Obesity is a particularly vexing public health challenge, since it not only underlies much disease and health spending but also largely stems from repeated personal behavioral choices. The newly enacted comprehensive health reform law contains a number of provisions to address obesity. For example, insurance companies are required to provide coverage for preventive-health services, which include obesity screening and nutritional counseling. In addition, employers will soon be able to offer premium discounts to workers who participate (...) in wellness programs that emphasize behavioral choices. These policies presume that government intervention to reduce obesity is necessary and justified. Some people, however, argue that individuals have a compelling interest to pursue their own health and happiness as they see fit, and therefore any government intervention in these areas is an unwarranted intrusion into privacy and one's freedom to eat, drink, and exercise as much or as little as one wants. This paper clarifies the overlapping individual, employer, and social interest in each person's health generally to avoid obesity and its myriad costs in particular. The paper also explores recent evidence on the impact of government interventions on obesity through case studies on food labeling and employer-based anti-obesity interventions. Our analysis suggests a positive role for government intervention to reduce and prevent obesity. At the same time, we discuss criteria that can be used to draw lines between government, employer, and individual responsibility for health, and to derive principles that should guide and limit government interventions on obesity as health reform's various elements (e.g., exchanges, insurance market reforms) are implemented in the coming years. (shrink)

The obesity epidemic is not only impairing the health of millions of Americans but also giving rise to billions of added dollars in health care spending. Climbing rates of obesity over the past decades are one of the predominant determinants behind the surging progression of health care expenses in the United States. Moreover, the less fit and less productive U.S. workforce has gradually eroded the nation’s industrial competitiveness. Since the early 1970s, adult obesity rates have doubled and (...) childhood obesity rates have more than tripled, while health expenditures have risen two percentage points faster than the Gross Domestic Product, burgeoning from 8.8 percent in 1980 to a projected 17.9 percent in 2011. Studies analyze that greater than a quarter of America’s health care expenses are attributed to obesity. The stunning growth in obesity has been imputed for 20 to 30 percent of the increase in health care costs since the late 1970s. If the proportion of obese population had stayed unchanged, then health care expenditures in America would be approximately 10 percent less on a per capita average than they are today. (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: a principle of social justice, the Just Sharing of the costs of illness, and 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 (...) class='Hi'>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 , 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)

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)

We are never illness or disease, but, rather, always their sum in the world of day-to-day experience. Disease and illness are not closed systems, but mutually constitutive and continuously interacting worlds. In the patient’s case it is always experience as well. Pain, sickness and death help make that particular experienced identity unavoidable, and at some level ultimately inaccessible to medicine’s changing understanding of disease and tools for managing it. Health—rather than cost containment, specific conditions, or technologies—should be the central (...) focus for health care and health-care reform. A compelling reason to focus on health comes from the observation that the prevalence of disease over the .. (shrink)

Worldwide, healthcare has been touched by neoliberal policies to the extent that it has some of its characteristics, such as being asymmetrical, competitive, dehumanized, and profit driven. In Colombia, Law 100/93 was created as an ambitious reform aimed at integrating the social security and public sectors of healthcare in order to create universal access, and at the same time to generate market competence with the objective of improving effectiveness and responsiveness. Instead, however, Colombian health reform has served (...) to generate competition which has aggravated inequalities among people. Within this context, we practice nursing. As nurses, our responsibility is to advocate for our patients. We cannot ignore what is happening worldwide in hospitals and community health settings because our responsibility is to promote health, prevent disease, and care for human beings. So, today, when the world pushes for economical profit and competence on one hand, and, on the other, for moral compromises to care, respect, and advocacy for all human beings, being a nurse in the Colombian health system represents a challenge for us. This challenge is especially significant because harm and benefit, justice and injustice, respect and disrespect are separated by a fine line that is easy to transgress. (shrink)

