Our health care system in the United States reflects the inequities that are part of the larger society, which is why our system for financing access to needed and effective health care is so complicated and unfair.

Book reviewed in this article: Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. By Lynn Payer. Health Care Systems: Moral Conflicts in European and American Public Policy. Edited by Hans‐Martin Sass and Robert U. Massey.

Based on a qualitative study, this paper explores how United States public health professionals view and think about the existing U.S. healthcare system, while also allowing these study participants to imagine new ways of structuring and practicing public health. Using semi-structured qualitative interviews, I show how public health professionals engage with the concept of “the social” and their personal experiences with public health to question the status quo. By giving public health professionals space in (...) which to imagine changes and different ways of practicing public health, I demonstrate the effectiveness of imagination as a capacity that public health professionals possess to take the lead in creating the changes they hope for. (shrink)

Stark disparities exist in the United States' health care system. Thirty-five million Americans are uninsured, severely impeding their access to necessary health care. Concurrently, others receive health care services that are of unproven necessity and benefit. We assert that this situation is unjust and morally indefensible.

Policy officials often assert that the U.S. has the best health care system in the world, but a recent scorecard on U.S. health system performance finds that the U.S. achieves a score of only 65 out of a possible 100 points on key indicators of performance in five key domains: healthy lives, access, quality, equity, and efficiency, where 100 represents the best achieved performance in other countries or within the U.S. The U.S. should aim higher (...) by adopting a set of policies that will extend affordable health insurance to all; align financial incentives for health care providers to enhance value and achieve savings; organize the health care system around the patient to ensure that care is accessible and coordinated; meet and raise benchmarks for high-quality, efficient care; and ensure accountable national leadership and public-private collaboration. The incoming president and Congress should aspire to have the best health system in the world — not just assert it — and can do so by learning from examples of excellence within the U.S. and abroad. (shrink)

On the eve of the presidential inauguration, the U.S. health system faces rising costs of care, growing numbers of uninsured, wide variations in quality of care, and mounting public dissatisfaction. Despite spending more on health care than any other country, a recent Commonwealth Fund Commission on a High Performance Health Care System National Scorecard reports that the United States is lagging far behind other major industrialized countries — all of which provide (...) universal health insurance — in five key domains: healthy lives, access, quality, equity, and efficiency. U.S. national performance is well below benchmarks of top performance set by other countries or high performing states, hospitals, or health plans within the United States, with broad disparities in experience depending on geographic location, income, race/ethnicity, and insurance coverage. National leadership is required to manage the growing health care crisis in the United States and improve care for all Americans. (shrink)

Describing the U.S. health care system meansdescribing managed care under commercial forces. Managed care creates new moral tension forpractitioners, but more importantly, in its currentform it intensifies the commercialization of healthexpectations and interactions. The largely unregulatedmarketing of health services under managed care hasbeen a major factor in the increasing number ofuninsured citizens, while claims for cost reductionthrough managed care are equivocal. Risk-ratingpractices integral to the current medical marketplacethwart concerns for justice in allocation (...) and createvulnerabilities for almost everyone. Thepolitical-moral concern of the early 1990s for a rightto health care is nowhere in sight. (shrink)

Restructured health care reimbursement systems and new requirements for nonprofit hospitals are transforming the U.S. health system, creating opportunities for enhanced integration of public health and health care goals. This article explores the role of public health practitioners and lawyers in this moment of transformation. We argue that the population perspective and structural strategies that characterize public health can add value to the health care system but could get (...) lost in translation as changes to tax requirements and payment systems are rapidly implemented. We urge public health leaders to take a more active role in hospital assessments of community health needs and evaluation of the patient outcomes for which providers are accountable. (shrink)

