The Oregon Health Plan gained national attention by changing the focus of health care from who is covered to what is covered. This change was facilitated by insurance reforms in the areas of small market, employer mandates, high risk pooling and Medicaid. Most controversial of the reforms is the use by the legislature of a prioritized list of health services to determine benefit levels for the insurance programs. Significant debate has occured over whether the use of such (...) a list is rationing or reasoning. The Oregon Health Plan represents a thoughtful and deliberate blending of fact with public value for the purpose of responsible health policy. It is that unique blending of public values developed through community participation with fact that focused the attention of the world on Oregon. Keywords: community participation, employer mandates, health care reform, prioritization, rationing, small market insurance reform CiteULike Connotea Del.icio.us What's this? (shrink)

In Kentucky Association of Health Plans, Inc. v. Miller,, the Supreme Court unanimously held that states’ “any willing provider” laws are not preempted by the Employee Retirement Income Security Act of 1974. The Court ruled that states can regulate their health maintenance organizations, and thus upheld a Kentucky law that requires insurers to reimburse services of any health care provider who is willing and able to meet established criteria. The Supreme Court has heard several cases related to (...) ERISA in the last few years, and other such cases are working their way through the court system. Coupled with this most recent decision in Miller, the Supreme Court may significantly alter the shape of the insurance industry. (shrink)

In 2007, Massachusetts instituted a universal coverage health plan that requires all citizens to purchase insurance. I argue that there is nothing wrong in principle with the use of an individual mandate to force citizens to secure health insurance. I argue that state neutrality is not tenable on this issue. Then I proceed to show that even if state neutrality were viable, it is not a violation of state neutrality (thought of as neutrality of intent) to force citizens (...) to insure themselves with the primary purpose of securing the normative good of health. I adapt recent work on universal medical coverage to demonstrate that such a mandate is in keeping with several principles of fairness shared in liberal democratic societies. This argument not only applies to the Massachusetts plan but likely to any other health care coverage schemes using individual mandates in the US political context, including recently passed federal health care reform measures. However, even though the Massachusetts plan may provide increased access to health care for many, there are still legitimate worries that it currently places disproportionate financial burdens on the working poor and thus will need refinement. (shrink)

President Clinton, already facing formidable obstacles in reforming the health care system, denies that it will involve any rationing. This is politically understandable, but wrong. Infinite needs are rapidly overtaking finite resources. Most health providers recognize that the genius of modern medicine has outpaced our ability to pay. But the public still has unlimited expectations and a blind faith that everything can be provided to everyone by simply eliminating "waste, fraud, and abuse." Rationing is inherent in any (...) class='Hi'>health care system. As government undertakes to define what is "medically necessary or appropriate," it will unavoidably undertake a series of rationing decisions. Health care is being transformed from a private good to a public good. Government, when it reforms the health care system, must inevitably ask: How do we buy the most health for the public? Keywords: Clinton Health Plan, public good, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 24-25, February 2012.

This paper presents an empirical analysis of the determinants of quantity of health insurance in the context of employer-based health insurance using the micro-level data from the 1987 National Medical Expenditure Survey (NMES). It extends the previous research by including additional factors in the analysis, which significantly affect health insurance offers by employers. This paper emphasizes two determinants of employers’ insurance offer decisions that are particularly relevant: union membership and selfinsured versus not self-insured health plans. The (...) conducted empirical analysis reported in this paper reveals the following predictors of higher health insurance coverage: union membership, not self-insured health plan(s), union membership in Midwest or South, as well as self-insured union membership. Further, other factors such as: age, male, income, for profit and other employer organizational forms, and firm’s size determine a higher level of health insurance. (shrink)

"Cluster randomized trials," in which groups of patients are randomly assigned to different therapeutic interventions, provide a powerful way of evaluating drugs. CRTs have not been widely used, in good part because of concerns about whether patients must give informed consent to participate in them. A better understanding of how CRTs fit into clinical practice resolves the concerns.

As the only nation in the western world without a national health insurance program, the United States faces ongoing issues of access and fairness in health care coverage. The Clinton administration tried and failed to address the problem of universal coverage. Since then we have focused on the narrower, but nonetheless real, issues of fairness and equity in the benefits package provided in insurance plans. The LORAN Commission spent two years trying to devise agreed-upon principles to govern such (...) issues. The lesson learned was the same as that of the Ethics Force study: there was no possibility of getting agreement, let alone consensus, among the participants on how to decide what should be a covered benefit. There were, however, two generally agreed upon principles that emerged regarding health care: “Every individual should be treated alike,” and “When it comes to health, cost cannot be a consideration.” That formula translated into providing everyone with everything. The only certain outcome from such a policy would be fiscal insolvency and ultimately bankruptcy. (shrink)