Most writers now recognize that mental health policy and the mental health system are extremely resistant to real changes that reflect genuine biopsychosocial paradigms of mental disorder. Writers bemoaning the intransigence of the mental health system tend to focus on a small analytical level, only to find themselves mired in the rationalities of the existing system. Problems are acknowledged to be system-wide, yet few writers have used a method of analysis appropriate for systemic (...) problems. Drawing upon the General System Theory (GST) analytical perspective, this article advances a systematic approach to understand the mental health system and to facilitate the development of reform strategies that recognize the system's complexity and changing nature. The article first discusses the failure of major reform efforts in the mental health system and the limitations of mainstream analysis of mental health politics and policies with respect to the objectives of analysis and reform. This article describes how systems thinking has thus far influenced the study of the mental health policy and politics system, and argues that a systemic perspective is profitable for reconceiving the mental health system, enabling a fresh basis for the development of reform strategies. The mental health system should be seen as a social system influenced by larger political and economic dimensions, not just as a 'delivery system' scientifically constructed by neutral experts. Furthermore, the policy planning process should be viewed as part and parcel of a mental health system modeled as complex and dynamic. The systemic perspective outlined here should help both to clarify the value-based objectives that we hold for the system and, consequently, to plan for the strategic reforms that have so far eluded us. (shrink)

Debates over health care have focused for so long on economics that the proper goals for medicine seem to be taken for granted; yet problems in health care stem as much from a lack of agreement about the goals and priorities of medicine as from the way systems function. This book asks basic questions about the purposes and ends of medicine and shows that the answers have practical implications for future health care delivery, medical research, and the (...) education of medical students. The Hastings Center coordinated teams of physicians, nurses, public health experts, philosophers, theologians, politicians, health care administrators, social workers, and lawyers in fourteen countries to explore these issues. In this volume, they articulate four basic goals of medicine — prevention of disease, relief of suffering, care of the ill, and avoidance of premature death — and examine them in light of the cultural, political, and economic pressures under which medicine functions. In reporting these findings, the contributors touch on a wide range of diverse issues such as genetic technology, Chinese medicine, care of the elderly, and prevention and public health. The Goals of Medicine clearly demonstrates the importance of clarifying the purposes of medicine before attempting to change the economic and organizational systems. It warns that without such examination, any reform efforts may be fruitless. (shrink)

ABSTRACTThe health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance . In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee (...) education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives. (shrink)

THERE IS WIDESPREAD DISSATISFACTION WITH THE HEALTH CARE SYSTEM in this country. This essay outlines why. It then reviews and evaluates the contributions of the faith community to the discussions of health care reform to assess whether the perspective and contributions of religious actors are distinct from secular approaches. Finally, it proposes different emphases for the religious community's future involvement with health care reform.

The COVID-19 pandemic has brought to light significant failures and fragilities in our food, health, and market systems. Concomitantly, it has emphasized the urgent need for a critical re-evaluation of many of the policies and practices that have created the conditions in which viral pathogens can spread. However, there are many factors that are complicating this process; among others, the uncertain, rapidly evolving, and often poorly reported science surrounding the virus’ origins has contributed to a politically charged and often (...) rancorous public debate, which is concerning insofar as the proliferation of divisive discourse may hinder efforts to address complex and collective concerns in a mutually cooperative manner. In developing ethical and effective responses to the disproportionate risks associated with certain food production and consumption practices, we argue that the focus should be on mitigating such risks wherever they arise, instead of seeking to ascribe blame to specific countries or cultures. To this end, this article is an effort to inject some nuance into contemporary conversations about COVID-19 and its broader implications, particularly when it comes to trade in wildlife, public health, and food systems reform. If COVID-19 is to represent a turning point towards building a more equitable, sustainable, and resilient world for both humans and nonhuman animals alike, the kind of fractioning that is currently being exacerbated by the use of loaded terms such as “wet market” must be eschewed in favour of a greater recognition of our fundamental interconnectedness. (shrink)

Instead of benefitting from open meetings and public discussions, the Clintons drafted their health care plan in private and asked that it be accepted in haste. They advance an ideology that claims we can receive the best care for all without any increase in cost or rationing, and then they use "ethicists" to justify this ideology through a supposedly common morality. However, there is no such common morality. In the context of American pluralism, one must look to the actual (...) consent of the governed and recognize the limits on state authority. The result will be a two tiered system of health care, with a basic tier focusing on cost-effective care for the poor that eliminates suffering rather than equalizing inputs, and a space for collateral private insurance. Keywords: Clinton health plan, egalitarianism of envy, egalitarianism of altrusim, limited democracy, moral pluralism CiteULike Connotea Del.icio.us What's this? (shrink)