There were two ways for the solicitor general of the United States to litigate the constitutional challenge to the Patient Protection and Affordable Care Act of 2010 brought by twenty‐six states and the National Federation of Independent Business. One path, which the solicitor general pursued, was to cautiously navigate judicial precedents, claim the barest increment of new congressional authority, and give the Supreme Court as many hooks as possible on which to hang a favorable decision.The road not traveled was (...) to offer a full‐throated defense of federal authority to comprehensively regulate the U.S. health care system, a multitrillion dollar commercial and social enterprise that represents the largest component of federal expenditure after national defense. The ACA has three cornerstones. First, make health insurance coverage as widespread as possible. Second, improve the quality and efficiency of health care delivery. Third, make individuals and communities healthier. The second and third pillars are sometimes overlooked because so much attention is paid to expanding coverage, but the hallmark of the ACA is that it combines major changes to health insurance, health care delivery, and health in a single piece of federal legislation.The Obama administration's timidity echoes what is strikingly absent from the new law. Although the ACA represents the successful culmination of a decades‐long struggle to universalize coverage, its structure and text never convey the intent that all Americans have a common stake in the health care system. This lack of shared national identity is the missing fourth pillar of the ACA. (shrink)

This paper examines the structural features of the U.S. Health Care System that make it particularly vulnerable to fraud, and which help to account for the types of fraud that arise and the difficulties authorities confront in controlling them. These structural features include the predominance of fee-for-service structures, private sector involvement in health care delivery and health insurance, highly automated cl aims processing systems, and a processing culture and audit mentality that emphasize process accuracy (...) over verification. The paper also discusses the underlying pathology of fraud as a white-collar crime problem, and explains how the more general challenges of controlling fraud are exacerbated by particular features of the health system. The central and unsolved problem of False Claims is examined in some detail. A series of recent governmental responses to medically impossible claims of various types is shown to align more closely with a claims-process-improvement mindset than with a crime-control approach. A more mature crime-control orientation is a pre-requisite for any serious progress in reducing the levels of fraud in the U.S. health system. (shrink)

The case for U.S. health system reform aimed at achieving wider insurance coverage in the population and disciplining the growth of costs is fundamentally a moral case, grounded in two principles: (1) a principle of social justice, the Just Sharing of the costs of illness, and (2) a related principle of fairness, the Prevention of Free‐Riding. These principles generate an argument for universal access to basic care when applied to two existing facts: the phenomenon of “market failure” (...) in health insurance and, in the U.S., the existing legal guarantee of access to emergency care. The principles are widely shared in U.S. moral culture by conservatives and liberals alike. Similarly, across the political spectrum, the fact of market failure is not contested (though it is sometimes ignored), and the guarantee of access to emergency care is rarely challenged. The conclusion generated by the principles is not only that insurance for a basic minimum of care should be mandatory but that the scope of that care should be lean, efficient, and constrained in its cost. -/- . (shrink)

There are many reasons for dissatisfaction with current U.S. health care. One-sixth of the population is uninsured, costs are 150-200% of those in other economically advanced nations, and the quality of care, as measured by disease specific mortality and morbidity data, is rarely better and often worse than in others nations’ less costly systems. A case for reform can mirror any or all of these concerns: cover more of the population with insurance, control costs, improve the effectiveness (...) of prevention and treatment. I argue that two of these goals — greater population coverage and more disciplined costs — gain a significant part of their justification from moral beliefs about justice and fairness. (shrink)

This essay discusses the challenges faced by veterans returning to society in light of the current organization and structure of the military, veterans', and overall U.S. health care systems. It also addresses the need for an integrated health care financing and delivery system to ensure a continuum of care for service members, veterans, dependents, and other family members. The health care systems of both the Department of Defense and the Department of Veterans (...) Affairs execute their responsibilities to active duty service members, while their families and retirees/veterans are under separate legal authorities. Although they perform their mandates with extraordinary commitment and demonstrably high quality, both systems need to explore improved communication, coordination, and sharing, as well as increased collaboration with the Department of Health and Human Services programs serving the same populations, far beyond current efforts. The health care-related missions and the locus of health care delivery of each agency are admittedly unique, but their distinctions must not be permitted to impede system integration and coordination of a continuum of care provided to the men and women who serve the nation, and their families. (shrink)

Donald A. Barr's Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America (second edition, 2007) offers a lucid and informative overview of the U.S. health system and the dilemmas policy makers currently face. Barr has provided a balanced introduction to the way health care is organized, financed, and delivered in the United States. The thirteen chapters of the book are quite comprehensive in the topics they cover. Even (...) those knowledgeable about the U.S. health care system are likely to find much to stimulate their thinking in the text. The book can also appropriately serve as a basic text for a health policy course or in the medical or nursing school curriculum. (shrink)

