Ethics of Resource Allocation and Rationing Medical Care in a Time of Fiscal Restraint - US and Europe

Abstract

Background: All resources are scarce. The ethical dilemma in health care is how to balance the precepts of autonomy, beneficence, and distributive justice. Rationing may affect three dimensions of coverage: the share of the population covered, the services covered, and the extent to which services are covered. United States: The US spends 50 percent more per capita on health care than any other country while achieving worse health than many. Poorly coordinated insurance mechanisms leave 19 percent of the population uninsured. Until passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, health care was effectively a privilege, not a right. While PPACA seeks to rectify this, by 2019 five percent of non-elderly US residents will likely remain uninsured. Europe: Most European countries provide universal or near-universal population coverage to people resident in the respective country. Central and Eastern European countries inherited the Soviet-era commitment to universal coverage free at the point of use. Faced with a decline in government spending on health, almost all of them reduced the scope of services and introduced official user fees. In contrast, other European countries expanded entitlement to publicly funded health care, resulting in greater equity. A number of countries have attempted to depoliticize decisions on rationing by using health technology assessments and dedicated agencies. Discussion: Resource allocation and rationing differ considerably between the US and Europe. In the US, where social welfare remains controversial, there are few restrictions on the use of health care technology regardless of cost or clinical effectiveness. European countries engage in more explicit debates about these limits, though these are complicated by media and lobby power.

Income‐related inequality and inequity in the use of dental services in Finland after a major subsidization reform

“…On the other hand, the public healthcare sector, municipal administrations and state government do not show any great enthusiasm for combating the inequity in the use of dental services as the access to PDS is still restricted by out‐of‐pocket payments which are considerably higher than those charged by other primary public healthcare providers in Finland. It could be beneficial to move from rationing the entire area of dental care to setting priorities and/or rationing the scope of care in the realm of the entire health care ‘based on explicit and a broad public debate involving government, providers, the public and patients’ . Overall, Finland is a rather equal society, for instance in terms of income equality and risk of poverty , with a relatively high number of dental personnel and ‘sufficient’ public resources for health care .…”

Smoking behaviour and health care costs coverage: a European cross-country comparison

“…The latter is just one way of offering health care cost coverage. Health care coverage can have three dimensions: breadth, the proportion of the population covered by the health care system; scope, the generosity of the benefit package (the services/goods covered); and depth, the level of coverage (the proportion of cost covered) (Teutsch and Rechel 2012 ). The institutional arrangements regarding the above dimensions vary between countries.…”

Health Care for All in Ireland? The Consequences of Politics for Health Policy

“…Rationing of care can be described as denying a potentially beneficial treatment to a patient on the grounds of scarcity (Scheunemann & White, ). Such rationing according to Teutsch and Rechel () can affect three dimensions of coverage: (i) the share of the population covered (eligibility); (ii) the services covered; and (iii) the extent to which these services are covered (scope). This raises questions about fairness in the equitable distribution of resources and what ethical principles should guide such distribution.…”

“…It can be difficult for stakeholders in health‐care systems to agree the principles that should guide rationing. Some countries attempt to depoliticize decisions regarding rationing by using health technology assessments through dedicated agencies (Teutsch & Rechel, ). In the Irish context, HIQA was established to drive improvement in health services and to monitor the safety, and quality of these services as an independent authority.…”