As health policy-makers around the world seek to make progress towards universal health coverage, they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states’ efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points (...) of tension stem largely from inadequate interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play. (shrink)

In recent years, there has been a growing groundswell of support for the idea that universal health coverage should be provided even in the developing world. While I wholeheartedly agree with the eventual goal of attaining universal health coverage globally, and the sooner the better, I have worries as to whether the world's rich countries, or institutions like the World Health Organization, should be pushing the world's poorest countries to take whatever steps are (...) necessary to achieve that goal. My fear is that universal health coverage in the developing world is an intoxicating, but potentially dangerous, idea whose time may not yet have come. This article's aim is not to settle the question of whether the developing world should be urged, or pushed, to adopt policies of universal health coverage. It is merely to explore some worries about the wisdom of such a tack. The article is divided into eight sections. In Section 1, I give a brief introduction. In Section 2, I provide some background for my topic. In Section 3, I discuss the notion of universal health coverage, and what the push for such a goal in the developing world seemingly involves. In Section 4, I raise some general worries I have about the push for universal health coverage in the developing world. In Section 5, I present a wide range of possible justifications for universal health coverage in the developing world. In Section 6, I discuss whether any of the purported justifications of universal health coverage in the developing world actually do so. In Section 7, I consider some comments, objections, and responses. Finally, in Section 8, I offer a brief conclusion. (shrink)

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can (...) guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for the worse off, and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting. (shrink)

Objective: To assess the relation between autocratisation—substantial decreases in democratic traits (free and fair elections, freedom of civil and political association, and freedom of expression)—and countries’ population health outcomes and progress toward universal health coverage (UHC). -/- Design: Synthetic control analysis. -/- Setting and country selection: Global sample of countries for all years from 1989 to 2019, split into two categories: 17 treatment countries that started autocratising during 2000 to 2010, and 119 control countries that never (...) autocratised from 1989 to 2019. The treatment countries comprised low and middle income nations and represent all world regions except North America and western Europe. A weighted combination of control countries was used to construct synthetic controls for each treatment country. This statistical method is especially well suited to population level studies when random assignment is infeasible and sufficiently similar comparators are not available. The method was originally developed in economics and political science to assess the impact of policies and events, and it is now increasingly used in epidemiology. -/- Main outcome measures: HIV-free life expectancy at age 5 years, UHC effective coverage index (0-100 point scale), and out-of-pocket spending on health per capita. All outcome variables are for the period 1989 to 2019. -/- Results: Autocratising countries underperformed for all three outcome variables in the 10 years after the onset of autocratisation, despite some improvements in life expectancy, UHC effective coverage index, and out-of-pocket spending on health. On average, HIV-free life expectancy at age 5 years increased by 2.2% (from 64.7 to 66.1 years) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 3.5% (95% confidence interval 3.3% to 3.6%, P<0.001) (from 64.7 to 66.9 years) in the absence of autocratisation. On average, the UHC effective coverage index increased by 11.9% (from 42.5 to 47.6 points) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 20.2% (95% confidence interval 19.6% to 21.2%, P<0.001) (from 42.5 to 51.1 points) in the absence of autocratisation. Finally, on average, out-of-pocket spending on health per capita increased by 10.0% (from $4.00 (£3.1; €3.4) to $4.4, log transformed) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by only 4.4% (95% confidence interval 3.9% to 4.6%, P<0.001) (from $4.0 to $4.2, log transformed) in the absence of autocratisation. -/- Conclusions: Autocratising countries had worse than estimated life expectancy, effective health service coverage, and levels of out-of-pocket spending on health. These results suggest that the noticeable increase in the number of countries that are experiencing democratic erosion in recent years is hindering population health gains and progress toward UHC. Global health institutions will need to adjust their policy recommendations and activities to obtain the best possible results in those countries with a diminishing democratic incentive to provide quality healthcare to populations. (shrink)

