Health care reform is being assaulted from all sides. In January, the House of Representatives voted to repeal The Patient Protection and Affordable Care Act (the "Affordable Care Act"). For now, that effort will not succeed, owing to Democratic control of the Senate and the presidential veto. But conservative lawmakers in the House threaten to withhold key funding for implementation, and we can expect ongoing efforts to enact various partial amendments.Meanwhile, a core component of the reform law is running the (...) gauntlet of constitutional challenges in dozens of courts.1 So far, two federal district judges—in Richmond, Virginia, and Pensacola, Florida—have declared the individual mandate unconstitutional, as .. (shrink)
As politicians revisit the merits of health insurance reform and courts deliberate its constitutionality, government regulators are busily working on the wonky details of implementation. The Affordable Care Act leaves vast swaths of regulation for various agencies to prescribe, most notably the Department of Health and Human Services. Infamously (or perhaps apocryphally, since I'm certainly not going to bother counting), the statute contains more than a thousand commands to the effect of, "the Secretary shall decide." This massive delegation of authority (...) is unavoidable in any attempt to comprehensively reform, yet preserve, our Byzantine health insurance system.Throughout this regulatory nativity, the government .. (shrink)
Changes in healthcare financing increasingly rely upon patient cost-sharing to control escalating healthcare expenditures. These changes raise new challenges for physicians that are different from those that arose either under managed care or traditional indemnity insurance. Historically, there have been two distinct bases for arguing that physicians should not consider costs in their clinical decisions?an ?aspirational ethic? that exhorts physicians to treat all patients the same regardless of their ability to pay, and an ?agency ethic? that calls on physicians to (...) be trustworthy advisors to their patients. In the setting of greater patient cost-sharing, physicians' aspiration and agency roles increasingly conflict. Satisfactorily navigating the new terrain of consumer-driven healthcare requires physicians to consider these two roles and how they can best be reconciled so as to maximize quality of care while respecting the heterogeneity of patients' financial resources and willingness to pay. (shrink)
This book explores the making of health care rationing decisions through the analysis of three alternative decision makers: patients paying out of pocket; officials setting limits on treatments and coverage; and physicians at the bedside. Hall develops this analysis along three dimensions: political economics, ethics, and law. The economic dimension addresses the practical feasibility of each method. The ethical dimension discusses the moral aspects of these methods, while the legal dimension traces the most recent developments in jurisprudence and health law.
Centralized, democratic rules are often asserted as a superior basis for rationing than individualized physician discretion. This article counters this prevailing wisdom by exploring the deficiencies of rule-based rationing. Rules are too imprecise to accurately reflect all the nuances of physical and mental impairment and the complexity of medical science, particularly considering the widely varying personal values that different patients attach to medical risk and benefit. Rule-based rationing also suffers from the biasing effects of interest group pressure on political processes (...) and the tendency to absolve physicians from any moral responsibility for the rationing decisions they implement. Internalizing cost constraints is a more socially and professionally acceptable means of rationing and, in any event, it is inevitable since even a preponderance of rule-based rationing will leave considerable areas of discretion for physician judgment in the implementation and interpretation of the rules. As a consequence, despite the flaws of bedside rationing, it is foolhardy to dispense with it entirely in favor of an exclusively rule-based system. Keywords: Bedside rationing, cost-constraints, rule-based rationing CiteULike Connotea Del.icio.us What's this? (shrink)