Hong Kong is undergoing a public debate on the need to reform and future directions of reforming its health care system. This paper highlights the debates and considerations brought up by the Hospital Authority, the largest provider of public health care in Hong Kong, on the ethical principles and societal values underlying the upcoming reform. It is recognized that the exact meanings behind each ethical principle and value must be debated and clarified during the (...) class='Hi'>reform process. In a modern day society like Hong Kong, societal values are likely to be diversified. A health care system also has to fulfil different and often conflicting objectives of equity, efficiency, quality and choice. It would be difficult for a health care system to satisfy these different values and objectives based on a single value parameter. The Hong Kong experience shows that a society may prefer a combination of strategies in addressing different societal values. The re-structuring of the health care system in Hong Kong should therefore be based on a balanced and optimum combination of various financing and delivery strategies. (shrink)

The need for change in the system of health care delivery in the United States has finally emerged as a political issue alongside continuing budget deficits, a growing national debt, declining educational outcomes, and decreased competitiveness of American business in the global economy. The two most pressing health care problems at the present time are rapidly increasing costs and lack of access to the system. A more distant but potentially more recalcitrant problem is the ageing of (...) our population. This paper outlines and discusses some of the options for reform which are currently under consideration in the United States. (shrink)

The United States is culturally oriented more toward individual rights and values than to communitarian values. That proclivity has made it hard to develop a common good, or solidarity-based, perspective on health care. Too many people believe they have no obligation to support the health care of others and resist a strong role for government, higher taxation, or reduced health benefits. I argue that we need to build a communitarian perspective on the concept of solidarity, which has (...) been the concept underlying European health care systems, by focusing not on individual needs, but rather, on those of different age groups—that is, what people need at different stages of life. (shrink)

The purpose of this paper is to examine the outcomes arising from ideologically driven health reforms, which confronted an enduring socialized model of public health care in New Zealand. The primary focus is on the narratives arising from the unprecedented strike action of junior doctors, symbolic of industrial unrest in the public health sector. Analysis revealed the way in which moral obligations ingrained in the professional identities of junior doctors can be both enacted and persistently challenged by (...) ongoing and extensive ideologically embedded reform. A socialized public healthcare system privileges cooperation and relies on a public service ethos, espousing commitment and goodwill of health professionals. The inverse tenets of a pursuit of efficiency through New Public Management validate an ideology of market principles which legitimate competitive and self-interested behavior. The value-based disconnect that occurred not only affected the goodwill and trust of junior doctors, but also destabilized their commitment to their work in a way that threatened the ongoing sustainability of the public health service. This paper suggests four areas in which research might help solve the ethical conundrums currently undermining a public health service. The suggested direction moves the emphasis on systems and activities toward the cognitive and emotional needs of healthcare professionals. (shrink)

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)

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government regulations tend (...) to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

Throughout the post-World War II decades, the United States has wrestled in its own unique style with a problem that is shared by all modern societies: how to achieve a reasonably equitable distribution of health care, without losing control of total spending on health care, and without suffocating the delivery system with controls and regulations that inhibit technical progress.Because an equitable distribution of health care inevitably requires at least some government regulation, and because government regulations tend (...) to impose rigidity on any system, it is widely believed in the United States that a trade-off actually exists between fairness in the distribution of care and the health system’s ability to innovate. This troublesome trade-off bedevils American policy makers to this day. (shrink)

It is generally agreed that the current methods of providing health care in the West need to be reformed. Such reforms must operate within the practical limitations to which any future system of health care will be subject. These limitations include an increase in the demand for costly end-of-life health care coupled with a reduction in the proportion of the population who are working taxpayers (and hence a reduction in the proportionate amount of health care (...) funding that can be secured through taxation) and the fact that the imposition of bureaucratic regulations on health care systems is costly. Recognizing these limitations should naturally lead one to consider market-based reforms. Yet despite the practical impetus for such reforms, there is still widespread concern that market-based health care is unethical. The purpose of this paper is to address this concern and, in so doing, to pave the way for the market-based reform of health care to proceed. (shrink)

In most other nations, insurance for medical care is called sickness insurance, and it covers sick people. In the United States, we have “health insurance,” and its major carriers — commercial insurers, large employers, and increasingly government programs — strive to avoid sick people and cover only the healthy. This perverse logic at the heart of the American health insurance system is the key to reform debates.Focusing on sick people versus healthy people might seem a strange (...) way to view the coverage issue. Most discussions of insurance categorize people into other groupings: the insured versus the uninsured; Caucasian whites versus other racial and ethnic groups; men versus women; poor and low-income people versus everybody else; children, adults, and the elderly; or citizens versus immigrants and undocumented aliens. More recently, health researchers have begun talking about “vulnerable populations,” using most of the same demographic groupings and adding other illness-inducing factors such as social isolation, stress, and impoverished neighborhoods. But as I will show, insurance plans now use premiums, cost-sharing, and other design features in ways that indirectly divide each of these groups into the sick and the healthy, to the detriment of the sick. By shifting the costs of illness onto people who use medical care — that is, sick people — market-oriented reforms of the last few decades have eroded insurance in the name of strengthening it. (shrink)