In response to our critics, we clarify and defend key ideas in the report Open and Inclusive: Fair Processes for Financing Universal Health Coverage. First, we argue that procedural fairness has greater value than Dan Hausman allows. Second, we argue that the Report aligns with John Kinuthia’s view that a knowledgeable public and a capable civil society, alongside good facilitation, are important for effective public deliberation. Moreover, we agree with Kinuthia that the Report’s framework for procedural fairness (...) applies not merely within the health sector, but also to the wider budget process. Third, we argue that while Dheepa Rajan and Benjamin Rouffy-Ly are right that robust processes for equal participation are often central to a fair process, sometimes improvements in other aspects of procedural fairness, such as transparency, can take priority over strengthening participation. Fourth, while we welcome Sara Bennett and Maria Merritt’s fascinating use of the Report’s principles of procedural fairness to assess the U.S. President’s Emergency Plan for AIDS Relief, we argue that their application of the Report’s principle of equality to development partners’ decision-making requires further justification. (shrink)

We summarize key messages from the World Bank report Open and Inclusive: Fair Processes for Financing Universal Health Coverage. A central lesson of the Report is that in decision-making on the path to UHC, procedural fairness matters alongside substantive fairness. Decision systems should be assessed using a complete conception of procedural fairness that embodies core commitments to impartial and equal consideration of interests and perspectives. These commitments demand that comprehensive information is gathered and disclosed and that justifications (...) for policies are publicly debated; that participation in decision-making is enabled; and that these characteristics of the decision system are institutionalised rather than up to the good will of decision-makers. Procedural fairness can improve equity in outcomes, raise legitimacy and trust, and can help make reforms last. While improving procedural fairness can be costly and there are barriers to achieving it, the range of instruments that countries at varying levels of income and institutional capacity have used with some success shows that, in many contexts, advances in procedural fairness in health financing are possible and worthwhile. (shrink)

China’s efforts in Universal Health Coverage since the birth of the People’s Republic in 1949 has passed four stages: 1949–1983, Maoist UHC; 1984–2003, Deng’s Free-market healthcare experiment; 2004–2008, response to people’s call and restorative efforts; 2009-present, reducing fragmentation, co-payment and improving primary care. The efforts of the first three stages aimed more at extending coverage and service scope, and those of the fourth stage for better equity, quality, and affordability. This article updates recent efforts in the (...) fourth stage and looks ahead to the future after 2018, with the hope of providing references for the world in healthcare reform and development. (shrink)

This World Bank Report offers a new conception of fair decision processes in health financing. It argues that such procedural fairness can contribute to fairer outcomes, strengthen the legitimacy of decision processes, build trust in authorities, and promote the sustainability of reforms on the path to health coverage for all.

Progress towards Universal Health Coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the WHO Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases and how should one adjudicate between them when their demands (...) conflict? This paper by some members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three principal dimensions of progress towards UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to pre-payment with pooling of funds. Our cases are simplified to highlight common trade-offs. While we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC. (shrink)

The WHO Consultative Group on Equity and Universal Health Coverage published a comprehensive report titled “Making Fair Choices on the Path to Universal Health Coverage” detailing strategies that countries should adopt when moving towards providing healthcare coverage to the entire population. The report provides detailed guidelines on how to expand coverage to more people, what services should be covered, and how to prioritize these healthcare resources in achieving universal healthcare coverage. (...) The main goal of this WHO report is to ensure fair and equitable access for all population groups within a country during the implementation of UHC. In principle, the group’s approach is sound and fair, but we argue that each country must take into account its own unique situations in designing a pathway towards UHC. China has achieved near UHC but did so by an approach that would have been deemed completely unacceptable based on this group’s recommendations. In this article, we provide a brief review of the Chinese healthcare system and argue that the implementation of the recommendations in the report is not always feasible. We argue that there are alternate pathways towards achieving UHC and there are good reasons for China’s departure from the approach outlined by the WHO report. Nevertheless, we acknowledge substantial inequities still exist for various segments of the population and among the diverse areas of China in accessing healthcare services and make suggestions on how to reduce such inequities within the system. (shrink)

