Objectives The study aims to evaluate the impact of the Revised Health Insurance Law 2014 on the utilisation of outpatient and inpatient care services, healthcare services utilisation at different levels of providers, types of providers and types of visits across different entitlement groups. Design/setting Secondary data from two waves of the Vietnam Household Living Standard Survey (VHLSS) 2016, VHLSS 2014 were used. A cross-sectional study applying propensity score matching was conducted. Participants A total of 4900 individuals who reported (...) using healthcare services are analysed. Outcomes measure Numbers of outpatient and inpatient visits, frequency of healthcare service utilisation at commune health stations, district hospitals, provincial hospitals, public and private health facilities, number of visits at health facility for medical treatment and health checks per year. Results The result indicates that health insurance (HI) policy increased the number of outpatient visits for the enrolled between 0.87 and 1.29. The greatest impact was found on participants of heavily subsidised health insurance (HSHI) programmes with 1.29 visits per person per year. Similarly, an increase between 0.08 and 0.16 in the number of inpatient admissions was because of participation in HI. With regard to type of healthcare providers, the study found that participation in HI has the most effect on the use of healthcare services at district hospitals. However, the study demonstrated that the impacts of HI on the increase in the frequency of visiting commune health stations, number of visits at the provincial hospital for HSHI groups, and number of visits at health facilities for health check and consultation were sensitive to unobserved characteristics. Conclusion Our findings imply that policy-makers in Vietnam could continue expanding health insurance coverage to increase access to healthcare services for citizens, especially vulnerable groups. In addition, the government should draw more attention to primary healthcare level. (shrink)

Background: The World Health Organization has endorsed a community-based health insurance scheme (CBHIS) as a shared financing plan to improve access to health services and ensure universal coverage of the healthcare delivery system. Such a contributory scheme is the most likely option to provide health insurance coverage when governments cannot offer direct health care support. Despite improvements in access to current healthcare services, Ethiopia’s healthcare delivery remained low, owing to the country’s underdeveloped healthcare (...) finance system. As a result, the present study assessed CBHIS coverage and its predictors in Ethiopia at the individual and community level. Methods: The availability of CBHIS was checked via a criterion: at least one of the cluster respondents had to be enrolled in CBHIS. This study was based on secondary data from the Ethiopia Mini Demography and Health Survey (EMDHS) 2019 and included 7724 respondents. The study population was described using percentage and frequency. Four multilevel mixed-effects logistic regression modelling stages were performed to control for variations due to heterogeneity across clusters, and determinant predictors of CBHIS enrollment were outplayed. Results: The prevalence of CBHIS enrollment in Ethiopia was 33.13%. Rural residents were 3.218 times (AOR = 3.218; 95% CI: 1.521, 6.809), male household heads were 1.574 times (AOR = 1.574, 95% CI: 1.105, 2.241), getting funds from the safety net program were times 2.062 (AOR = 2.062, 95% CI: 1.297, 3.279), attending the primary educational level was 1.686 times (AOR = 1.686, 95% CI: 1.007, 2.821), bank accounts were 1.373 times (AOR = 1.373, 95% CI: 1.052, 1.792), and wealth index was 1.356 times (AOR = 1.356, 95% CI: 1.001, 1.838) more likely associated with CBHIS coverage, whereas the regions, the other religions, and women aged 20– 24 had lower odds of CBHIS coverage. Conclusion: In Ethiopia, regional healthcare expenditure per capital, religious affiliation, women age range, residents, sex of household head, funds from the safety net program, formal educational level, and having bank accounts were associated with community-based health insurance scheme coverage. (shrink)

Background: The World Health Organization has endorsed a community-based health insurance scheme (CBHIS) as a shared financing plan to improve access to health services and ensure universal coverage of the healthcare delivery system. Such a contributory scheme is the most likely option to provide health insurance coverage when governments cannot offer direct health care support. Despite improvements in access to current healthcare services, Ethiopia’s healthcare delivery remained low, owing to the country’s underdeveloped healthcare (...) finance system. As a result, the present study assessed CBHIS coverage and its predictors in Ethiopia at the individual and community level. (shrink)

I critically examine a common liberal egalitarian view about the justification for, and proper content of, mandatory health insurance. This view holds that a mandate is justified because it is the best way to ensure that those in poor health gain health insurance on equitable terms. It also holds that a government should mandate what a representative prudent individual would purchase for themselves if they were placed in fair conditions of choice. I argue that this (...) common justification for a mandate is incomplete. A further reason for mandated insurance is that it helps secure social egalitarian public goods that would be underprovided if insurance were optional. I also argue that rather than mandating what a representative individual would choose for themselves, we should design the mandatory package by appealing to a pluralistic egalitarian view, which cares about improving people’s well-being, reducing unfair inequality, and maintaining egalitarian social relations. (shrink)