Background: Patients today interact with physicians, physician groups, and health plans, each of which may follow distinct ethical guidelines.Method: We systematically compared physician codes of ethics with ethics policies at physician group practices and health plans, using the 1998–99 policies of 38 organisations—18 medical associations , nine physician group practices , and 12 health plans —selected using random and stratified purposive sampling. A clinician and a social scientist independently abstracted each document, using a 397-item health care (...) ethics taxonomy; a reconciled abstraction form was used for analysis. This study focuses on ethics policies regarding professional obligation towards patients, resource allocation, and care for the vulnerable in society.Results: A majority in all three groups mention “fiduciary obligations” of one sort or another, but associations generally address physician/patient relations but not health plan obligations, while plans rarely endorse physicians’ obligations of advocacy, beneficence, and non-maleficence. Except for occasional mentions of cost effectiveness or efficiency, ethical considerations in resource allocation rarely arise in the ethics policies of all three organisational types. Very few associations, groups, or plans specifically endorse obligations to vulnerable populations.Conclusions: With some important exceptions, we found that the ethics policies of associations, groups, and plans are narrowly focused and often ignore important ethical concerns for society, such as resource allocation and care for vulnerable populations. More collaborative work is needed to build integrated sets of ethical standards that address the aims and responsibilities of the major stakeholders in health care delivery. (shrink)

: In spite of recent political setbacks for the movement toward universal health insurance, considerable support remains for the idea. Among those supporting such plans, most assume that a universal insurance system, especially if it is a single-payer system, would offer a single list of basic covered services. This paper challenges that assumption and argues for the availability of multiple lists of services in a universal insurance system. The claim is made that multiple lists will be both more efficient (...) and more fair. Any single list will fund some services that are quite attractive to some people, but only marginally attractive to others. Thus any single-list plan will fund some services that produce only marginal benefit for the resources used. Moreover, since some people will hold values quite compatible with the single list and others will hold values leading to preferences for unfunded services, some people will get much more benefit from any single list than other people will. Fairness and efficiency require providing an entitlement to universal access to health insurance that could be purchased by typical consumers for a fixed price of perhaps $3500. By permitting everyone to pick their preferred list of services available at that price, each person will efficiently use his or her entitlement while getting more equal opportunity for benefits. (shrink)

Background: A better understanding of the pattern of epidemic-related referrals to healthcare centers might allow the identification of vulnerabilities and the required changes that the healthcare management system should undergo. Objectives: This study aimed to investigate the COVID-19 referral pattern and the role of media and health management planning in changing the trends. Methods: Data extracted from the electronic medical database of Imam Khomeini Hospital Complex (IKHC), located in Tehran, Iran, from February 20 to June 4, 2020 were (...) examined. Individuals were divided into two groups, COVID-19 positive and negative. We used Google Trends to evaluate Google Internet search queries and also available policy documents, programs, and official news related to COVID-19 in Iran during the mentioned period. Results: In this study, 8647 individuals aged 46.05 ± 16.5 years were referred to IKHC. Approximately 57% were male, and 70% were COVID-19 positive. The most clinical symptoms were dyspnea, fever, cough, and myalgia. Chronic kidney disease (CKD) and type 2 diabetes mellitus were the most common underlying health conditions. In the first two weeks, the percentage of negative cases was higher than positive cases and then the pattern was reversed, when people searched for information about COVID-19 in media. Conclusions: Proper and timely information and education to people through the media and health management measures can be effective in reducing unnecessary visits to health centers, preventing the exhaustion of medical staff, and controlling the disease during epidemics. (shrink)

Ford, Norman This is an article to introduce readers to the issue of people planning their options for future health care and medical treatment, and the importance of taking it seriously and acting on it.

California has focused on health equity in the state’s COVID-19 reopening plan. The Blueprint for a Safer Economy assigns each of California’s 58 counties into 1 of 4 tiers based on 2 metrics: test positivity rate and adjusted case rate. To advance to the next less-restrictive tier, counties must meet that tier’s test positivity and adjusted case rate thresholds. In addition, counties must have a plan for targeted investments within disadvantaged communities, and counties with more than 106 000 residents (...) must meet an equity metric. California's explicit incorporation of health equity into its reopening plan underscores the interrelated fate of its residents during the COVID-19 pandemic and creates incentives for action. This article evaluates the benefits and challenges of this novel health equity focus, and outlines recommendations for other US states to address disparities in their reopening plans. (shrink)

This book examines the relevance of modern medicine and healthcare in shaping the lives of elderly persons and ageing societies. Combining individual and social dimensions, Planning Later Life discusses the ethical, social, and political consequences of increasing life expectancies and demographic change in the context of biomedicine and public health. By focusing on the field of biomedicine and healthcare, the authors engage readers in a dialogue on the ethical and social implications of recent trends in dementia research and (...) care, advance healthcare planning, or the rise of anti-ageing medicine and prevention. Bringing together the largely separated debates of individualist bioethics on the one hand, and public health ethics on the other, the volume deliberately considers the entanglements of envisioning, evaluating, and controlling individual and societal futures. The process of devising and exploring the various positive and negative visions and strategies related to later life is rarely reflected systematically from a philosophical, sociological, and ethical point of view. As such, this book will be crucial to those working and studying in the life sciences, the humanities, and the social sciences, particularly in the areas of bioethics, social work, gerontology and aging studies, healthcare and social service, sociology, social policy, and geography and population studies. (shrink)