In the current era of the Sustainable Development Goals, many countries are attempting to strengthen their health system and achieving Universal Health Coverage. The Korean National Health Insurance system functions as a core element of health financing, contributing to achieving UHC by promoting public health and social security through insurance benefits for prevention, diagnosis, treatment, rehabilitation, childbirth, and health promotion. The Republic of Korea achieved 100% NHI coverage of the target population (...) in 1989, 12 years after the introduction of the social insurance system. However, poor coverage of health services and lack of financial protection are major obstacles to achieving UHC. Therefore, the Korean government announced and implemented ‘Moon Jae-in Care’ in August 2017 to enhance the coverage rate of NHI by 70%. First, this study reviews the existing health insurance system in Korea from the perspective of health financing and UHC. Second, it analyses ‘Moon Jae-in Care’, based on the main framework of UHC. Third, it considers the ethical implications of these developments, with focus on the principles of equity, fairness, autonomy, and solidarity. Although the NHI reform is expected to propel Korean health care closer to UHC, many ethical, social, and political issues remain. (shrink)

This report by the WHO Consultative Group on Equity and Universal Health Coverage addresses how countries can make fair progress towards the goal of universal coverage. It explains the relevant tradeoffs between different desirable ends and offers guidance on how to make these tradeoffs.

Universal health coverage is often implemented within countries through several national insurance schemes that collectively cover their populations. Yet the extent of services and benefits available can vary substantially between different schemes. This paper argues that these variations in coverage comprise tiering and then reviews different accounts of health and social justice that consider whether and when a tiered health system is fair. Using these accounts, it shows that the fairness of tiering can be (...) determined by assessing whether differences in coverage mean enrolees under some national insurance schemes do not achieve sufficient health or normal functioning and/or feel inferior relative to those belonging to other national insurance schemes. The paper further contends that these determinations of fairness should involve the people covered by different insurance schemes. Key universal health coverage questions to involve the public in answering are: Do the sum of differences between the schemes in your country generate feelings of unequal moral worth and/or mean enrolees struggle to achieve sufficient health or normal functioning? Which specific differences between health insurance schemes generate the greatest feelings of unequal moral worth in individuals? Which specific differences generate the greatest barriers to individuals achieving sufficient health or normal functioning? Rather than identifying which services to extend coverage to first, answering these questions will identify which disparities in services and benefits are the most morally urgent to address. Finally, some initial thoughts are offered on who from the public should be involved in making these decisions and how they might be involved as a matter of justice. (shrink)

Temkin asks how we should distribute resources between the social determinants of health and health care; Sreenivasan argues that if our goal is fair opportunity, funding universal health coverage is the wrong policy. He argues that social equality in health has not improved under UHC and concludes that fair opportunity would be better served by using the resources to address the SDOH instead. His criticism applies more broadly than he claims: it applies to any (...) argument for UHC based on health equity. However, neither his strong causal conclusion nor his stark policy proposal is justified. I review methodological challenges for establishing the relative causal contributions of health care and social policy, concluding that we may never have a robust causal account to support a consequentialist choice. Fortunately, we may not need to answer the allocation question as a dichotomy. Given what Sen calls the multidimensional nature of health equity and the role of UHC in cost containment, UHC may not be a threat to health equity. I also argue against Sreenivasan's claim that the data he discusses should not trouble sufficientists and prioritarians. The worst-off are not simply lagging in improvement; rather, their health status is stagnating or worsening. (shrink)

We offer a summary of the WHO Report "Making Fair Choices on the Path to Universal Health Coverage".