The 2010 Patient Protection and Affordable Care Act was designed to increase health insurance coverage in the United States. Its most controversial feature is the requirement that US residents purchase health insurance. Opponents of the mandate argue that requiring people to contribute to the collective good is inconsistent with respect for individual liberty. Rather than appeal to the collective good, this Viewpoint argues for a duty to buy health insurance based on the moral duty (...) individuals have to reduce certain burdens they pose on others. When some people have a duty to rescue, others may have a duty to take rescue precautions, in this case, to purchase health insurance to cover acute and emergency care needs. Requiring that individuals meet this obligation is consistent with respect of individual liberty. (shrink)

The present article is presenting the ‘Healthcare Hazards and Its Impact on Health Insurance Business – An Overview during COVID-19’. The present paper studied the health insurance, health insurance plans in India, Indian market size, health care industry, government actions for the COVID-19, and healthcare business in India, private health insurance in India, hazardous of the healthcare industry and health insurances, and Indian healthcare issues in 2019. The author has concluded (...) that all insurance policies are levied higher taxes by the government, these lead higher income to the companies, and these are creating how commissions to the agents and other insurance organizations under reinsurance, but no benefits to the insured. It may not be a long term benefit, why because there is no maturity fund/income, because of these are shortterm benefits; how many of the policyholders are getting the benefits from the general health insurance companies. Hence, the research is required to calculate for the need of levy-the tax from the non-claimant portion of the income of the general health insurance on an annual basis to the health department of the nation. (shrink)

Citizens in wealthy liberal democracies are typically expected to see to basic needs like food, clothing, and shelter out of their own income, and those without the means to do so usually receive assistance in the form of cash transfers. Things are different with health care. Most liberal societies provide their citizens with health care or health care insurance in kind, either directly from the state or through private insurance companies that are regulated like public (...) utilities. Except perhaps for small co-pays or deductibles, citizens are not expected to see to their health needs out-of-pocket, at least for some basic level of care. Instead, when a citizen gets sick, the state or her insurance company foots the... (shrink)

This chapter explores two questions in detail: How should we determine the threshold for costs that individuals are asked to bear through insurance premiums or care-related out-of-pocket costs, including user fees and copayments? and What is an adequate relationship between costs and benefits? This chapter argues that preventing impoverishment is a morally more urgent priority than protecting households against income fluctuations, and that many health insurance plans may not adequately protect individuals from health care costs that (...) threaten to drop their financial status below a decent minimum. A design that places greater emphasis on preventing impoverishment and finances the achievement of that goal by reducing unnecessary subsidies to better-off households would better accord with a sufficientarian approach to health care. -/- . (shrink)

The truth about health care policy lies between two exaggerated views: a market view in which individuals purchase their own health care from profit maximizing health-care firms and a control view in which costs are controlled by regulations limiting which treatments health insurance will pay for. This essay suggests a way to avoid on the one hand the suffering, unfairness, and abandonment of solidarity entailed by the market view and, on the other hand, to diminish (...) the inflexibility and inefficiency of the control view. It suggests that the way to mitigate these problems is to recognize the malleability of motivation and the range of factors, in addition to financial incentives, that may influence the behavior of patients and especially physicians. (shrink)

This thesis under the title “Public Health Policy in Resource Allocation: the Role of Ubuntu Ethics in Redressing Resource Disparity between Public and Private Healthcare in South Africa” explores health care disparities pertaining to resource allocation between public and private sector. It is of relevance and importance in South Africa where 54% of the population live on less than US$3 per day. Although the government has instituted certain changes aimed at transforming the public health care system, the (...) resource allocation gap between the two persists and remains wide. The research gives special attention to the role that Ubuntu ethics can play in redressing the resource allocation disparities between public and private health care sectors in South Africa, pointing out the existing gap in financing, as well as human resource between public and private health care sectors, which leads to poor health outcomes in public sector. Therefore, the problem is the prevalent inequality of resource allocation between private and public health care sectors. The analysis of policy gaps, as well as evaluating the cause of disparities in the health system is the goal of this research. The study endeavours to redress the disparities within the context of Ubuntu ethical principles and proposes a change in public policy so as to enhance healthcare for the benefit of the people. The study is philosophical and ethical, so the methodology used is discursive in nature, majorly focusing on critically reviewing existing literature, that is, the philosophical resources on Ubuntu ethics and justice theories as well as a range of government resources inclusive of public health policy documents. Social determinants of health and their impact in a South African context are discussed with the implication that health is not merely freedom from disease and or incapacity, but rather being well mentally, physically and socially. The attainment of a healthy status goes beyond ability to access healthcare services, and incorporates social determinants including but not limited to conditions in which people have been born into, stay, establish career and grow old in. It also includes the arrangements put in place to deal with illness and determine health. Issues of revenue, literacy, communal safety networks, vocation and conditions under-which vocation is undertaken, lack of work and vocation insecurity, early stages of human development, gender, cultural group, dietary insecurity, housing communal exclusion and disability all come into the picture as factors that determine health. But there is also discussion of the socio-economic status as contributors to health inequity wherein alcohol abuse, sugar intake, and smoking are identified as behavioural factors that complicate public health. One outstanding feature of this research is that it establishes a link between Ubuntu and public health policy. The researcher establishes that Ubuntu ethics is appropriate for not only discussing public morality, but also for formulating public policy that is morally tenable for South Africa, especially for the public health sector. This thesis calls for an application of Ubuntu in a proper context in order to enhance societal well-being for the benefit of many, if not all. The research proposes the fundamental principle of Ubuntu ethics in which the good of the community is as important as the good of every member of the community. Since Ubuntu ethics does not merely seek to fulfil what benefits the majority, as would be the case in a utilitarian society, the researcher advocates for the building of consensus on the common good, which should be understood to imply not just what is good for everyone in the community, but also what is good for the continued well-being of the community as a single unit. In this regard, the research finds it important that deliberate effort be made to integrate Ubuntu ethics into policies, citing the example of the National Health Insurance (NHI). The good health of all the members of a community is an assurance of the well-being and continuity of the whole national community. The research concludes that public health policy should integrate Ubuntu ethical values such as community, sharing, care, solidarity, identity, harmony, respect, and dignity into policy documents and legislation. (shrink)