Extensive media coverage of the nation’s response to its obligation to furnish health care for service members wounded in current overseas conflicts in Iraq and Afghanistan has elevated public consciousness of the importance of the U.S. military and veteran’s health care systems to a level not seen since the end of the Vietnam War. The number of casualties of U.S. military engagements has varied in each specific conflict and is a direct result of both the type (...) of battle and the military’s ability to handle battlefield injuries. (shrink)

Donald A. Barr's Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America (second edition, 2007) offers a lucid and informative overview of the U.S. health system and the dilemmas policy makers currently face. Barr has provided a balanced introduction to the way health care is organized, financed, and delivered in the United States. The thirteen chapters of the book are quite comprehensive in the topics they cover. Even (...) those knowledgeable about the U.S. health care system are likely to find much to stimulate their thinking in the text. The book can also appropriately serve as a basic text for a health policy course or in the medical or nursing school curriculum. (shrink)

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform. Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and (...) class='Hi'>health care systems in both countries reflect the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms. (shrink)

The current U.S. health care system, with both rising costs and demands, is unsustainable. The combination of a sense of individual entitlement to health care and limited acceptance of individual responsibility with respect to personal health has contributed to a system which overspends and underperforms. This sense of entitlement has its roots in a perceived right to health care. Beginning with the so-called moral right to health care, the issue (...) of who provides health care has evolved as individual rights have trumped societal rights. The concept of government providing some level of health care ranges from limited government intervention, a ‘negative right to health care’, to various forms of a ‘positive right to health care’. The latter ranges from a decent minimum level of care to the best possible health care with access for all. We clarify the concept of legal rights as an entitlement to health care and present distributive and social justice counter arguments to present health care as a privilege that can be provided/earned/altered/revoked by governments. We propose that unlike a ‘right’, which is unconditional, a ‘privilege’ has limitations. Going forward, expectations about what will be made available should be lowered while taking personal responsibility for one’s health must for elevated. To have access to health care in the future will mean some loss of personal rights and an increase in personal responsibility for gaining or maintaining one’s health. (shrink)

The greatest change, once it is accomplished, is simply the outcome of a vast series of adaptations and responsive accommodations, each to its own particular situation.”1It is in no way controversial to say that the U.S. health care system is failing to serve many of its citizens satisfactorily. While it is certainly true that most U.S. citizens are dissatisfied with our current health care system, creating agreement through open dialogue on what, more precisely, is (...) wrong with the system, as well as on what we should do to fix the system, seems to many to be impossibly optimistic. Leonard Fleck, professor of philosophy and medical ethics at Michigan State University and author of Just Caring: The Ethical .. (shrink)

This book focuses on justice and its demands in the way of providing people with medical care. Building on recent insights on the nature of moral perceptions and motivations from the neurosciences, it makes a case for the traditional medical ethic and examines its financial feasibility. The book starts out by giving an account of the concept of justice and tracing it back to the practices and tenets of Hippocrates and his followers, while taking into account findings from the (...) neurosciences. Next, it considers whether the claim that it is just to limit medical care for everyone to some basic minimum is justifiable. The book then addresses finances and expenditures of the US health care system and shows that the growth of expenditures and the percentage of the gross national product spent on health care make for an unsustainable trajectory. In light of the question what should be changed, the book suggests that overdiagnosis and medicalizing normal behavior lead to harmful, costly and unnecessary interventions and are the result of unethical behavior on the part of the pharmaceutical industry and extensive ethical failures of the FDA. The book ends with suggestions about what can be done to put the U.S. health care system on the path to sustainability, better medical care, and compliance with the demands of justice. (shrink)

has a wide range of options in choosing a health care system. Rational choice of a system depends on analysis and prioritization of the basis moral goals of equitable access to all citizens, the just sharing of financial costs between well and ill, respect for the values and choices of subscribers and patients, and efficiency in the delivery of costworthy care. These moral goals themselves, however, tell us little about what health care (...) class='Hi'>system the United States should have. Equitable access does not demand a level and scope of care for the poor equal to that rationally chosen by the middle class, and there are ways within mixed systems, though not easy ways, to achieve a fair distribution of costs between well and ill. Despite pluralistic systems' apparent advantage in allowing subscribers to choose their own forms of rationing, problems in translating serious long-term subscriber choices into actual medical practice may be greater in pluralistic than in unitary systems. Final choice of a system hinges primarily on peculiar historical facts about U.S. political culture, not on moral principle. Keywords: access to health care, autonomy, efficiency, equality, experience rating, national health insurance CiteULike Connotea Del.icio.us What's this? (shrink)

