Journal of Urban Health

, Volume 76, Issue 2, pp 176–191 | Cite as

Decisions about access to health care and accountability for reasonableness

  • Norman Daniels
Martin Cherkasky Symposium


Insurers make decisions that directly limit access to care (e.g., when deciding about coverage for new technologies or formulary design) and that indirectly limit access (e.g., by adopting incentives to induce physicians to provide fewer or different services). These decisions raise questions about legitimacy and fairness. By holding health plans accountable for the reasonableness of their decisions, it is possible to address these questions. Accountability for reasonableness involves providing publicly accessible rationales for decisions and limiting rationales to those that all “fair-minded” persons can agree are relevant to meeting patient needs fairly under resource constraints. This form of accountability is illustrated by examining its implications for the three examples of direct and indirect limit setting noted here.


Public Health Health Care Limit Setting Health Plan Limit Access 
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  1. 1.
    Kaiser Family Foundation/Harvard. Kaiser Family Foundation/Harvard national survey of Americans' views on consumer protection in managed care. 1998. Available at: Scholar
  2. 2.
    Daniels N, Sabin J. Limits to health care: fair procedures, democratic deliberation, and the legitimacy problem for insurers.Philos Public Aff. 1997;26(4):303–350.PubMedGoogle Scholar
  3. 3.
    Daniels N, Sabin J. The ethics of accountability and the reform of managed care organizations.Health Aff. 1998;17(5):50–69.CrossRefGoogle Scholar
  4. 4.
    Daniels N.Just Health Care. New York: Cambridge University Press; 1985.Google Scholar
  5. 5.
    Daniels N, Light D, Caplan R.Benchmarks of Fairness for Health Care Reform. New York: Oxford University Press; 1996.Google Scholar
  6. 6.
    Daniels N.Seeking Fair Treatment: From the AIDS Epidemic to National Health Care Reform. New York: Oxford University Press; 1995: chap. 4.Google Scholar
  7. 7.
    Daniels N, Sabin J. Closure, fair procedures, and setting limits within managed care organizations.J Am Geriatr Soc. 1998;46(3):351–354.PubMedGoogle Scholar
  8. 8.
    Arrow K. Uncertainty and the welfare economics of medical care.Am Econ Rev. 1963; 53:941–973.Google Scholar
  9. 9.
    Daniels N, Sabin J. Last-chance therapies and managed care: pluralism, fair procedures, and legitimacy.Hastings Cent Rep. 1998;28(2):27–41.PubMedGoogle Scholar
  10. 10.
    Daniels N. Justice, fair procedures, and the goals of medicine.Hastings Cent Rep. 1996; 26(6):10–12.PubMedGoogle Scholar
  11. 11.
    Newhouse JP. Medical care costs: how much welfare loss?J Econ Perspect. 1992;6(3): 3–21.PubMedGoogle Scholar
  12. 12.
    Sabin J, Daniels N. Making insurance coverage for new technologies reasonable and accountable.JAMA. 1998;279(9):703–704.CrossRefPubMedGoogle Scholar
  13. 13.
    Gold MR, Hurley R, Lake T, Ensor T, Berenson R. A national survey of the arrangements managed-care plans make with physicians.New Engl J Med. 1995;333(25):1678–1683.CrossRefPubMedGoogle Scholar
  14. 14.
    Hellinger FJ. The impact of financial incentives on physician behavior in managed care plans: a review of the evidence.Med Care Res Rev. 1996;53(3):294–314.PubMedGoogle Scholar
  15. 15.
    Orentlicher D. Paying physicians more to do less: financial incentives to limit care.Univ Richmond Law Rev. 1996;30(1):155–197.PubMedGoogle Scholar
  16. 16.
    Berwick DM. Payment by capitation and the quality of care.New Engl J Med. 1996; 335(16):1227–1231.CrossRefPubMedGoogle Scholar
  17. 17.
    Pearson SD, Sabin JE, Emanuel EJ. Ethical principles to guide physician compensation systems based on capitation.New Engl J Med. 1998;339(10):689–693.CrossRefPubMedGoogle Scholar
  18. 18.
    Daniels N. Why saying no to patients in the United States is so hard: cost containment, justice, and provider autonomy.New Engl J Med. 1986;314:1381–1383.Google Scholar

Copyright information

© The New York Academy of Medicine 1999

Authors and Affiliations

  • Norman Daniels
    • 1
  1. 1.Department of PhilosophyTufts UniversityMedford

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