Medicine is often thought of as a science of the body, but it is also a science of data. In some contexts, it can even be asserted that data drive health. This article focuses on a key piece of data technology central to contemporary practices of medicine: the medical record. By situating the medical record in the perspective of its history, we inquire into how the kinds of data that are kept at sites of clinical encounter often depend on (...) informational requirements that originate well outside of the clinic, in particular in health insurance records systems. Although this dependency of today's electronic medical records on billing requirements is widely lamented by clinical providers, its history remains little studied. Following the archaeology of medicine developed by Michel Foucault in The Birth of the Clinic and expanding his methodology in light of more recent contributions to the field of media archaeology, this article excavates some of the underexplored technological conditions that help constitute today's electronic medical record. If in some contexts, it is true that data drive health, then an archaeology of medical records helps reveal how health insurance records often impact clinical care and, by extension, health and disease. (shrink)

I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I (...) also argue against an overly strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort. (shrink)

We offer a summary of the WHO Report "Making Fair Choices on the Path to Universal Health Coverage".

In this paper, I distinguish two conceptions of solidarity, which I call solidarity as beneficence and solidarity as mutual advantage. I argue that only the latter is capable of providing a complete foundation for national universal health care programs. On the mutual advantage account, the rationale for universal insurance is parallel to the rationale for a labor union’s “closed shop” policy. In both cases, mandatory participation is necessary in order to stop individuals free-riding on an ongoing system of (...) mutually advantageous cooperation. (shrink)

President Bush and his Council of Economic Advisors have claimed that the U.S. shouldn’t adopt a national health program because doing so would slow innovation in health care. Some have attacked this argument by challenging its moral claim that innovativeness is a good ground for choosing between health care systems. This reply is misguided. If we want to refute the argument from innovation, we have to undercut the premise that seems least controversial -- the premise that our (...) current system produces more innovation than a national health program would. I argue that this premise is false. The argument requires clarifying the concept ‘national health program’ and examining various theories of human well-being. (shrink)

This dissertation aimed to examine the consequence of health-induced poverty and two policy responses to address this issue among older adults in the United States and China. Specifically, Paper I investigates whether public transfers crowded out private transfers among rural and urban Chinese older families and if this dynamic would change when health care expenses were high. Paper II examines the effect of New Rural Cooperative Medical Insurance, a national health insurance program for rural residents (...) in China, on changing the incidence of health-induced poverty among middle-aged and older beneficiaries. Paper III tests the effects of closing the Medicare Part D donut hole (coverage gap) through the Affordable Care Act (ACA) on changing prescription drug cost-induced poverty. Overall, the findings obtained from these three papers provide empirical evidence that health-induced poverty is prevalent among older adults in both China and the United States and the current public transfers and health policies are either ineffective or insufficient to reduce health-induced poverty as intended. (shrink)

The study investigated factors that influence the uptake of maternal healthcare services by women in Zimbabwe, using a logit model. Data from the Zimbabwe Demographic Health Survey (ZDHS, 2015) was used. Deteriorating maternal health indicators motivated the study. The effect of socio-economic and demographic factors on the probability of utilising maternal healthcare services was examined. Descriptive statistics and a logit model were used for data analysis. Results from the logit model show that region of residence, insurance cover, (...) educational level, employment status, maternal age, birth order, place of residence, number of living children, maternal age and household income all influence the utilisation of maternal healthcare services by women in Zimbabwe. Basing on research findings, the study recommends that relevant authorities make more available vocational training centres and education institutions since education was found to influence the uptake of maternal healthcare services. There is need to encourage family planning so as to reduce the number of children, especially among the apostolic sect, which affects the uptake of maternal healthcare. Compulsory national health insurance schemes could be adopted to mitigate the effect of low income that discourages the use of institutional facilities for delivery. The issue of balanced regional development needs to be pursued through accelerating devolution to ensure equal access to maternal healthcare facilities in all provinces. (shrink)