In the last few years, the U.S. health care system has seemingly been gripped by “back to the nineties” fever. But there is a notable change in professional debates about how to better control health care costs. Discussion of health care rationing, which was hotly debated in the nineties, has become much more muted.Is health care rationing passé? I contend that debates about health care rationing have waned not because (...) the need to ration has dwindled nor because ethical debates about how or whether to ration have been resolved. They have declined because the word “rationing,” and unrelated concepts such as cost‐effectiveness analysis, have been replaced by terms—“parsimony,” “value,” and “CER”—that are not burdened by emotional and historical baggage.Sometimes the best way to promote healthy moral debate is to turn to new words that don't carry the burden of past debates. (shrink)

Many observers claim that business has become a powerful force in medicine and that the future of health care cannot escape that reality, even though some scholars lament it. The U.S. recently experienced the most devastating recession since the Great Depression. As health care costs rise, we face additional pressure to rein in health care spending. We also have important new legislation that could well mark a significant shift in how health care (...) is provided and who has access to care, namely the Affordable Care Act. These changes underscore the need to bring new thinking to the conversation about health care and to move beyond conceptual and practical obstacles that inhibit our progress.In this paper we do not to claim to have solutions. Rather, our aim is to try to identify some obstacles to fostering a better conversation about the future of health care and to envisioning a better health care system. (shrink)

The emergence of Covid‐19 in the United States has revealed a critical weakness in the health care system in the United States. The majority of people in the nation receive health care via employment‐based health insurance from providers in a competitive market. However, neither employment‐based health care nor a competitive health care market can adequately provide treatment during a global pandemic. Employment‐based health care will fail to provide (...) class='Hi'>care for a large number of people in any destabilizing economic event, including a pandemic. Competitive for‐profit health care systems distribute limited goods based on markets rather than health care needs. If a global pandemic results in unusually high demand for specific medical supplies, then these will be distributed suboptimally. The combined risk of suboptimal distribution of needed goods and a significant drop in health care access in a global pandemic indicates that the U.S. health care system has serious vulnerabilities that need to be addressed. (shrink)

The complex regulatory framework governing the U.S. health care system can be an obstacle to programming that address health-related social needs. In particular, health care fraud and abuse law is a pernicious barrier as health care organizations may minimize or forego programming altogether out of real and perceived concern for compliance. And because health care organizations have varying resources to navigate and resolve compliance concerns, as well as different levels of (...) risk tolerance, fears related to the legal landscape may further entrench inequities in access to meaningful programs that improve health outcomes. This article uses food and nutrition programming as a case study to explore the complexities presented by this area of law and to highlight pathways forward. (shrink)

American health policy today faces dual problems of too little health coverage at too high a cost. The mix of public and private financing leaves about one seventh of the population without any insurance coverage. At the same time, the coverage Americans do have costs an ever-larger share of our country's productive capacity. This "paradox of excess and deprivation" results from the incremental approach the U.S. has taken to promoting incompatible policy goals of increasing health insurance coverage (...) and medical quality while trying to control costs, without squarely confronting tradeoffs. This essay examines the record of incremental developments and draws lessons for current efforts at reform. (shrink)

The ACA shifted U.S. health policy from centering on principles of actuarial fairness toward social solidarity. Yet four legal fixtures of the health care system have prevented the achievement of social solidarity: federalism, fiscal pluralism, privatization, and individualism. Future reforms must confront these fixtures to realize social solidarity in health care, American-style.