This paper discusses two interrelated concepts: (1) the ethics of planned social change and (2) primary health care. It takes the World Health Organization’s definition of primary health care as a point of departure to examine four identified potential areas where ethical dilemmas may occur. In addition, questions are raised about nursing education, as well as about the class and status differences between nurses and patients and communities. It takes the position that our first task is to (...) encourage more discussion and examination of ethical issues in the planned social change of primary health care. (shrink)

Today, health systems around the world are under pressure to create greater value for patients and society [81, p. 1, 119]; increasing access, improving client orientation and responsiveness, reducing medical errors and safety, restraining utilization via managed care, and implementing priority allocation of resources for high-burden health problems are examples of strategies towards this end. The quality paradigm by virtue of its strategic consumer focus and its methods for achieving operational excellence has proved an effective approach for creating (...) higher value in many sectors. If applied in a deliberate and holistic manner, the quality paradigm can bring about a more cost-effective organization of the health systems. In this article, we apply quality concepts to healthcare in a conceptual format; we characterize the health system’s customers and outputs with their quality dimensions. The product of this effort is a blueprint for a customer-driven health system which identifies six types of customers, nine types of outputs and the associated operations. As a preliminary step, a new analysis and definition of health and disease is provided. Rethinking the structure of health system in this manner and the related conceptual model can guide medical research, health sciences education, and health services policy, and help the practitioner to integrate all modern trends in healthcare delivery. (shrink)

According to HealthCare.gov, by improving access to quality health for all Americans, the Affordable Care Act (ACA) will reduce disparities in health insurance coverage. One way this will happen under the provisions of the ACA is by creating a new health insurance marketplace (a health insurance exchange) by 2014 in which “all people will have a choice for quality, affordable health insurance even if a job loss, job switch, move or illness occurs”. This does not (...) mean that everyone will have whatever insurance coverage he or she wants. The provisions of the ACA require that each of the four benefit categories of plans (known as bronze, silver, gold and platinum) provides no less than the benefits available in an “essential health benefits package”. However, without a clear understanding of what criteria must be satisfied for health care to be essential, the ACA’s requirement is much too vague and open to multiple, potentially conflicting interpretations. Indeed, without such understanding, in the rush to provide health insurance coverage to as many people as is economically feasible, we may replace one kind of disparity (lack of health insurance) with another kind of disparity (lack of adequate health insurance). Thus, this paper explores the concept of “essential benefits”, arguing that the “essential health benefits package” in the ACA should be one that optimally satisfies the basic needs of the people covered. (shrink)

At the end of last year, President George Bush implemented a smallpox vaccination plan covering military operatives, health care workers, and “first-responders”. The program is administered by the federal Department of Health and Human Services in conjunction with the states and follows the smallpox vaccination guidelines established by the Centers for Disease Control and Prevention in September 2002. While inoculation is mandatory for military personnel, health care workers and first-responders are vaccinated on a voluntary basis. The Administration (...) had hoped that 450,000 health care workers would be inoculated within the first month of the program. Toward the end of February, however, only about 1 percent of the anticipated recipients had been inoculated. In Connecticut, which was the first state to begin the nonmilitary component of the program, only three people received vaccinations on the first day. (shrink)

In this discussion paper we consider the influence of ethnicity, religiosity, spirituality and health literacy on Advance Care Planning for older people. Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of advance care planning by this group across a number of countries where advance care planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life (...) decisions. Health literacy issues have been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote advance care planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape advance care planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities and to promote older peoples’ ability to enact moral agency in making such decisions. (shrink)

Background: Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute (...) decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making. Methods/DesignDyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments. DiscussionThis study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system. Trial RegistrationISRCTN89993391. (shrink)

In an earlier edition of CambridgeQuarterly, in the section (CQ Vol 9, No 4), Larry Gottlieb sought advice on ethics committee assembly and policy implementation for a community mental health center. One concern mentioned is that staff members frequently encounter ethical issuesregarding the care of clients whose decisionmaking abilities are impaired by chronic mental illness and/or substance abuse. My response offers a suggestion for policy development and implementation, which may be integrated into guiding staff members of community mental (...) class='Hi'>health centers toward a model of care planning that is centered on clients' experiences of their treatments and on relationship-building among clients, community members, and mental health professionals. (shrink)

The study is designed to provide an informal summary of what is known about consumer switching of health insurance plans and to contribute to knowledge about what motivates consumers who choose to switch health plans. Do consumers switch plans largely on the basis of critical reflection and assessment of information about the quality, and price? The literature suggests that switching is complicated, not always possible, and often overwhelming to consumers. Price does not always determine choice. Quality is very (...) hard for consumers to understand. Results from a random sample survey ( n = 2791) of the Alkmaar region of the Netherlands are reported here. They suggest that rather than embracing the opportunity to be active critical consumers, individuals are more likely to avoid this role by handing this activity off to a group purchasing organization. There is little evidence that consumers switch plans on the basis of critical reflection and assessment of information about quality and price. The new data reported here confirm the importance of a group purchasing organizations. In a free-market-health insurance system confidence in purchasing groups may be more important for health insurance choice than health informatics. This is not what policy makers expected and might result a less efficient health insurance market system. (shrink)