IntroductionHigh healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.MethodsUsing a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the (...) acceptability of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.ResultsGiving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms.ConclusionIn settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty. (shrink)

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional rather than a residual system. They argue that the concept contradicts the idea of comprehensiveness; leads to unsustainable expenditures; is too indeterminate for policy; and supports only a prioritarian distribution. I argue that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and that UHC (...) is a solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy are not transparent about the source of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option. (shrink)

America's patchwork quilt of health care coverage is coming apart at the seams. The system, such as it is, is built upon an inherently problematic base: employment. By definition, an employment-based approach, by itself, will not assure universal coverage of the entire population. If an employment-based approach is to be the centerpiece of a system that provides universal coverage, special attention must be paid to all the categories of individuals who are not employees – (...) children, unemployed spouses or singles, the unemployable ill and disabled, persons between jobs, students, retirees, the elderly. Moreover, in a purely voluntary employment-based arrangement, some employers will not provide insurance at all, and others will provide inadequate coverage, necessitating other special provisions for coverage. As a consequence, about one out of six people now has no health coverage whatsoever, and even more have inadequate coverage. All the while, the rapidly-increasing transaction costs of sustaining this grossly inadequate pluralistic system eat up sufficient funds to provide basic benefits to the entire population. The time for systematic reforms has come and gone; what is now needed is action to prevent disaster, followed by a complete rebuilding of this country's health coverage system. Although perhaps more likely to be tried than more radical, completely nationalized, ones, stepwise reforms may not go far enough to cure the significant ills of the current employment-based system. Passage of inadequate reforms, then, could well set the stage for nationalized health care in the not too distant future. (shrink)

Health care reforms, in particular the expansion of public and/or private health care benefit coverage to some or all population groups, is becoming an increasingly hot topic for discussion—and in some cases for action—at all levels of government. With almost 16% of Americans estimated to be uninsured for at least part of the year, opinion polls show health care near the top of the general public’s list of concerns. Little wonder that presidential candidates for the 2008 (...) election are incorporating ‘‘universal health care coverage’’ proposals in their campaign platforms. Will ‘‘cradle-to-grave’’ coverage for all become a reality or will they just experience cradle-to-grave debates over this issue? That is essentially one of the questions posed in the following discussion on the role of nonprofit health care organizations in promoting, and operating under, universal health care coverage. (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)

Most people are completely oblivious to the danger that their medical data undergoes as soon as it goes out into the burgeoning world of big data. Medical data is financially valuable, and your sensitive data may be shared or sold by doctors, hospitals, clinical laboratories, and pharmacies—without your knowledge or consent. Medical data can also be found in your browsing history, the smartphone applications you use, data from wearables, your shopping list, and more. At best, data about your health (...) might end up in the hands of researchers on whose good will we depend to avoid abuses of power.2 Most likely, it will end up with data brokers who might sell it to a future employer, or an insurance company, or the government. At worst, your medical data may end up in the hands of criminals eager to commit extortion or identity theft. In addition to data harms related to exposure and discrimination, the collection of sensitive data by powerful corporations risks the creation of data monopolies that can dominate and condition access to health care. -/- This chapter aims to explore the challenge that big data brings to medical privacy. Section I offers a brief overview of the role of privacy in medical settings. I define privacy as having one’s personal information and one’s personal sensorial space (what I call autotopos) unaccessed. Section II discusses how the challenge of big data differs from other risks to medical privacy. Section III is about what can be done to minimise those risks. I argue that the most effective way of protecting people from suffering unfair medical consequences is by having a public universal healthcare system in which coverage is not influenced by personal data (e.g., genetic predisposition, exercise habits, eating habits, etc.). (shrink)

In 2015, the U.S. Supreme Court issued its ruling on the Patient Protection and Affordable Care Act (ACA). Among other things, it found that states may refuse to expand Medicaid to all individuals earning less than 133% of the federal poverty line. In this article, I evaluate the strongest conservative objection to the Medicaid expansion, which runs as follows: "Defenders of the ACA promised that the Medicaid expansion (and all other parts of the ACA) would be paid for with compensating (...) cuts. However, it’s arguable that that claim is false and that the government is likely to follow its well-worn pattern of charging at least some of the increased spending to the national debt. Debt is already at dangerous levels, and adding to it increases the risk of a serious fiscal crisis. We should therefore oppose the Medicaid expansion." After laying out this argument, I evaluate its central claims and draw three main conclusions. First, some people could reasonably believe the assumptions behind the fiscal objection, and thus reasonably oppose the Medicaid expansion as well. Second, despite the fact that reasonable critics could hold those assumptions, most critics do not, and so they should not reject the Medicaid expansion on these fiscal grounds. Third, supporters of the ACA and the Medicaid expansion can reasonably reject the assumptions behind the fiscal objection, and thus the objection itself. (shrink)

