Ideological notions in public health care rationing : Case studies from Oregon, New Zealand and Finland

The purpose of this dissertation is to analyze and explicate the ideological content, which is often implicit, in the health care rationing discussion. The phrase "ideological content" refers to viewpoints and assumptions expressed in the rationing discussion that may be widespread and accepted, but without clear evidential support. The study method is philosophical text analysis. The study begins by exploring the literature from the 1970s that affects the present-day rationing discussion. Since ideological contents may have different emphases in realm of health care, three representative cases were studied. The first was a case study of the first and best-known rationing experiment in the American state of Oregon, namely, an experimental rationing plan within the public health program Medicaid, which is designed to provide care for the poor and underprivileged. The second was a study of the only national-level public priority setting that has been conducted in New Zealand. The third examined the Finnish Care Guarantee plan introduced in March 2005. The findings show that several problematic and scientifically mostly unproven concepts have remained largely uncontested in the debate about public health care rationing. Some of these notions already originated decades ago in studies that relied on outdated data or research paradigms. The problematic ideological contents have also been taken up from one publication into another, thereby affecting the rationing debate. The study suggests that before any new public health care rationing experiments are undertaken, these ideological factors should be properly examined, especially in order to avoid repetitious research and perhaps erroneous rationing decisions.

Rationing in healthcare

Rationing healthcare in some form is inevitable, even in wealthy countries, because resources are scarce and demand for healthcare is always likely to exceed supply. This means that decision-makers must make choices about which health programs and initiatives should receive public funding and which ones should not. These choices are often difficult to make, particularly in Australia, because: - 1 Make explicit rationing based on a national decision-making tool (such as Multi-criteria Decision Analysis) standard process in all jurisdictions. - 2 Develop nationally consistent methods for conducting economic evaluation in health so that good quality evidence on the relative efficiency of various programs and initiatives is generated. - 3 Generate more economic evaluation evidence to inform rationing decisions. - 4 Revise national health performance indicators so that they include true health system efficiency indicators, such as cost-effectiveness. - 5 Apply the Comprehensive Management Framework used to evaluate items on the Medicare Benefits Schedule (MBS) to the Pharmaceutical Benefits Scheme (PBS) and the Prosthesis List to accelerate disinvestment from low-value drugs and prostheses. - 6 Seek agreement among Commonwealth, state and territory governments to work together to undertake work similar to the National Institute for Health and Care Excellence in the United Kingdom and the Canadian Agency for Drugs and Technologies in Health.

Optimal Fiscal Policy with Rationing in the Labor Market

Published as an article in: Topics in Macroeconomics, 2005, vol. 5, issue 1, article 17.

Supporting the case for “progressive universalism” in health visiting: Scottish mothers and health visitors’ perspectives on targeting and rationing health visiting services, with a focus on the Lothian Child Concern Model.

Aims. To explore parents and professionals’ experience of family assessment in health visiting (public health nursing), with a focus on the Lothian Child Concern Model (LCCM). Background. Health visitors (HVs) currently assess families as requiring core, additional or intensive support, and offer support at a corresponding level. The majority of families are assessed as core and receive no pro-active support beyond the early days. Previous assessment tools, consisting of checklists, have been criticised as being ineffective in identifying a range of health needs and unacceptable to parents and HVs. The LCCM model was developed and introduced in the study area to promote a partnership approach with parents and assess strengths as well as difficulties in parents’ capacity to care for their child. Methods. Qualitative methods were used. Ten mothers and twelve HVs took part in individual semi-structured interviews. Results. Most mothers were aware of the assessment process but some felt that they were not involved in the decision making process. Explaining the assessment process to parents is problematic and not all HVs do so. The assessment process was stressful for some mothers. HVs find the model useful for structuring and documenting the assessment process. Many believe that most families benefit from some support, using public health approaches. Families are often assessed as core because there are insufficient resources to support all those who meet the criteria of the additional category, and managers assess caseloads in terms of families with child protection concerns. Conclusions. The study findings support the concept of “progressive universalism” which provides a continuum of intensity of support to families, depending on need. Mothers would like better partnership working with HVs. Relevance to clinical practice. The study endorses proposed policy changes to re-establish the public health role of HVs and to lower the threshold for families to qualify for support.

Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Efficiency, Equity, and Reality

Background: Rationing of access to antiretroviral therapy already exists in sub-Saharan Africa and will intensify as national treatment programs develop. The number of people who are medically eligible for therapy will far exceed the human, infrastructural, and financial resources available, making rationing of public treatment services inevitable. Methods: We identified 15 criteria by which antiretroviral therapy could be rationed in African countries and analyzed the resulting rationing systems across 5 domains: clinical effectiveness, implementation feasibility, cost, economic efficiency, and social equity. Findings: Rationing can be explicit or implicit. Access to treatment can be explicitly targeted to priority subpopulations such as mothers of newborns, skilled workers, students, or poor people. Explicit conditions can also be set that cause differential access, such as residence in a designated geographic area, co-payment, access to testing, or a demonstrated commitment to adhere to therapy. Implicit rationing on the basis of first-come, first-served or queuing will arise when no explicit system is enforced; implicit systems almost always allow a high degree of queue-jumping by the elite. There is a direct tradeoff between economic efficiency and social equity. Interpretation: Rationing is inevitable in most countries for some period of time. Without deliberate social policy decisions, implicit rationing systems that are neither efficient nor equitable will prevail. Governments that make deliberate choices, and then explain and defend those choices to their constituencies, are more likely to achieve a socially desirable outcome from the large investments now being made than are those that allow queuing and queue-jumping to dominate.

Optimal Credit Rationing in Not-For-Profit Financial Institutions

We examine the dynamic optimization problem for not-for-profit financial institutions (NFPs) that maximize consumer surplus, not profits. We characterize the optimal dynamic policy and find that it involves credit rationing. Interest rates set by mature NFPs will typically be more favorable to customers than market rates, as any surplus is distributed in the form of interest rate subsidies, with credit rationing being required to prevent these subsidies from distorting loan volumes from their optimal levels. Rationing overcomes a fundamental problem in NFPs; it allows them to distribute the surplus without distorting the volume of activity from the efficient level.

War, food rationing, and socioeconomic inequality in Germany during the First World War

Germany experienced a devastating period during the First World War due to severely restricted import possibilities and a general shortage of foodstuffs. This study uses the heights of some 4,000 individuals who served during the Second World War to quantify biological living standards from the 1900s to the 1920s, and focuses primarily on socioeconomic inequality during this period. The results suggest that generally the upper social strata, measured by fathers' occupation, exhibited the tallest average height, followed by the middle and lower classes. These socioeconomic differences became more pronounced during the First World War when the rationing system provided a limited food supply. Wealthier individuals were able to purchase additional foodstuffs on black markets. Therefore, children from upper-class families experienced only a small decline in average height compared to their counterparts from the middle and lower social strata.

On Fixed-Path Rationing Methods.

Moulin (1999) characterizes the fixed-path rationing methods by efficiency, strategy-proofness, consistency, and resource-monotonicity. In this note, we give a straightforward proof of his result.

An Egalitarian Argument in Favour of Free Access to Healthcare and Rationing

La pensée égalitariste a traditionnellement promu l’idéal d’un système de santé universel, gratuit et accessible à tous les membres de la société. J’appuie cette position en répliquant tout d’abord à la critique qui prétend que les riches tireraient plus d’avantages que les pauvres de la gratuité du système de santé. J’ouvre ensuite la réflexion sur ce qui me semble être un enjeu crucial pour l’avenir des systèmes modernes de santé : le rationnement de l’offre. Cette idée ne plaît généralement pas à la population, aux décideurs politiques et à de nombreux égalitaristes. Je considère pourtant que les principaux arguments invoqués contre le rationnement sont incohérents ou faussement égalitaristes. La gratuité des services de santé n’est pas incompatible avec la limitation de l’offre publique.