The Harvard Report, published in April 1999 for public consultation in Hong Kong, proposed a fundamental restructuring in its health care delivery and financing systems. The Report claims to be evidence-based in its approach (Hsiao et al., 1999a). While 'evidence' has been widely collected by the consultancy team through surveys, consultations and focus groups, the recommendations put forth are not value-free. They carry clear ideological preferences. The value assumptions and ethical presuppositions underlying the report are discussed in this paper. (...) The Harvard consultancy study is in favor of a positive government role in regulation and control, a single central body to administer compulsory health insurance for all citizens, and a purchaser-provider split to induce competition. Such preference is based on pre-existing ideology and generic health care management concepts, which are still in the experimental phase internationally. While value and ideology are inevitable factors in any policy choice, the challenge is to lay these values open for reflection and public debate. For Hong Kong, the challenge is also to take on local substantive issues in health care and deal with them head-on, rather than putting hope in a universal, generic solution. (shrink)

Food security, health, decent livelihoods, gender equity, safe working conditions, cultural identity and participation in cultural life are basic human rights that can be achieved at least in part through the food system. But current trends in the US prevent full realization of these economic, social, and cultural rights (ESCR) for residents, farmers, and wageworkers in the food system. Supply chains that strive to meet the goals of social justice, economic equity, and environmental quality better than the (...) dominant globalized food value networks are gaining popularity in the US. However, achieving important human rights has become conflated with other goals of food system reform over the past decade, such as being “community-based,” local, and sustainable. This conflation confuses means, ends, and complementary goals; and it may lead activists trying to help communities to regain control of their food system choices into less productive strategies. This paper introduces a new concept, rights-based food systems (RBFS), and explores its connection with localization and sustainability. The core criteria of RBFS are democratic participation in food system choices affecting more than one sector; fair, transparent access by producers to all necessary resources for food production and marketing; multiple independent buyers; absence of human exploitation; absence of resource exploitation; and no impingement on the ability of people in other locales to meet this set of criteria. Localization and a community base can help achieve RBFS by facilitating food democracy and reducing environmental exploitation, primarily by lowering environmental costs due to long-distance transportation. Sustainability per se is an empty goal for food system reform, unless what will be sustained and for whom are specified. The RBFS concept helps to clarify what is worth sustaining and who is most susceptible to neglect in attempts to reform food systems. Localization can be a means toward sustainability if local food systems are also RBFS. (shrink)

Are values and social priorities universal, or do they vary across geography, culture, and time? This question is very relevant to Asia’s emerging economies that are increasingly looking at Western models for answers to their own outmoded health care systems that are in dire need of reform. But is it safe for them to do so without sufficient regard to their own social, political, and philosophical moorings? This article argues that historical and cultural legacies influence prevailing social values (...) with regard to health care financing and resource allocation, and that the Confucian dimension provides a helpful entry point for a deeper understanding of ongoing health care reforms in East Asia – as exemplified by the unique case of Singapore. (shrink)

This article examines the barriers to quality health care for transgender, nonbinary, and gender-expansive people (TGE) who become pregnant and give birth, identifying three central themes that emerge from the literature. These insights suggest that significant reform will be necessary to ensure access to safe, appropriate, gender-affirming care for childbearing TGE people. After illustrating the need for systemic changes that untether rigid gender norms from the provision of perinatal care, the article proposes that the Midwives Model of Care (...) offers a set of values and clinical practices that are well-suited to meet the needs of many TGE patients during pregnancy and childbirth and which should be incorporated into the healthcare system more broadly. (shrink)

