate.
636
pay for police activity caused because they got into a
dangerous situation. This is not always the case, however. For example, when individuals tortuously cause
damages to public property, they are responsible for
the damages even though the property has been purchased and maintained with public funds.21
Whether we use a fault or a no fault basis, there are
powerful public policy reasons to compel those choosing not to vaccinate to bear the costs associated with
their actions.22 As demonstrated, imposing costs is
justified whether we see the decision not to vaccinate
as negligent or as blameless, since it is based on the
costs the choice not to vaccinate imposes on society,
costs those making the choice should internalize.
A Fault-Based Argument for Recouping Costs
Not vaccinating is, arguably, at least negligent. A
detailed discussion of the beliefs that lead people to
misestimate the risks of vaccinating and the risks of not
vaccinating and why they are incorrect is beyond the
scope of this paper and has already been done by others.23 But while nothing is guaranteed safe, it is clear
that serious harms from vaccines are extremely rare,
and as pointed out in a recent article that reviewed a
journal of law, medicine & ethics
Moser, Reiss, and Schwartz
large number of studies, far outweighed by the benefits
of vaccinating, even to the individual — and certainly
for society collectively.24 Because of this extensive evidence, vaccination is supported by the overwhelming
majority of doctors, scientists, and policymakers. Both
from a risk/benefit analysis and through a community
norm lens, the failure to vaccinate is problematic. The
justifications for not vaccinating are often based on
information that is simply incorrect.25 As a matter of
fact, modern anti-vaccine arguments are surprisingly
similar to those used in the early days of vaccines, and
are no better supported by evidence today than they
were in the 19th or early 20th centuries.26
Unlike intentional torts, negligence does not
require actual knowledge that one’s understanding of
the risks is wrong or that one is making a risky choice.
As long as the decision maker should have known that
the decision was unreasonable, then the decision is
negligent. Given the scientific consensus supporting
vaccines, the abundant information from reputable
sources supporting immunization, and the problematic sources relied upon by those who choose not to
vaccinate, it is easy to support the claim that those
who choose not to vaccinate should know they are
making an unreasonable choice. As is the case here,
when an individual engages in behavior that free rides
on others, puts others at risks, and is unreasonable or
even reckless, there is strong justification to require
the individual to internalize the costs of that behavior.
A No Fault-Based Argument for Recouping Costs
An argument can be made that the choice not to va …
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