This report by the WHO Consultative Group on Equity and Universal Health Coverage addresses how countries can make fair progress towards the goal of universal coverage. It explains the relevant tradeoffs between different desirable ends and offers guidance on how to make these tradeoffs.

In a context of imperfect risk protection, households may protect against the impact of a health shock by employing various financial and non-financial coping mechanisms, such as foregoing or reducing needed medical care, labor substitution, consumption reduction, borrowing money, dissaving, and selling assets. However, leveraging certain coping mechanisms may reduce future productivity, potentially trapping households in chronic or persistent poverty. Resources and risk are not necessarily shared equitably within a household; the ability and willingness of the household to leverage (...) coping mechanisms, or the choice of coping mechanism may depend on the social protection policy context, household socioeconomic status, and type of intrahousehold risk sharing. Vietnam has been making policy changes aimed towards achieving Universal Health Coverage for the past several decades, culminating in a 2015 change mandating universal insurance coverage. This can potentially influence both providers in making decisions around service delivery and households around financing care. This research aims to contribute to the literature exploring the relationships among direct and indirect health care costs, potentially maladaptive coping mechanisms, and household living standards, within the particular health financing and social protection environment in Vietnam. (shrink)

Introduction: The Kenyan government has put a spirited reform to ensure all Kenyans get universal healthcare. This has led to restructuring of several entities among them the health insurance industry. This is geared at alleviating the burden of catastrophic expenditure on health from the poor Kenyans. However, insurance uptake remains at less than a quarter of the population with many Kenyans still paying for healthcare out-of-pocket. These out-of-pocket payers often don’t afford the ever-increasing cost of healthcare (...) in Kenya. This study looked at how doctors deal with patients given their modality of payment. Methodology: This was an online based survey that was distributed to Kenyan doctors via email by Kenya Medical Association. The survey sought information from the respondents on how they dealt with patients given their modality of payment. In addition, respondents were asked to provide an example of a case they had dealt with that touched on each payment modality. Results: Respondents gave their experiences where insurance had influenced their clinical decisions. Codes developed from the prose were; “inability to pay”, “harmful to the patient”, “changed the prescription” among others Health insurance played a crucial role whenever respondents made decisions. Top on the list of things that the majority indicated would be considered is insurance status and/or their ability of patients to pay for the services. Conclusion: Respondents are stuck in a limbo; striving to give the best care to patients but limited by the patients’ inability to pay. In explaining their experiences, respondents explain a situation where they intend to offer the best, but patients cannot afford. This especially so for those without health insurance who end up either not getting services or at the very best, get inferior services. (shrink)

There is much philosophical literature on the duty to rescue. Individuals who encounter and could save, at relatively little cost to themselves, a person at risk of losing life or limb are morally obligated to do so. Yet little has been said about the other side of the issue. There are cases in which the need for rescue could have been reasonably avoided by the rescuee. We argue for a duty to take rescue precautions, providing an account of the circumstances (...) in which it arises. This novel duty has important implications for public policy. We apply it to the situation of some of the uninsured in the United States. Given the US clinician's duty to provide emergency care to all people regardless of ability to pay, some of the uninsured have a moral duty to purchase health insurance. We defend the duty against objections, including the possibility that a right to rescue can be waived, thus undermining a duty to take rescue precautions, that the duty of many professionals is voluntarily incurred, and that a distinction between actively assumed and passively assumed risks matters morally. (shrink)

Universal health coverage (UHC) is at the center of current efforts to strengthen health systems and improve the level and distribution of health and health services. This document is the final report of the WHO Consultative Group on Equity and Universal Health Coverage. The report addresses the key issues of fairness and equity that arise on the path to UHC. As such, the report is relevant for every actor that affects that path and governments in (...) particular, as they are in charge of overseeing and guiding the progress toward UHC. (shrink)

