C O L L A B O R A T I V E C A S E M A N A G E M E N T
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What is the correct balance? Is there a fiscally sustainable yetempathetic solution? In forming an opinion on this issue, what
elements – both conceptual and historical – must be considered?
his article examines the issue in its most current form – the debatesurrounding a system of universal health care in the United States –and reviews early attempts by some states to develop such a system.
CAN THEORY HELP?
Allocation of health care services is a form of distributive justice,and most advocates for universal coverage believe receiving healthcare s an ssue o ustce. Invuas nee access to quaty eat
care, and a just government would
distribute the resources necessary toever eat care to ts ctzens n aair manner. Affordable healthinsurance is often looked to as thevehicle to allow fair access toservices, so that the cost is covered.he details of how to finance theinsurance create tensions for policy akers. Who pays the cost, and for
how much universal insurance? What are the services to be provided?
Who decides the payment schedule,and for which individuals? Who
decides which services should be
rove? Tese questons an many
others have to be answered in order
o develop a system of allocation.Wen evauatng poces orallocating health care resources, multiple goals come into conflict:excellence of care, equality of care, efficiency of care and the freedomof choice for both patient and health care provider. As a society, wehave not prioritized these goals, and attempts at prioritization havecaused further conflict and yielded minimal progress toward theoverarching goal of health care.
Without agreed-upon priorities,
olicy development will not have a clear direction.On the surface, healthcare in the United States appears to operateas a free-market system – with the unique distinction that in mostcases a party other than the one consuming the services is paying forhe services. This creates distorted relationships between providers,atients, and payers. Patients and payers pay significantly differentrces or te same servces evere y te same prover, an teserices paid or reimbursed may be very different than the provider’sactual cost of delivering care. Furthermore, the actual market pricesfor health care services remain expensive, and unaffordable for asignificant portion of the population.The customary guideline for resource allocation is the general ruleof
ormal procedural justice
which seeks to treat “Likes” alike and“Unlikes” differently. Principles of formal justice suggest giving toindividuals according to a characteristic that can be quantified. Thequantae caracterstcs usuay rase n scusson o eat careare: need, demonstrated effort, equal share, contribution, and merit.However, there are problems with using each of these as defining crterons. I eat care s gven accorng to
tere may e vastdifferences in the amount and type of health care any person needs. Oneperson may nsst tat a pastcsurgery is needed while anotherperson will insist the surgery is notecessary. If health care is given
there will be lively discussion and potentially irresolvable issues of how hard aperson is working (for example, tostay in shape or manage chronic
conditions) in contrast to how hard
he/she ought to be working. If each
person is accorded an
share –each person receiving the same
aocaton o care – ten some wt
chronic illness will not receive
sufficient services while a healthy person may ave servces tat gounused. If health care is given according to personal
, avalue will have to be placed on the person’s contribution – engaging
another potentially irresolvable issue. How will we value thecontribution of the stay-at-home parent in contrast to the spouse who works at an office? If health care is given according to
, there will
have to be an assessment of merit. Does a mediocre artist deserve as
much health care as a dedicated garbage collector? Are merits received
for a healthy lifestyle while an unhealthy lifestyle receives demerits?
Conversations about how to distribute health care, how much care,
and who funds care have gone on for many years. National healthcoverage as een scusse snce te 1960s. Atoug not otenrecognized as such, there actually is some national coverage for certain
Universal Health Care – Developing a Just Solution
By Cynthiane J Morgenweck MD, MA