Health care reform poses numerous challenges. A core challenge is to make health care more efficient and effective without causing more harm than benefit. Additionally, those fashioning health-care policy must encourage patients to exercise caution and restraint when expending scarce resources; restrict the ability of politicians to advance their careers by promising alluring but costly entitlements, many of which they will not be able to deliver; face the demographic challenges of an aging population; and avoid regulations (...) that create significant inefficiencies and restrict access to health care. Given such real-world challenges, how should health care be reformed in the United States or elsewhere? This number of The Journal of Medicine and Philosophy examines many of the complex issues that must be considered in reforming a health-care system. (shrink)

This paper aims to provide a rendition of the care ethic in Confucian philosophy and to argue that social policy developments in Hong Kong society, including health care policy, have been significantly shaped and justified in terms of the ideal of care in the Confucian moral tradition. On the basis of this analysis, the paper raises a number of questions about a recent proposal for health care reform for Hong Kong put forth by the Harvard School of (...) Public Health which argues for adopting the principle of equity as the overriding value for the moral foundation of Hong Kong's health care system. The paper examines how the over-emphasis on equity in the Harvard Report proposals can lead to the erosion of care and ultimately the eclipse of the vision of care in Hong Kong's health care system. It argues that the pursuit of equity, which is itself a valuable principle, should not displace the importance of the value of care or undermine the ideal of care and that health care decisions must be firmly embedded in local cultures and moral traditions. (shrink)

In 2017, Americans spent over $3.4 trillion-nearly 18% of gross domestic poduct-on health care. This spending is unevenly distributed: Almost a quarter is spent on the costliest 1% of patients, and almost half on the costliest 5%. Most of these patients soon return to a lower percentile, but many continue to incur health care costs in the top percentiles year after year. This Article focuses on the challenges that persistently expensive patients present for health law and policy, (...) and how fairly dividing their medical costs among payers illuminates fundamental normative choices about the design and reform of health insurance. In doing so, this Article draws on bioethical and health policy analyses of the fair distribution of medical costs, and examines how legal doctrine shapes health systems' options for responding to expensive patients. Part I of this Article discusses two real-world examples of expensive patients and the debate surrounding them, including the case of an Iowa teenager with hemophilia whose treatments cost more than $10 million per year. Part II then examines the normative question of how the costs of treating expensive patients' medical conditions should be shared and identifies three different dimensions of sharing: (1) scope, from narrow (plan members only) to broad (all of society); (2) boundedness, whether there are limits on the costs others can be asked to bear; and (3) progressivity, whether wealthier individuals are asked to bear more costs (similar to progressivity in tax). Part III then considers how health care reform choices could advance or hamper the adoption of broad, bounded, progressive sharing, with a focus on recent state-level reinsurance programs that legal scholarship has not yet analyzed in depth. This Article contributes to the literature on health care reform in three interlocking ways. First, it develops a novel proposal for fairly sharing the cost of expensive patients' care that could usefully inform state- and federal-level policy discussions. Second, it provides a normative, rather than purely political or economic, analysis of existing and proposed options for sharing expensive patients' costs. Third, it bridges the disconnected literature on reinsurance, limit setting, and health care financing, identifying how proposals in these different areas intersect. (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)

The health care industry has moved at a rapid pace away from paper records to an electronic platform across almost all sectors — much of it at the encouragement and insistence of the federal government. Such rapid expansion has increased exponentially the risk to individuals in the privacy of their data and, increasingly, to their physical well-being when medical records are inaccessible through ransomware attacks. Recognizing the unique and critical nature of medical records, the United States Congress established the (...) Health Care Industry Cybersecurity Task Force under the Cybersecurity Information Sharing Act of 2015 for the purpose of reviewing cybersecurity risks within the health care industry and identifying who will lead and coordinate efforts to address such risks among the various agencies. The Task Force has since issued a report setting forth six high-level imperatives that the health care industry needs to achieve in order to combat cybersecurity, and, notably, many of the vulnerabilities plaguing the industry identified in the Report as requiring correction are not necessarily related to specific flaws in the current cybersecurity framework, but rather susceptibilities presented by the infrastructure and associated regulatory regime that has evolved over the last few decades over the health care industry generally. That is, the current health care infrastructure by its nature exacerbates cybersecurity risk. Between a lack of information sharing of industry threats, risks, and mitigations, disparate leadership and governance goals for cybersecurity, the confluence and contradiction of existing federal and state laws, fragmentation in the fee-for-service delivery system, lack of care coordination, and disparate resources across and among sectors, the industry suffers from heightened cyber risk. Solutions that are reactive to problems within the current infrastructure will likely have little long term impact toward reducing cybersecurity vulnerabilities because they do not address the underlying system challenges. All of these confluences causes one to wonder whether if in fact the current health care delivery infrastructure is a contributing factor to the incidents of cybersecurity attacks and the exorbitant costs associated with resolving data breaches, should Congress look not just to curb breach incidents, but to address root cause systematic challenges in the health industry infrastructure that create increased exposure of cybersecurity threats? This article argues that cybersecurity risks will continue to be heightened and more costly to the health care industry as compared to other industries unless and until some general system redesign is achieved that allows for greater sharing of resources among industry participants to ensure the same protections are implemented at all levels of the industry, which can be strengthened through greater interoperability of systems across the health care industry; and increased focus and attention on the importance of cybersecurity issues as a priority among system reforms. (shrink)