Decision-making regarding healthcare expenditure hinges heavily on an individual's health status and the certainty about the future. This study uses data on propensity of general health exam (GHE) spending to show that despite the debate on the necessity of GHE, its objective is clear—to obtain more information and certainty about one’s health so as to minimise future risks. Most studies on this topic, however, focus only on factors associated with GHE uptake and overlook the shifts in behaviours (...) and attitudes regarding different levels of cost. To fill the gap, this study analyses a dataset of 2068 subjects collected from Hanoi (Vietnam) and its vicinities using the baseline-category logit method. We evaluate the sensitivity of Vietnamese healthcare consumers against two groups of factors (demographic and socioeconomic-cognitive) regarding payment for periodic GHE, which is not covered by insurance. Our study shows that uninsured, married and employed individuals are less sensitive to cost than their counterparts because they value the information in reducing future health uncertainty. The empirical results challenge the objections to periodic health screening by highlighting its utility. The relevance of behavioural economics is further highlighted through a look at the bounded rationality of healthcare consumers and private insurance companies in using and providing the service, respectively. (shrink)

US Senate is considering legislation designed to immunize small businesses from lawsuits brought by customers alleging to have been infected with COVID-19 while on the premises. The legislation seeks to subsidize reopening small businesses by reducing their vulnerability to liability. I argue that the legislation produces worse public health outcomes than existing liability regimes, obliterates claims to redress supported by corrective justice, and unfairly burdens victims by forcing them to become de facto insurers of their injurers. In the US, (...) where health insurance is inextricably linked with employment, and during the pandemic with the consequent loss of employment, the legislation is cruel in addition to being ineffective, unjust, unfair and inappropriate. Since I first uploaded this manuscript to Philpapers, Senate Republicans have in fact introduced specific legislation that is marginally different than the one I discuss in the manuscript. Instead of offering blanket immunity, the current Republican proposal offers a series of substantial barriers both to filing lawsuits and to securing a successful verdict at trial. I discuss these as an addendum to the main paper. In short, though the changes impact some features of my argument, they do not alter any of the conclusions. The current proposal produces worse public health outcomes than would existing tort regime; it leaves the vast majority of those with legitimate claims to repair in corrective justice without a remedy, when providing the opportunity to secure a remedy for wrongs is in large measure, the essential nature of tort liability. Worse still, it continues to render victims the de facto insurers of those who have wronged them; it imposes the burden of spreading risks on victims who are considerably less efficient risk spreaders than are businesses and hospitals; it constitutes an inappropriate response to the challenge it seeks to address, i.e. subsidizing various sectors of the economy by reducing their overall costs; and given the fact that in the US health insurance is too closely linked to employment, it shifts the costs of the pandemic to those who are most at risk of losing their health insurance, rendering the proposal cruel in addition to inefficient, unjust, unfair and inappropriate. For those interested, I am considering a short op-ed piece assessing the particular legislative proposal. If I follow through I will let the readership know where that can be found. (shrink)

Many hold that distributing healthcare according to medical need is a requirement of equality. Most egalitarians believe, however, that people ought to be equal on the whole, by some overall measure of well-being or life-prospects; it would be a massive coincidence if distributing healthcare according to medical need turned out to be an effective way of promoting equality overall. I argue that distributing healthcare according to medical need is important for reducing individuals' uncertainty surrounding their future medical needs. In other (...) words, distributing healthcare according to medical need is a natural feature of healthcare insurance; it is about indemnity, not equality. (shrink)

Patients with serious illnesses or injuries may decide to quit their medical treatment if they think paying the fees will put their families into destitution. Without treatment, it is likely that fatal outcomes will soon follow. We call this phenomenon “near-suicide”. This study attempted to explore this phenomenon by examining how the seriousness of the patient’s illness or injury and the subjective evaluation of the patient’s and family’s financial situation after paying treatment fees affect the final decision on the treatment (...) process. Bayesian Mindsponge Framework (BMF) analytics were employed to analyze a dataset of 1042 Vietnamese patients. We found that the more serious the illnesses or injuries of patients were, the more likely they were to choose to quit treatment if they perceived that paying the treatment fees heavily affected their families’ financial status. Particularly, only one in four patients with the most serious health issues who thought that continuing the treatment would push themselves and their families into destitution would decide to continue the treatment. Considering the information-filtering mechanism using subjective cost–benefit judgments, these patients likely chose the financial well-being and future of their family members over their individual suffering and inevitable death. Our study also demonstrates that mindsponge-based reasoning and BMF analytics can be effective in designing and processing health data for studying extreme psychosocial phenomena. Moreover, we suggest that policymakers implement and adjust their policies (e.g., health insurance) following scientific evidence to mitigate patients’ likelihood of making “near-suicide” decisions and improve social equality in the healthcare system. (shrink)

