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Universal Coverage and Social Justice . Norman Daniels, HSPH PEH Conference on Universal Coverage April 19, 2013. Overview . Rationale for Universal Coverage Some Issues and Objections Reasonable disagreements about UC Bearing of conference on these points.

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universal coverage and social justice
Universal Coverage and Social Justice
  • Norman Daniels, HSPH
  • PEH Conference on Universal Coverage
  • April 19, 2013
overview
Overview
  • Rationale for Universal Coverage
  • Some Issues and Objections
  • Reasonable disagreements about UC
  • Bearing of conference on these points
fair equality of opportunity feo and health 1
Fair Equality of Opportunity (FEO) and health (1)
  • Ill health diminishes exercisable opportunities
  • Health protection and health care help preserve exercisable opportunities
  • If there is social obligation to assure fair equality of opportunity, then have principle that can be extended to health/health care
  • justice and health (not just medical care)
feo and health 2
FEO andhealth (2)
  • Protecting range of exercisable opportunities--convergence with capabilities view
  • Risk reduction (population health) not simply medical care
  • Right to health/health care--special case of right to FEO (entitlements from fair deliberative process)
  • Financial protection as a way to protect fair share of opportunities (Brendan Saloner thesis 2012)
feo and uc
FEO and UC
  • We cannot prevent all illness, so need UC even if get more health from other determinants
  • Financial protection is a form of opportunity protection
  • Fair financing--ability to pay (progressivity), well to ill
  • Sustainability important to equity, solidarity
  • Efficiency as ethical concern-- more needs covered
  • Reasonable disagreement about what to cover--need for fair deliberative process
objections 1
Objections (1)
  • We can improve population health and equity more by a fair distribution of social determinants of health than by assuring equal access to some medical care with UC
    • The visible failure to rescue those in ill health is not responded to psychologically or politically by statistical success in reducing the risk to population health
objections 2
Objections (2)
  • UC favors equality over helping the worst off-- it might ignore the impact of targetted vertical programs that better reach the worst off
    • UC does not imply uniform interventions and can accommodate use of vertical programs that may better reach targeted groups as part of a mix of services that improve universal access
objections 3
Objections (3)
  • UC misdirects resources toward medical care and away from more effective ways of improving population health
    • People who become ill are “identified” people who make significant, visible claims on others for assistance--this fact unavoidably affects the politics of resource allocation to health; when does what is politically feasible affect claims about what is justifiable as matter of justice?
objections 4
Objections (4)
  • A focus on financial protection distorts the health system away from a focus on health outcomes
    • Both financial protection and improvement of population health are goals of UC-- a properly designed system can achieve improvements in both, but the goals can pull apart
reasonable disagreement rd and fair process
Reasonable disagreement (RD) and fair process
  • RD is pervasive in design of UC
    • Medical Care vs Social Determinants
    • Access vs Financial Protection
    • Instances of unsolved rationing problems
      • best outcomes/fair chances; aggregation; priorities
  • Requires deliberative fair process to establish legitimacy and lead to arguably fairer decisions
human rights and social justice
Human Rights and Social Justice
  • HR approach calls for governments to progressively realize right to health/health care
    • focuses attention on broad range of rights affecting health
    • priorities to be negotiated with governments in setting targets
    • fair deliberative process needed to supplement HR approach, as it is needed to supplement SJ
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