Menzel and Light have argued that the conservative principle of self-sufficiency gives good reasons to strive for universal health coverage. This paper gives further reasons for connecting universal health care with self-sufficiency and continues Menzel’s and Light’s project in four more ways. First, a more extended analysis of a conservative conception of government shows how a general opposition to welfare programs is consistent with guaranteeing universal basic health care. Second, common fears about the (...) abuse of health care when universal access is guaranteed are unfounded. Third, worldwide experience shows that the most effective way to bring high quality health care to a population is through a government mandate, not the free market. Fourth, while socioeconomic status is an important determinant of health independent of the accessibility of health care itself, this does not undermine the case for universal health care based on a minimal, conservative conception of equality of opportunity. (shrink)

American policymakers and health policy analysts have a love-hate relationship with job-based health insurance. The policy press routinely runs articles about the demise of the current system of voluntary employer-sponsored health insurance coverage. Conservatives argue that it ought to be replaced with individually-purchased insurance, such as tax-favored spending accounts. Liberals assert that government insurance ought to supplant it.Meanwhile, as the debate rages on about the future of employer coverage, states and the federal government pass legislation (...) buttressing and building on the existing employment-based system. Most recently, California has passed an employer mandate requiring employers to cover their workers and Maine has adopted a universal coverage initiative that includes a voluntary small employer insurance program offered through a state agency. (shrink)

As pressures increase to contain growing healthcare expenditures, there is currently a prominent rise in the shift of healthcare costs to patients in the form of deductibles, co-pays, and co-insurance. Rising co-payments are part of a larger picture of increasing overall out-of-pocket healthcare expenditures. From 1990 to 2000, per capita out-of-pocket payments for healthcare reached $707 in the United States, and doubled in several European countries with universal health insurance, reaching $396 in Denmark, $290 in Germany, and $466 (...) in Italy in 2000. (shrink)

The singular message in Global Health Law is that we must strive to achieve global health with justice—improved population health, with a fairer distribution of benefits of good health. Global health entails ensuring the conditions of good health—public health, universal health coverage, and the social determinants of health—while justice requires closing today’s vast domestic and global health inequities. These conditions for good health should be incorporated into public (...) policy, supplemented by specific actions to overcome barriers to equity. A new global health treaty grounded in the right to health and aimed at health equity—a Framework Convention on Global Health —stands out for its possibilities in helping to achieve global health with justice. This far-reaching legal instrument would establish minimum standards for universal health coverage and public health measures, with an accompanying national and international financing framework, require a constant focus on health equity, promote Health in All Policies and global governance for health, and advance the principles of good governance, including accountability. While achieving an FCGH is certainly ambitious, it is a struggle worth the efforts of us all. The treaty’s basis in the right to health, which has been agreed to by all governments, has powerful potential to form the foundation of global governance for health. From interpretations of UN treaty bodies to judgments of national courts, the right to health is now sufficiently articulated to serve this role, with the individual’s right to health best understood as a function of a social, political, and economic environment aimed at equity. However great the political challenge of securing state agreement to the FCGH, it is possible. States have joined other treaties with significant resource requirements and limitations on their sovereignty without significant reciprocal benefits from other states, while important state interests would benefit from the FCGH. And from integrating the FCGH into the existing human rights system to creative forms of compliance and enforcement and strengthened domestic legal and political accountability mechanisms, the treaty stands to improve right to health compliance. The potential for the FCGH to bring the right to health nearer universal reality calls for us to embark on the journey towards securing this global treaty. (shrink)

Several countries maintain universal health coverage, which implies responsibility to organize delivery formats of healthcare services and products for citizens. In Brazil, the health system has a principle of universal access for more than 30 years, but many deficiencies remain and the country observes a day practice for those seeking judicial decisions to determine provision of healthcare.