Introduction: The purpose of this study was to assess dental care professionals' drug prescription knowledge, practices, and reporting of adverse drug reactions (ADRs). -/- Methods: A cross-sectional exploratory study was conducted by using a face-to-face survey administered to a sample of dentists from tertiary care hospitals in Adana, Türkiye. A questionnaire consisted of six sections with closed-ended items including sociodemographic characteristics, knowledge about drugs, patient history information, counseling practices during prescribing, source of information and ADR reporting. -/- Results: The study (...) included 180 dentists, with a 95.3% response rate. More than half of the dentists (50.6%) stated their level of knowledge about drug price/cost as low. Most of the dentists (50.6%;n=91) claimed that they never/rarely asked about health insurance during patient history information. Moreover, most of the participants reported that they never/rarely and sometimes counsel the patients regarding drug mechanism of action, side effects of the drug, interaction of prescribed drug with other drugs/nutrients. It was determined that the dentists learned about the drugs from Vademecum (Turkish Medication Guidebook: 70%;n=126) and the internet (55%;n=99). A higher proportion (85.5%) of the dentists indicated that they did not report ADR during their clinical practice. -/- Conclusion: This study showed a general improvement in dentists prescribing knowledge and practices, although they reported some lack of knowledge regarding drug cost, discussion about the possible side effect of a drug/interaction with other drugs/nutrients with patients and under-reporting of ADRs. Periodic education and training for dentists are critical to overcoming any problem related to prescribing errors and potential ADRs. (shrink)

The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA’s provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA is (...) neither uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the health care system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry. (shrink)

A principal challenge facing the progressive bioethics project is the crafting of a consistent message on biopolitical issues that divide progressives. -/- The regulation of enhancement technologies is one of the issues central to this emerging biopolitics, pitting progressive defenders of enhancement, “technoprogressives,” against progressive critics. This essay [PDF] will argue that technoprogressive biopolitics express the consistent application of the core progressive values of the Enlightenment: the right of individuals to control their own bodies, brains and reproduction according to their (...) own conscience, under democratic states that work for the public good. -/- Insofar as left bioconservatives want to ensure the safety of therapies and their equitable distribution, these concerns can be addressed by thorough and independent regulation and a universal health care system, and a progressive bioethics of enhancement can unite both enthusiasts and skeptics. Insofar as bioconservative concerns are motivated by deeper hostility to the Enlightenment project however, by assertion of pre-modern reverence for human uniqueness for instance, then a common program is unlikely. -/- imageAfter briefly reviewing the political history and contemporary landscape of biopolitical debates about enhancement, the essay outlines three meta-policy contexts that will impact future biopolicy: the pressure to establish a universal, cost-effective health insurance system, the aging of industrial societies, and globalization. Technoprogressive appeals are outlined that can appeal to key constituencies, and build a majority coalition in support of progressive change. Finally, some guiding principles for a technoprogressive approach to biopolicy are offered. (shrink)

Credentials play an important role in all modern societies, but the analysis of their nature and function has thus far been neglected by social philosophers. We present a view according to which the function of credentials is certify the identity and the institutional status (including the rights) of individuals. More importantly, credentials enable rights-holders to exercise their rights, so that for a particular right to be exercisable the right-holder should possess, carry and sometimes show to an authority (or QR code (...) scanner) a document of a specific kind. Driving licenses, identity cards, passports, boarding passes, library passes, credit cards, ATM cards, health insurance cards are all examples of credentials in this sense. Credentials have in every case a bearer, and the bearer should be able to carry them easily on his or her person. Credentials should also be inspectable – not least because credentials can be forged. The authors analyse several historical and contemporary examples of credentials, focusing on the credentials carried by the pilgrims of the Way of Saint James. (shrink)

Patients with serious illnesses or injuries may decide to quit their medical treatment if they think paying the fees will put their families into destitution. Without treatment, it is likely that fatal outcomes will soon follow. We call this phenomenon “near-suicide”. This study attempted to explore this phenomenon by examining how the seriousness of the patient’s illness or injury and the subjective evaluation of the patient’s and family’s financial situation after paying treatment fees affect the final decision on the treatment (...) process. Bayesian Mindsponge Framework (BMF) analytics were employed to analyze a dataset of 1042 Vietnamese patients. We found that the more serious the illnesses or injuries of patients were, the more likely they were to choose to quit treatment if they perceived that paying the treatment fees heavily affected their families’ financial status. Particularly, only one in four patients with the most serious health issues who thought that continuing the treatment would push themselves and their families into destitution would decide to continue the treatment. Considering the information-filtering mechanism using subjective cost–benefit judgments, these patients likely chose the financial well-being and future of their family members over their individual suffering and inevitable death. Our study also demonstrates that mindsponge-based reasoning and BMF analytics can be effective in designing and processing health data for studying extreme psychosocial phenomena. Moreover, we suggest that policymakers implement and adjust their policies (e.g., health insurance) following scientific evidence to mitigate patients’ likelihood of making “near-suicide” decisions and improve social equality in the healthcare system. (shrink)