From a giant of health care policy, an engaging and enlightening account of why American health care is so expensive -- and why it doesn't have to be. Uwe Reinhardt was a towering figure and moral conscience of health care policy in the United States and beyond. Famously bipartisan, he advised presidents and Congress on health reform and originated central features of the Affordable Care Act. In Priced Out, Reinhardt offers an engaging (...) and enlightening account of today's U.S. health care system, explaining why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it. The problem, Reinhardt says, is not one of economics but of social ethics. There is no American political consensus on a fundamental question other countries settled long ago: to what extent should we be our brothers' and sisters' keepers when it comes to health care? Drawing on the best evidence, he guides readers through the chaotic, secretive, and inefficient way America finances health care, and he offers a penetrating ethical analysis of recent reform proposals. At this point, he argues, the United States appears to have three stark choices: the government can make the rich help pay for the health care of the poor, ration care by income, or control costs. Reinhardt proposes an alternative path: that by age 26 all Americans must choose either to join an insurance arrangement with community-rated premiums, or take a chance on being uninsured or relying on a health insurance market that charges premiums based on health status. An incisive look at the American health care system, Priced Out dispels the confusion, ignorance, myths, and misinformation that hinder effective reform. (shrink)

In an age of rapid advances inlife-prolonging treatment, patients and caregivers areincreasingly facing tensions in making end-of-lifedecisions. An examination of the history of healthcare in the United States reveals technological,economic, and medical factors that have contributed tothe problems of terminal care and consequently to themovement of assisted suicide. The movement has itsroots in at least two fundamental perceptions andexpectations. In the age of technological medicineenergized by the profit motive, dying comes at a highprice in suffering and in personal economic (...) loss. Thefailure to provide affordable resources for terminalcare is the result of the marketplace in health care. The medical profession has been painfully slow inresponding to the challenges of terminal care, mainlybecause of the pressures of the marketplace and lackof adequate training. This has occurred at a time ofrapid advances in life-sustaining treatment and ofexpanding public awareness of personal rights underthe law. Overly aggressive treatment in the finalstages of terminal illness has enhanced anxieties overa painfully prolonged and expensive dying. Thesefactors have promoted the movement to assistedsuicide. In the U.S. debate of the issues, ethiciststend to argue abstractly without examiningadequately the context of terminal care that is thehealth care system. It is a system in dire need of areform that will remove it from the marketplace. (shrink)

American health policy today faces dual problems of too little coverage at too high a cost. The mix of private and public financing leaves about one seventh of the population without any insurance coverage. At the same time, the coverage Americans do have costs an ever-larger share of our country’s productive capacity. The U.S. pays well above what other countries pay and what many people, health plans, businesses, and governments want to pay. This “paradox of excess and deprivation” (...) results from the incremental approach the U.S. has taken to promoting incompatible policy goals of increasing health insurance coverage and medical quality while trying to control costs, without squarely confronting tradeoffs. This essay examines the record of incremental developments and draws lessons for current efforts at reform. (shrink)

The most ambitious effort in many years to reform the U.S. health insurance system was signed into law earlier this year in Massachusetts. In the essay below, a health economist who advised the state on the reform describes the plan and how it unfolded. Five commentaries weigh its odds of success and ask whether it can provide a model for the nation.

The complexity and inefficiency of the U.S. health care system complicates the distribution of life-saving medical technologies. When the public health is at stake, however, there are alternatives. The proposal for a national PrEP program published in this issue of the Journal applies some of the lessons of the national COVID vaccine campaign to HIV prevention. In doing so, it draws on other examples of public health approaches to the financing of medical technology, from vaccines (...) for children to hepatitis C treatment. (shrink)

The Institute of Medicine reporting on the quality of health care in America recommends six aims for achieving the health care system we could have. Together with the Institute for Healthcare Improvement Triple Aim initiative, a framework has emerged to challenge providers, educators, and policymakers to remake the health care system according to specific objectives: to provide care that is safe, effective, patient-centered, timely, efficient, and equitable to more people at a (...) price we can afford. Complicating this mission of better prevention and better care at a lower cost is a daunting demographic: January of 2011 marked the month and year that the first of the baby boomers turned 65. The U.S. Census Bureau in May 2010 projected the number of Americans of this age and over to reach 88 million by 2050, more than double the current figure of 40.2 million. Parekh and Barton forecast in stark detail what it will be like to address these burgeoning numbers of older Americans with comorbidities, including the fact that over 20% of the population currently experiences at least two chronic medical conditions. (shrink)