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that threaten to (...) drop their financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

The overriding goal of health reform is to provide every American affordable access to adequate health care. Yet in every national effort to date, the focal means to this end has always been health insurance. Massachusetts is congratulated for having achieved nearly universal insurance coverage, and congressional Democrats are aiming for the same. But what if they don't succeed? Even in Massachusetts, 167,000 residents remain uninsured. Is it still possible to provide adequate access to medical (...) care for those without insurance? If so, shouldn't we reframe social goals to achieve universal access through any means possible, whether or not insurance is involved? (shrink)

This study examines the relative effects of three policy levers on health coverage and costs in plans aimed at covering all Americans. Specifically, using microsimulation analysis and hypothetical proposals, it assesses how the generosity of financial assistance, an employer mandate, and an individual mandate affect the level of uninsurance, distribution of coverage, and federal costs, holding delivery system and benefits constant. The results suggest that only an individual mandate would cover all the uninsured; neither an employer mandate (...) nor generous subsidies alone would be sufficient. The distribution of coverage would be least disrupted by an employer mandate, while 7.3% of people could lose employer coverage with generous subsidies and a voluntary purchasing pool. Federal costs would be highest under a combined individual and employer mandate since there would be costs to minimize disruption. Although less generous subsidies coupled with an individual mandate could yield universal coverage at a low federal cost, doing so would require large, new payments by individuals. Other key trade-offs are discussed. (shrink)

Despite a consensus across the political spectrum that the problem of the chronically uninsured is in dire need of solution, little progress has heen made. Public spending goes to topping up coverage for the elderly, already heavily subsidized under Medicare, or helping people temporarily without insurance because of international trade dislocations, so that it is clear that something is lacking in the case for significantly reducing the number of uninsured persons. In this paper I suggest that there have been (...) two missing ingredients: a strategy for breaking the political deadlock around this issue, and information about the benefits of coverage sufficient to persuade kindly but skeptical taxpayers that they should be willing to pay to help solve this problem.This article begins with a discussion of these two problems. It then outlines a strategy based on income-related or conditioned refundable tax credits for private and public insurance, coupled with a plan to assemble persuasive information that may move things forward. (shrink)

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)

Between 2010 and 2016, the percentage of uninsured higher education students dropped by more than half. All the Affordable Care Act's key access provisions contributed, but the most important factor appears to be the Medicaid expansion. This article is the first to highlight this phenomenon and ground it in data. It explores the reasons for this dramatic expansion of coverage, links it to theoretical frameworks, and considers its implications for the future of health reform. Drawing on Medicaid universality (...) scholarship, I discuss potential consequences of including the educationally privileged in this historically stigmatized program. Extending this scholarship, I argue that the student experience and its reverberating effects portend support for emerging proposals to make Medicare a more common option. Woven into both analyses is the role of the Trump-era retrenchment, notably the administration's promotion of Medicaid “work or community engagement” requirements and of cheap, skimpy plans. Higher education students were an afterthought in the ACA's debates, and yet the law has profoundly impacted their coverage options. Students are now much more likely to have health insurance, and for it to be comprehensive. Looking to the next decade, the student experience harbingers support for both Medicaid universality and Medicare commonality. (shrink)