Background: Smart sensors have been developed as diagnostic tools for rehabilitation to cover an increasing number of geriatric patients. They promise to enable an objective assessment of complex movement patterns. -/- Objective: This research aimed to identify and analyze the conflicting ethical values associated with smart sensors in geriatric rehabilitation and provide ethical guidance on the best use of smart sensors to all stakeholders, including technology developers, health professionals, patients, and health authorities. -/- Methods: On the basis of (...) a systematic literature search of the scientific databases PubMed and ScienceDirect, we conducted a qualitative document analysis to identify evidence-based practical implications of ethical relevance. We included 33 articles in the analysis. The practical implications were extracted inductively. Finally, we carried out an ethical analysis based on the 4 principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice. The results are reported in categories based on these 4 principles. -/- Results: We identified 8 conflicting aims for using smart sensors. Gains in autonomy come at the cost of patient privacy. Smart sensors at home increase the independence of patients but may reduce social interactions. Independent measurements performed by patients may result in lower diagnostic accuracy. Although smart sensors could provide cost-effective and high-quality diagnostics for most patients, minorities could end up with suboptimal treatment owing to their underrepresentation in training data and studies. This could lead to algorithmic biases that would not be recognized by medical professionals when treating patients. -/- Conclusions: The application of smart sensors has the potential to improve the rehabilitation of geriatric patients in several ways. It is important that patients do not have to choose between autonomy and privacy and are well informed about the insights that can be gained from the data. Smart sensors should support and not replace interactions with medical professionals. Patients and medical professionals should be educated about the correct application and the limitations of smart sensors. Smart sensors should include an adequate representation of minorities in their training data and should be covered by health insurance to guarantee fair access. (shrink)

In this paper, I aim to demonstrate that the consequences of the current United States health insurance scheme on both physician and patient autonomy is dire. So dire, in fact, that the only moral solution is something other than what we have now. The United States healthcare system faces much criticism at present. But my focus is particular: I am interested in the ways in which insurance interferes with physician and patient autonomy. I will argue in favor (...) of an expansion of the traditional conception of what I call “medical autonomy” or “healthcare autonomy” and the usual role it plays in bioethical discussions. More generally, I show that in morally designing or evaluating any healthcare system, serious attention should be paid to how this system helps foster what I call active autonomy. (shrink)

The author reviews the planned withdrawal of healthcare from the primary public hospital, Grady Memorial Hospital, of Atlanta, Georgia. Prior to passage of the Affordable Care Act of 2010, at least half of the patients had no public or private health insurance and their care was financially supported by State and County funding as well as supplementation from Emory University. New administration in the elected positions of the State and County and at the University reached agreement to decrease (...) care. The University President stated that the Hippocratic Oath was no longer valid for salaried physicians who must follow the direction of their business manager. The author, a tenured Professor, was forcibly transferred to the Veterans Hospital, which also was withholding standard medical care, including life-saving medications. Organizing multiple concerned organizations including members of the King Center, the Carter Center, the Open Door Community Center, Gay Rights, etc., (Grady Coalition) multiple public protests were successful in raising the necessary funds to continue adequate care at Grady and begin an investigation of the Veterans Affairs Hospital. (shrink)

This is part of a symposium on conscientious objection and religious freedom inspired by the US Catholic Church's claim that being forced to pay for health insurance that covers abortions (the effect of 'Obamacare')is the equivalent of forcing pacifists to fight. This article takes issue with this claim, and shows that while it would be unjust on democratic principles to force pacifists to fight, given their willingness to serve their country in other ways, there is no democratic objection (...) to forcing those who believe abortion to be murder to pay for health insurance coverage that includes abortion. (shrink)

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this (...) programme have forced clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians’ duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them. (shrink)

Ongoing research in the fields of genetics and biotechnology hold the promise of improved diagnosis and treatment of genetic diseases, and potentially the development of individually tailored pharmaceuticals and gene therapies. Difficulty, however, arises in determining how these services are to be evaluated and integrated equitably into public health care systems such as Canada's. The current context is one of increasing fiscal restraint on the part of governments, limited financial resources being dedicated to health care, and rising costs (...) for new health care services and technologies. This has led to increasing public debate in the last few years about how to reform public health care, and whether we should prohibit, permit or perhaps even encourage private purchase of health care services. ;In Canada, some of these concerns have crystallized around the issue of gene patents and commercial genetic testing, in particular as illustrated by the case of Myriad Genetics' patented BRACAnalysis test for hereditary breast and ovarian cancer. While most Canadians who currently access genetic services do so through the public health care system, for those with the means, private purchase is becoming an option. This situation raises serious concerns---about justice in access to health care; about continued access to safe and reliable genetic testing supported by unbiased patient information; and about the broader effects of commercialization for ongoing research and the Canadian public health care system. Commercial genetic testing presents a challenge to health care professionals, policy analysts, and academics concerned with the social, ethical and policy implications of new genetic technologies. Using the Myriad case as an exemplar, tools from moral philosophy, the social sciences, and health policy and law will be brought to bear on the larger issues of how as a society we should regulate commercial research and product development, and more coherently decide which services to cover under public health insurance and which to leave to private purchase. Generally, the thesis is concerned with the question of "how best to bring capital, morality, and knowledge into a productive and ethical relationship". (shrink)