Objectives To characterize the prevalence and content of pediatric triage policies.Methods We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators.Results Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children’s hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions (...) shared their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions.Conclusions While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities. (shrink)

Within health care systems, negative perceptions of lesbian, gay, bisexual, and transgender persons have often translated into denial of services, denial of visitation rights to same‐sex partners, reluctance on the part of LGBT patients to share personal information, and failure of workers to assess and recognize the unique health care needs of these patients. Other bureaucratic forms of exclusion have included documents, forms, and policies that fail to acknowledge a patient's valued relationships because of, for example, (...) a narrow definition of “spouse,” “parent,” or “family.” Bureaucratic exclusion has taken a particularly prominent form in the U.S. military. Until its repeal and termination in 2011, the “Don't Ask, Don't Tell” policy had for eighteen years barred openly gay men and lesbians from serving in the military. Among the effects of DADT is a dearth of information about the number and needs of LGBT service members who transition to the Veterans Health Administration for health care at the end of their military service. The long‐standing social stigma against LGBT persons, the silence mandated by DADT, and the often unrecognized bias built into the fabric of bureaucratic systems make the task of creating a welcoming culture in the VHA urgent and challenging.The VHA has accepted a commitment to that task. Its Strategic Plan for fiscal years 2013 through 2018 stipulates that “[v]eterans will receive timely, high quality, personalized, safe, effective and equitable health care irrespective of geography, gender, race, age, culture or sexual orientation.” To achieve this goal, the VHA undertook a number of coordinated initiatives to create an environment and culture that is informed, welcoming, positive, and empowering for the LGBT veterans and families whom the agency serves. (shrink)

In considering the challenges medical educators face in addressing the needs of today's health-care system, it is instructive to review the challenges Abraham Flexner (1910) was called upon to address at the turn of the last century. As Flexner surveyed the state of U.S. medical schools 100 years ago, he found a legacy system of medical education that was failing to prepare 20th-century physicians to meet the evolving needs and expectations of patients. That legacy system (...) was based largely on an outmoded apprenticeship model of education, was failing to incorporate the rapidly developing natural sciences, and to make matters worse, was devoid of external scrutiny and uniform standards by which medical schools .. (shrink)

: Although nothing could be less fashionable today than talk of comprehensive health care reform, the major problems of American health care have not gone away. Only a radical change in the way the U.S. finances health care--specifically, a single-payer system--will permit the achievement of universal coverage while keeping costs reasonably under control. Evidence from other countries, especially Canada, suggests the promise of this approach. In defending the single-payer approach, the author identifies several (...) political and cultural factors that make it difficult for Americans to obtain a clear view of this option. Finally, the author argues that much discussion of rationing is vitiated by bracketing more systemic questions to which the issue of rationing is inextricably linked. (shrink)

The legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity. In response to the increased interest in social justice, medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations. This paper aims to explore decolonising ideas of healing within medical education following recent events including the University College London Medical School’s Decolonising the Medical Curriculum public engagement event, the Wellcome Collection ’s Ayurvedic (...) Man: Encounters with Indian Medicine exhibition and its symposium on Decolonising Health, SOAS University of London’s Applying a Decolonial Lens to Research Structures, Norms and Practices in Higher Education Institutions and University College London Anthropology Department’s Flourishing Diversity Series. We investigate implications of ‘recentring’ displaced indigenous healing systems, medical pluralism and highlight the concept of cultural humility in medical training, which while challenging, may benefit patients. From a global health perspective, climate change debates and associated civil protests around the issues resonate with indigenous ideas of planetary health, which focus on the harmonious interconnection of the planet, the environment and human beings. Finally, we look further at its implications in clinical practice, addressing the background of inequality in healthcare among the BAME populations, intersectionality and an increasing recognition of the role of inter-generational trauma originating from the legacy of slavery. By analysing these theories and conversations that challenge the biomedical view of health, we conclude that encouraging healthcare educators and professionals to adopt a ‘ decolonising attitude ’ can address the complex power imbalances in health and further improve person-centred care. (shrink)