The current health care system is not operating with a properly functioning market. Health care costs are hidden and often shifted, consumers and providers are insulated from the economic consequences of their decisions, and costs therefore go up dramatically. Instead of attacking both the structural deficiencies and the consequent inequities of the current employer based insurance system, the Clinton Plan simply expands them, and adds a heavier level of government regulation. The ultimate choice for the public (...) is between a health care system based on consumer choice or a government controlled system. In pursuing a market based health care reform that enhances personal freedom and responsibility, two ethical principles are served. First, American consumers will be made aware of the true costs of health care services, and market forces will thus introduce incentives on the part of providers to control costs. Second, justice will be served; for not only will providers of medical services receive their due, but public policy makers can target relief more effectively to those who need it most. Keywords: Clinton health plan, free market, freedom, responsibility CiteULike Connotea Del.icio.us What's this? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working on the Clinton Administration's Health Care Reform Task ForceNancy Neveloff Dubler (bio)This narrative is based on my understanding of the elements of the Health Security Act that may have ethical implications. I have reconstructed these elements from my experience on the Health Care Reform Task Force and they are part of the health care plan that the President presented to Congress. (At (...) the time this article went to press, the actual legislation, which should answer my remaining specific questions more clearly, had not yet been released.) I perceive the most important features of the plan to be:• The legislation will create a "right" to health care for all citizens—access to care will be universal;• The plan will involve some form of managed competition in which groups of providers (called Approved or Accredited Health Plans (AHPs)) will offer comparable benefit packages at slightly (or widely) different costs;• The AHPs will negotiate with the Health Alliance (HA) to determine the price that they will charge their consumer-patients;• There will be open enrollment with no barriers to coverage, such as exclusions for pre-existing conditions;• Community rating will be in effect in different localities and enrolled persons in any AHP will pay the same premium;• The coverage for any enrolled person will be portable;• The overall structure will be a cooperative federal/state enterprise in which the states will have quite extensive abilities to fashion variations of the basic plan to meet their particular needs;• Primary care will be encouraged and incentives for physicians to train in primary care specialties provided;• Non-physician providers will be central to the functioning of the health care plans;• Efforts will be made to develop a "person power" pool so that people with an abstract "right" to health care will have real access to providers, in their localities, who can fulfill the promise that the right creates; [End Page 421]• The goal of cost containment will be central to the organization and regulation of the system;• Administrative simplicity and quality protections will be central.Co-chairing the Bioethics Working Group (BWG) of the White House Task Force on Health Care Reform was a unique experience. Approximately 40 Task Force working groups were established by Hillary Rodham Clinton, the President, and the senior Task Force staff. Various members of the President's office and other knowledgeable members of the Executive Branch selected the participants. In our group, appointments were made largely on the recommendations of the co-chairs. The BWG, among the last of the groups formed, carried the official name "The Working Group on the Ethical Foundations of the New System" and was jointly led by me and Marion Gray Secundy, a Professor of Bioethics at Howard University. The fact that the leadership of the Task Force saw fit to establish such a group, thereby confirming that bioethics is a player in the arena of health care policy, was in itself significant and was made no less so by the lack of clarity regarding the group's aims and goals.The working groups of the Task Force were organized into clusters, determined by the relatedness of the somewhat distinct, but always overlapping, content of their investigations. Separate clusters and working groups, for example, looked at mental health, long term care, and the benefit package and coverage for low-income and non-working families. On this last issue there was also a working group that explored health policy initiatives for underserved populations. This multiple focus on related issues proved to be an excellent method for ensuring that the complexity of these topics was sufficiently explored. There was a published schedule for when these groups met together, and members of other groups who had similar or overlapping concerns were invited to attend and to participate.Every week or so, all of the working groups reported to the Task Force leadership, under the direction of Ira Magaziner, in a process called a "tollgate." Prior to the tollgate, the working groups were required to submit formal written analyses of the problems they had most recently been considering. Copies of these documents were placed in a special room so that those who were interested could review... (shrink)