For individuals pursuing medically assisted gender transition, gender-affirming surgical treatments, such as oophorectomy (removal of the ovaries) and orchiectomy (removal of the testicles), cause sterility, and gender-affirming hormone treatment with medications (i.e., testosterone and estrogen) may negatively impact infertility. The major United States (US) medical associations already endorse fertility preservation (FP) through cryopreservation (i.e., “freezing” egg and sperm) for transgender individuals. Despite these endorsements from the relevant medical societies, medical insurance coverage for FP remains very limited in the US. (...) Given the high out-of-pocket costs for FP services, fertility preservation remains financially out of reach for many transgender individuals who may desire it. We present an ethical justification for universal FP coverage for all transgender and gender diverse (TGD) individuals who request this option during medically assisted gender transition. First, we argue that gender-affirming medical care is analogous to other medical interventions and treatment regimens that compromise fertility, such as cancer care, and that both types of interventions need to be afforded the same medical benefits and assistance in pursuing fertility goals. Second, we argue that the lack of FP for transgender individuals contributes to the ongoing and profound transphobia and anti-trans bias that has been exacerbated in the past several years across the healthcare landscape in the United States. We argue that the provision of FP coverage for transgender individuals is necessary for clinicians and third-party payers to state their unequivocal support for TGD patients and their healthcare needs. (shrink)

Systems of universal health coverage may aspire to provide care based on need and not ability to pay; the complexities of this aspiration call for normative analysis. This special issue arises in the wake of a judicial inquiry into preferential access in the Canadian province of Alberta, the Vertes Commission. I describe this inquiry and set out a taxonomy of forms of differential and preferential access. Papers in this special issue focus on the conceptual specification of (...) class='Hi'>health system boundaries and on the normative questions raised by complex models of funding and delivery of care, where patients, providers, and services cross system boundaries. (shrink)

Global health is at a crossroads. The 2030 Agenda for Sustainable Development has come with ambitious targets for health and health services worldwide. To reach these targets, many more billions of dollars need to be spent on health. However, development assistance for health has plateaued and domestic funding on health in most countries is growing at rates too low to close the financing gap. National and international decision-makers face tough choices about how scarce (...) class='Hi'>health care resources should be spent. Should additional funds be spent on primary prevention of stroke, treating childhood cancer, or expanding treatment for HIV/AIDS? Should health coverage decisions take into account the effects of illness on productivity, household finances, and children's educational attainment, or just focus on health outcomes? Does age matter for priority setting or should it be ignored? Are health gains far in the future less important than gains in the present? Should higher priority be given to people who are sicker or poorer? Global Health Priority-Setting provides a framework for how to think about evidence-based priority-setting in health. Over 18 chapters, ethicists, philosophers, economists, policy-makers, and clinicians from around the world assess the state of current practice in national and global priority setting, describe new tools and methodologies to address establishing global health priorities, and tackle the most important ethical questions that decision-makers must consider in allocating health resources. (shrink)

The World Health Assembly has encouraged WHO member-states to establish capacity in health technology assessment (HTA) as a support for achieving universal health coverage (UHC). Simultaneously, the WHO has stated that UHC is “a practical expression of the concern for health equity and the right to health.” This has prompted questions about potential tensions between priority-setting efforts and the right to health on the road to UHC. South Africa (SA) is an ideal (...) setting in which to explore how the priority-setting work of an HTA body may be integrated with an existing rights framework. (shrink)

In modern industrial society the issue of access to healthcare is inseparable from the question of whether there is a right to healthcare and whether government has the correlative duty to assure a minimum level of care to all citizens. While discussion in terms of rights and duties tends to direct our attention to broader, more theoretical ethical issues, discussion in terms of invites consideration of more practical concerns. The news media rarely report in terms of whether a citizen's right (...) to healthcare has been abridged or disregarded, but rather offers tales of people being denied access. Advocacy groups for specific illnesses do not necessarily argue for universal health insurance, but rather press that certain conditions, such as renal failure requiring dialysis, receive unlimited insurance coverage and that people with the condition be given automatic access to care. (shrink)