The U.S. health care system is ostensibly market based and therefore at least partially reliant on competition and consumer demand to regulate costs. Yet information about an essential feature of market transactions—costs—is typically obscure to patients until long after treatment. When discussing what must be disclosed for informed consent, the same list of required information is often mentioned regardless of the health care system in question, and information about costs rarely merits a place within (...) this list. However, our assumptions about what a moral principle requires need to be responsive to the realities of the health care system in which the principle is applied.This paper explores the moral foundations of disclosure and informed consent to argue that, in a market‐based system of the sort found in the United States, these same considerations support a requirement to disclose out‐of‐pocket costs before patients receive care. Next, I consider two objections to this view: first, that health care practitioners should focus solely on medical considerations in their encounters with patients and, second, that disclosing out‐of‐pocket costs would be too difficult to be mandated. I argue that medical and financial interests are inseparable within the U.S. health care system. If the difficulties in disclosing costs are deemed insurmountable, then the current system may prove unsustainable, both morally and financially, since we face the same practical impediments to implementing any meaningful consumer‐driven, market‐based health care reform. Finally, I explore some of the consequences of failing to disclose costs. The requirements of disclosing costs can be supported by the principle of respect for autonomy, regardless of the consequences, but in light of the consequences of the decision of whether to disclose, a concern about justice provides further support. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Managed Health Care: New Ethical Issues for All*Martina Darragh (bio) and Pat Milmoe McCarrick (bio)Changes in the way that health care is perceived, delivered, and financed have occurred rapidly in a relatively short time span. The 50-year period since World War II encompasses enormous growth in medical technology, soaring health care costs, and significant fragmentation of the two-party patient- physician relationship. This relationship (...) first grew to include the third-party payer, the health insurance industry, and now “with great speed and relatively little public awareness, a significant change has occurred in the way some decisions are made about a patient’s medical care” (III, Institute of Medicine 1989).The new means of providing health care bring an increasing number of parties into clinical decision-making processes. With this change, ethical issues that once concerned only health care professionals, the physician or the nurse, have expanded to include the patient and the groups who “manage” care—e.g., health maintenance organizations (HMOs), preferred provider organizations (PPOs), point of service groups (POSs), independent practice associations (IPAs), insurance reviewers, hospital administrators, institutional managers, and, the most recent players, purchasers of group health care who base their decisions on competitive pricing.The term “managed care” refers to a variety of continually adapting and developing arrangements that involve four groups. These groups, which have been labeled by the world of business, not health, are the “consumer” (once the patient), the “provider” (the physician and other health care professionals), the “insurer” (the reimburser for any care), and the “purchaser of care” or the primary buyer of health services (the large employer organization). Capitation is a common way to pay for health services in managed care systems. A certain dollar amount is negotiated for health services for a specified number of patients whether the care is delivered or not; the provider shares with the [End Page 189] insurer any financial risk for the actual cost of care (III, Centers for Disease Control 1995).When the Clinton administration’s health care reform movement failed to gain support in the U.S. Congress, the use of managed care to control rising health care costs accelerated. The literature on managed care and its effect on the patient-physician relationship reflects this shift. During the era of health care reform, “debate centered on how managed care could control costs, on the use of technology and patient satisfaction, [and] on access and barriers to care” (IV, Emanuel and Dubler 1995). When managed care organizations began contracting with physicians to provide health care services subject to the plans’ provisions, these plans became agents in clinical decision making on a wide-spread basis. HMO enrollment grew to 51 million persons by 1994 (III, Centers for Disease Control 1995). This “corporatization” of health care has sparked a plethora of articles about the effects of the marketplace on the physician’s ability to do what is best for the patient, and on the patient’s ability to trust the physician to do so.Many authors make it clear that managed care itself is not the problem, but rather the development of for-profit managed care plans by “corporate conglomerates with billions of dollars in assets that compensate their executives as grandly as basketball players” (V, Kassirer 1995) “in a marketplace that is largely unregulated” (I, Zoloth-Dorfman and Rubin 1995). “Some, mostly older plans that were created when cost containment was an unexpected benefit rather than their central purpose, deliver high-quality care economically. Unfortunately, others cut costs by recruiting the healthiest patients, excluding the sickest, rationing care by making it inconvenient to obtain, and denying care by a variety of mechanisms” (V, Kassirer 1995).These cost-containment features now play an intimate role in clinical practice. When a managed care plan contracts with a physician, the doctor becomes a “double agent” with contractual obligations to the plan to provide a preset amount of services and professional responsibilities to each patient to authorize necessary treatment (V, Angell 1993). This duality can undermine the physician’s fiduciary responsibility to the patient wherein the physician “has power over the affairs of [the patient]...and is required by law to act on that person’s... (shrink)