In this essay, I explore John Stuart Mill’s theory of government and its application to the issue of health care reform. In particular, I ask whether Mill’s theory of government would justify or condemn the creation of a public health-insurance option. Although Mill’s deep distrust of governmental authority would seem to align him with Republicans, Tea Partiers, libertarians, and others, who cast the public option as a “government takeover” of “our” health care system, I argue (...) that Mill offers good reasons for seriously considering some form of government-operated health insurance. For Mill theorizes government as having a positive as well as a negative role to play in people’s lives, and he explicitly endorses “public options” in different areas of life. According to his theory of government, a public health-insurance option would be just as long as it would meet the following two conditions: (1) it would not invade the “reserved territory” of individual liberty; and (2) “the case of expediency is strong.” I argue that a public option would in fact meet both of these conditions, and that Mill would have likely endorsed it as an effective solution to the current health care crisis in the United States. (shrink)

The health care systems in Austria, Germany and Switzerland owe their institutional structure to different historical developments. While Austria and Germany voted for the Bismarck-Model of social health insurance,Switzerland adopted a voluntary system of health insurance. In all three countries, until very recently, the different challenges which the healthcare sector faced were met by piecemeal approaches and by stop and go policies, which, in the long run were not very successful either in containing costs or in (...) improving efficacy and efficiency. During the 1990 more fundamental reforms in the health care systems of all three countries took place. Germany and Switzerland chose the path of deregulation of the health insurance system, which consequently strengthened the competition between the insurance companies, and, to some extent between the suppliers of medical services. While this can be seen as an essential part of the reform process for these two countries, Austria favors a state-oriented and interventionist approach in order to meet the challenges. (shrink)

The “Father of the United States Constitution,” James Madison, once described justice as “the end” of both government and of civil society. Yet curiously, Madison said little about justice in elaborating the principles of American federalism in The Federalist Papers and elsewhere. His fundamental concerns, to the contrary, were in contriving a system of separated, countervailing powers and in establishing a first federal principle of enumerated powers — in which federal powers “are few, and defined.” This strategy, for Madison, (...) was the most feasible way of checking the innate tendency of political power to accumulate, centralize, and trample on citizens’ liberties. (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)

It is frequently claimed that nursing is vital to the safe, humane provision of health care and health service to our populations. It is also recognized however, that nursing is a costly health care resource that must be used effectively and efficiently. There is a growing recognition, from within the nursing profession, health care policy makers and society, of the need to analyse the contribution of nursing to health care and its costs. This becomes increasingly (...) pertinent and urgent in a situation, such as that existing in Ireland, where the current financial crisis has lead to public sector employment moratoria, staff cuts and staffing deficits, combined with increased patient expectation, escalating health care costs, and a health care system restructuring and reform agenda. Such factors, increasingly common internationally, make the identification and effective use of the nursing contribution to health care an issue of international importance. This paper seeks to explore the nature of nursing and the function of the nurse within a 21st century health care system, with a focus on the Irish context. However, this analysis fits into and is relevant to the international context and discussion regarding the nursing workforce. This paper uses recent empirical studies exploring the domains of activity and focus of nursing, together with nurses perceptions of their role and work environment, in order to connect those findings with core conceptual questions about the nature and function of nursing. (shrink)

The Affordable Care Act is an essential first step toward making health insurance more affordable for lower and moderate income Americans. It has accomplished historic reductions in the proportion of Americans who are uninsured. The number of Americans reporting delaying medical care for financial reasons has declined by approximately one-third since 2010. Medicaid expansions, in particular, have significantly reduced financial burdens and accompanying anxieties experienced by low-income Americans in states that have embraced this opportunity. Consistent with these finding, one (...) recent analysis of credit report data finds that Medicaid expansion was associated with between a $600 and $1000 decline in collection balances among individuals who gained coverage. Notwithstanding these gains, premiums and cost-sharing are still too high for many Americans. And cost-sharing has continued to edge higher for the majority of Americans who have coverage through employer-based plans. Measures to address these challenges must build on the ACA to provide greater protection to millions of Americans and to address continued dissatisfaction with our health care financing system among middle-income Americans. (shrink)