Universal health coverage (UHC) is the condition in which every member of a certain community have access to essential, effective care without financial hardship. Increasing older adults suffering from chronic morbidities and/or social isolation struggle to receive the care they need precisely when they need it most. These patients need care personalization, multidisciplinary integration and professional cooperation more than high-tech biomedical treatment, as plenty of social determinants frequently hamper the effectiveness of each single treatment received. If the (...) health inequalities resulting from suboptimal organization of care can be reduced, taking action becomes a question of social justice. This paper aims to 1) describe some relevant determinants of health that prevent many older adults from receiving the care they need, 2) outline some policies to avoid ageism and minimize rationing. (shrink)

Human rights offer to ground global health law in equity and justice. Human rights norms, advocacy, and strategies have proven successes in challenging private and public inequities and in realizing more equitable domestic and global health governance. However, mobilizing human rights within global health law faces enormous political, economic, technological, and epidemiological challenges, including from the corrosive health impacts of power, politics, and commerce. This article focuses on what human rights could bring to three major global (...) health law challenges — health systems strengthening and universal health coverage, the commercial and economic determinants of health, and pandemic disease threats. We argue that human rights offer potentially powerful norms and strategies for achieving equity and justice in these and other key global health domains. The challenge for those working in human rights and global health law is to work nimbly, creatively, and courageously to strengthen the contribution of these instruments to health justice. (shrink)

The first National Health Service (NHS) was introduced in the United Kingdom providing free universal health care (UHC) at the point of use. Within decades, increasing European countries adopted the same intervention to improve the health of citizens on the entire life span. Today, several reasons put at risk (1) empirically, the sustainability and fairness of these systems, (2) theoretically, the same consistency of solidarity, as vulnerable patients struggle most to receive essential care. Preserving solidarity from (...) the pressure of modern medicine and society needs to identify a fair and sustainable type of coverage at the same time. This paper aims (1) to describe the short circuit of solidarity in European NHSs; (2) to discuss alternative versions of UHC and support redistributive neo-universalism; (3) to promote the role of medical humanities in implementing this solution. (shrink)

Because the goal of military medicine is salvaging the wounded who can return to duty, military medical ethics cannot easily defend devoting scarce resources to those so badly injured that they cannot return to duty. Instead, arguments turn to morale and political obligation to justify care for the seriously wounded. Neither argument is satisfactory. Care for the wounded is not necessary to maintain an army's morale. Nor is there any moral or logical connection between the right to health care (...) (a universal human right) and the duty to defend one's nation (a local political duty). Once badly wounded, soldiers enjoy the same right to medical care as any similarly ill or injured individual. National health care systems grasp this point and offer few additional health care benefits to veterans. In the United States, however, lack of universal health coverage skews the debate to focus on special entitlements for veterans without considering the health care rights that other citizens enjoy. (shrink)

In 2017, Ukraine’s Parliament passed legislation establishing a single health benefit package for the entire population called the Programme of Medical Guarantees,‎ financed through general taxes and administered by a single national purchasing agency. This legislation was in line with key principles for financing universal health coverage. However, health professionals and some policymakers have been critical of elements of the reform, including its reliance on general taxes as the source of funding. Using qualitative methods and (...) drawing on deliberative democratic theory and criteria for procedural fairness, this study argues that the acceptance and sustainability of these reforms could have been strengthened by making the decision-making process fairer. It suggests that three factors limited the extent of stakeholders’ participation in this process: first, a perception among reformers that fast-paced decision-making was required because there was only a short political window for much needed reforms; second, a lack of trust among reformers in the motives, representativeness, and knowledge of some stakeholders; and third, an under-appreciation of the importance of dialogic engagement with the public. These findings highlight a profound challenge for policymakers. In retrospect, some of those involved in the reform’s design and implementation believe that a more meaningful engagement with the public and stakeholders who opposed the reform might have strengthened its legitimacy and durability. At the same time, the study shows how difficult it is to have an inclusive process in settings where some actors may be driven by unconstrained self-interest or lack the capacity to be representative or knowledgeable interlocutors. It suggests that investments in deliberative capital (the attitudes and behaviours that facilitate good deliberation) and in civil society capacity may help overcome this difficulty. (shrink)