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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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