Background Metaphors are central to the human understanding of complex issues; through the immediate associations they evoke and frame problems and suggest solutions. Our suggestion of Music in the Park as a metaphor for health systems reform brings to the forefront the environmentally diverse but bounded spaces of health services that offer a variety of attractors within their confines, while pushing into the background organizational and economic concerns.Reflections Parks, like health services, are embedded in their local (...) landscape, serving their communities, but most importantly parks are public spaces, publically funded, ideally offering universal access and equity and to be shared by all who want to go there.Music, like health, is tangible, technical and scientific, yet ultimately experiential and based on meaning. While it encompasses a wide range of styles and approaches, music making requires as its most important skill active listening which brings with it to be ‘in the moment’, to take personal risks and to draw energy and inspiration from the participants. Hence ‘audiences’ are equally active participants because music only has meaning if it internally resonates with the listener and only can exist in what is a co-constructed experience.Conclusions Music in the Park is a metaphor for primary health care systems based on shared values of experts and unique local communities. Health professionals are players in this arena, who develop and practise the full range of their skills in response to individual and community needs and preferences. Their leadership works through inspiration and empowerment, making patients ‘co-producers’ of their own health and ‘co-shapers’ of their health services. (shrink)

The National Conference of Catholic Bishops has argued for significant government involvement in health care in order to assure respect for what they regard as the right to health care. Critics charge that the bishops are wrong because health care is not a right. In this article, it is argued that these critics are correct in their claim that health care is not a right. However, it is also argued that the premise that health care (...) is not a right does not imply that the market is the most equitable and just system for providing health care. Natural law arguments in the tradition of Roman Catholic social teaching lead to the conclusion that a just and prosperous society has a moral obligation to provide health care even if there is no such right. Further, there are strong moral grounds for concluding that the bishops are correct in their claim that health care ought not to be considered a market commodity. It is argued that if health care ought not to be considered a commodity, then national health insurance is the best available alternative for fulfilling the social obligation to distribute health care resources justly and fairly at this time in American history. The bishops' case for government involvement can be made on the strength of the Catholic tradition in theological argumentation, independent of the claim that health care is a right. (shrink)

A typical discussion around health reform in the U.S. focuses on how the nation can most effectively and efficiently extend insurance coverage to the rising number of people who have none. Furthermore, discussions about health care reform typically are centered on times of normalcy, when the health care system is not overly taxed and there is the luxury of time to think about everyday matters of health and health care, including health (...) care services needed to prevent illness, treat conditions, and address individual emergencies. But in light of the lessons learned over the past decade, it is also essential to consider how any reformed health care system will react to and mitigate the consequences of a public health emergency. (shrink)

Any reformed health care system must be able to react to and mitigate the consequences of a public health emergency. This article identifies four essential components of public health emergency preparedness, and presents measures that can be taken immediately to improve our capacity to respond to emergencies.

Proposed solutions to the problems of this country's health care system range along a spectrum from central planning to free market. Central planners and free market advocates provide various ethical justifications for the policies they propose. The crucial flaw in the philosophical rationale of central planning is failure to distinguish between normative and metanormative principles, which leads to mistaken understanding of the nature of rights. Natural rights, based on the principle of noninterference, provide the link between individual morality (...) and social order. Free markets, the practical expression of natural rights, are uniquely capable of achieving the goals that central planners seek but find beyond their grasp. The history of this country's health care system and the experiences of other nations provide evidence of the superiority of free markets in reaching for the goals of universal access, control of costs, and sustaining the quality of health care. (shrink)

Reform in public health: where does it take nursing?The Australian healthcare system is undergoing changes that are impacting tangibly on professional nursing practice. While the evidence is clear that the changes pose a challenge to maintaining standards amidst resource cuts and restructuring, the processes through which these changes occur and the decisions which drive the reforms remain complex and largely obscure. This paper intends to stimulate further thinking and debate among nurses about the effects of these reforms (...) on the conduct of practice, both in terms of our emerging discipline and our ability to conduct clinical nursing practice. It offers a way of understanding the policy ‘reform’ process through an application of policy analysis grounded in critical social theory. The discussion sets out to apply these analytical propositions to specific events that constitute examples of change in the nursing workplace, and to focus on the implications for nurses and health service clientele. (shrink)