The United States health care industry is the second largest in the world, expending an estimated 479 million metric tons (MMT) of carbon dioxide per year, nearly 8 percent of the country's total emissions. The importance of carbon reduction in health care is slowly being accepted. However, efforts to “green” health care are incomplete since they generally focus on buildings and structures. Yet hospital care and clinical service sectors contribute the most carbon dioxide (...) within the U.S. health care industry, with structures/equipment and pharmaceuticals ranking as the third and fourth highest emitters in the industry. Given the magnitude of health care carbon emissions—and the paucity of attention to the carbon of hospital care and clinical services—this essay identifies overuse of health care as a health threat with serious ethical implications, offers a data‐driven action plan for carbon reduction in health care, and provides practical suggestions for more sustainable health care delivery in the United States. (shrink)

Various kinds of consumer-driven reforms have been attempted over the last 20 years in an effort to rein in soaring costs of health care in the United States. Most are based on a theory of moral hazard, which holds that patients will over-utilize health care services unless they pay enough for them. Although this theory is a basic premise of conventional health insurance, it has been discredited by actual experience over the years. While ineffective in (...) containing costs, increased cost-sharing as a key element of consumer-driven health care leads to restricted access to care, underuse of necessary care, lower quality and worse outcomes of care. This paper summarizes the three major problems of U.S. health care urgently requiring reform and shows how cost-sharing fails to meet that goal. (shrink)

Through the Louisiana Purchase in 1803, the United States expanded its size by over 800,000 square miles. But neither President Thomas Jefferson nor Congress knew exactly what they had bought until 1806, when Meriwether Lewis and William Clark returned from their famous expedition. One of the most significant contributions of the Expedition was a better perception of the geography of the Northwest. Lewis and Clark prepared approximately 140 maps and filled in the main outlines of the previously blank map of (...) the northwestern United States. Robert I. Field has done much the same for the vast territory of U.S. health care regulation.On the front cover of Fields new book, Health Care Regulation in America: Complexity, Confrontation, and Compromise, is a picture of a giant three-dimensional labyrinth. Rarely is cover art so perfectly appropriate. (shrink)

The U.S. Supreme Court held, in American Manufacturers Mutual Insurance Co. v. Sullivan, 119 S. Ct. 988, that state workers’ compensation system insurers cannot be sued for withholding health care benefits for work-related injuries while they decide whether the treatment is “reasonable” and “necessary.” The respondents, ten employees and two organizations representing employees who received medical benefits under the Workers’ Compensation Act, brought a 42 U.S.C. § 1983 action against state officials, the Pennsylvania State Workers’ Insurance (...) Fund, private insurers, and the school district, alleging that their due process rights were violated by provisions of the Pennsylvania Workers’ Compensation Act, 77 Pa. Cons. Stat. Ann. § 1 et seq.. The Act permits suspension of benefits without notice or opportunity to be heard pursuant to a “utilization review” process.To control costs, Pennsylvania amended its workers’ compensation system in 1993. Under the Act, an employer or its insurer must pay for all reasonable and necessary medical treatment. (shrink)

Medicine and health are surprisingly separate. In the introduction to his 1963 master work on medical economics, Kenneth Arrow acknowledged that “the subject is the medical-care industry, not health.” In the 50 years that followed, researchers, policymakers, and public health professionals generated valuable and varied insights into health, impacting both behaviors and environments while addressing social determinants and demographic trends. Yet medical care has followed an even steeper upward trajectory, growing rapidly in scientific precision, (...) public esteem, and technical sophistication.As a result, the economic gap between the two domains has widened. The U.S. health care system spends almost $3 trillion annually. Preventive screening and early intervention bridge medical care and health, as do nutrition, behavioral health, aging, and a few other fields. But the money is overwhelmingly in medical care, particularly rescue care for those with acute illnesses or serious complications of chronic disease. (shrink)