Abstract
Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional (universal, comprehensive) rather than a residual (minimalist, safety net) system. They argue that the concept (a) contradicts the idea of comprehensiveness; (b) leads to unsustainable expenditures; (c) is too indeterminate for policy; and (d) supports only a prioritarian distribution (and therefore a residual system). I argue (a) that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and (b) that UHC is a solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy (c) are not transparent about the source (ethical, semantic, political, or other) of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that (d) the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option.
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Notes
Throughout I refer to Canadian medicare in lower case, to indicate that, unlike US Medicare or the NHS in the UK, it is not a centrally-organized system either of payment or of delivery. Federal standards for the provincial health insurance programs are set by the Canada Health Act [4] and delivery is by diverse public, not-for-profit, and private service providers. The decentralized systems informed by the principles of the CHA but also by various provincial laws and regulations are typically referred to in policy and politics as though they constituted a single system called ‘medicare’.
I discuss limitations to and qualifications of this claim below.
E.g. the Health Canada website on Canada’s health care system refers to “the underlying Canadian values of equity and solidarity.” http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php (visited June 1, 2016; last modified 2010-12-09).
There are nuances and limitations to this idea of “all Canadians” sharing the same coverage. Coverage is primarily dependent on provincial residency (not just federal citizenship) with a waiting period to establish residency; having coverage is defined as being an “insured person.” Other government-funded programs alongside medicare, or that existed before medicare, include the Interim Federal Health Program for refugees, workers’ compensation schemes, coverage for the armed forces, and the Non-Insured Health Benefits Program for Inuit and First Nations: these provide funding that may replace medicare for certain incidents for otherwise insured persons (workers compensation), or be equivalent to medicare for certain persons insured or non-insured (IFHP, armed forces), or provided services in addition to medicare for certain persons insured or non-insured (IFHP, armed forces, NIHB, workers compensation).
Substantial empirical concerns can, of course, be raised about whether Canada actually achieves this ideal.
Flood suggests that keeping management costs low has deprived Canada of the benefits of active management [11, p. 20].
This view persists in the Vertes report on preferential access in the Alberta health care system [40], which accepts the idea that the clinical judgment of physicians is the appropriate gate-keeping mechanism.
See Lahey in this volume for a discussion of the ‘locus’ of medicare in Canada.
A desire to have a need met or an interest in having a need met is a desire or an interest because the need is a need, rather than a needs being a subset of particularly strong desires or interests.
These dimensions encompass epistemic considerations (our current state of knowledge), technological considerations (what interventions are possible), and social considerations (social agreements and disagreements relating to valued human functionings). These three considerations, while being particularly prominent in each of the respective domains, may also pertain to any of the others.
Hasman, Hope and Østerdal argue that need in health care should be interpreted in relation to a health state-intervention pairing. Wiggins also claims there can be no need for an intervention that does not exist, and that the need for an intervention is subject to its feasibility in a context. This is a modification of the ordinary concept of need: we would normally say that that persons with ALS need a cure, although health care does not have one to offer. It may be felt that within the scope of the health care system, this is an acceptable and practical limitation. However, women and children in Africa needed prevention of mother-to-child-transmission of HIV/AIDS before it was feasible in that context. The moral imperative in this case changed the standards for feasibility, so that things became feasible.
The fact that what the market offers one can be constrained indirectly by what one’s fellow market participants choose may be implicitly accepted by Meadowcroft. As noted above, it seems that his arguments should be addressed against a single-tier system that compels (or comes close to compelling) universal participation (pp. 5–6); he argues instead that all systems of UHC impinge on freedom, not limiting this claim to single-tier systems. But non-compulsory systems constrain the choices of those who opt out only insofar as enough market participants are happy with the non-compulsory UHC, take it up, and so exit the private market—and then the private markets have less to offer, limiting the choices of those who have opted out. Absent such a dynamic, the mere existence of a UHC option does not impinge on freedom.
Hasman, Hope and Østerdal have taken this approach [18], in contrast to Culyer and Wagstaff [8], who treat acuity of need not as an input to resource allocation but as a determination reached through an allocation process. For deep reasons, the question of severity of need is not always distinguished from the question of equality in treatment—the prioritarian concern can be expressed as one for equal treatment for equally severe needs, whatever the cost of the treatment [41].
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Reid, L. Medical Need: Evaluating a Conceptual Critique of Universal Health Coverage. Health Care Anal 25, 114–137 (2017). https://doi.org/10.1007/s10728-016-0325-3
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DOI: https://doi.org/10.1007/s10728-016-0325-3