Objectives: This study aimed to fill the gap between Vietnamese diabetic patients' needs and care through a qualitative study asking about their experiences with diabetes and quality of care. -/- Methods: Interviews with five diabetic patients were conducted at a tertiary general hospital located in southern Vietnam. The transcribed data were first subjected to quantitative text analysis using KH Coder to identify major categories of frequently used words, followed by a qualitative analysis of selected cases using the Steps for Coding (...) and Theorization (SCAT) method. -/- Results: The major categories of frequently used words were chronic health conditions, services, facilities, insurance, patient-doctor communication, and medication. SCAT analysis of three selected cases identified six themes: “Disregarding the disease at the early stage,” “Fear of complications,” “Satisfaction with hospital services and medical staff,” “Insurance-related problems,” “Long waiting times,” and “Communication barriers between patients and doctors.” Patients were satisfied with improved hospital facilities and services; however, the overloading of one hospital led to long waiting times and communication difficulties with doctors. Difficulties with health insurance were also observed, and patients were rather passive in disease management and needed to be empowered through improved communication with doctors and other care providers. -/- Conclusion: These findings from our trial of introducing a qualitative study into service evaluation suggest that listening to patients can help health providers learn their perspectives and be more responsive to their needs. (shrink)

BACKGROUND Preconception sex selection for non-medical reasons is a controversial issue in bioethics. Little research has described preferences for preconception sex selection among Arab populations. This study describes the sex preference and interest in employing sex selection techniques among pregnant women in northern Jordan. -/- METHODS A self-reported questionnaire was administered to 600 pregnant women in Irbid, Jordan. χ2 test and binary logistic regression were used to examine the factors associated with interest in preconception sex selection. -/- RESULTS In general, (...) the interest in using sex selection was low. Women who preferred boys were more likely to be interested in sex selection, if paid for by the couple [odds ratio (OR) = 4.40, 95% confidence interval (CI): 1.75–11.11] or by health insurance (OR = 3.42, 95% CI: 1.94–6.06), or, if feasible, administered through oral medication (OR = 8.84, 95% CI: 5.05–15.63). Women with lower education were more likely to be interested in sex selection, if paid by health insurance (OR = 1.96, 95% CI: 1.10–3.45) and were more likely to believe that sex selection is legal (OR = 1.79, 95% CI: 1.06–2.86). Women who had no boys were more likely to be interested in sex selection, if paid by health insurance (OR = 1.94, 95% CI: 1.10–3.42) or, if feasible, through medication (OR = 3.03, 95% CI: 1.82–5.00). -/- CONCLUSIONS The majority of participants were not in favor of using preconception sex selection. Those with a preference to have boys, with lower education, and those with an imbalanced family were more likely to be interested in using sex selection technology. (shrink)

In response to Ruud ter Meulen’s contribution, it is argued that, although the relationship between these concepts is both tight and complex, solidarity should be carefully distinguished from justice. Although ter Meulen wants to defend a normative conception of solidarity, the relation to its descriptive component is not always very clear. As a normative concept it should not collapse into that of justice; and as a descriptive notion it is obviously defective. In order to successfully navigate between these unhappy alternatives, (...) ter Meulen rightfully turns to critical theory. But then it is still not entirely clear how the normative considerations that ter Meulen wants to defend follow from this promising framework. (shrink)

The current economic crisis caused by the COVID-19 pandemic has created new changes and challenges for society, which has led to a deeper identification of pressing problems and to develop strategies and models for overcoming crises in various countries, industries and businesses. The formation and improvement of modern strategies and models of crisis management is impossible without optimizing the resources of economic entities, providing assistance at various levels of government to support priority sectors of the economy, finding additional sources of (...) funding to combat the COVID-19 pandemic. To ensure the effective develop and implementation of modern strategies and models of crisis management it is necessary to have information about the state of economic entities, relevant commodity, raw materials, financial markets, explore the internal and external environment, determine the impact of risks on current activities business entities or industries. The effectiveness of crisis management strategies and models is determined by the ability of the management system to ensure the support of business activity of economic entities in the relevant market and to stimulate effective consumer demand. The purpose of writing this scientific monograph is to substantiate the theoretical and methodological foundations and to form and improve strategies and models of crisis management taking into account new changes and challenges for society related to the COVID-19 pandemic and declining business activity of economic entities. The object of the author’s research was the process of formation and improvement of crisis management strategies and models in the conditions of market imbalance and change of the external environment, reduction of activity volumes of economic entities, growth of budget expenditures to combat the COVID-19, formation of new forms of activities and penetration of information technology into various spheres of life to optimize the negative consequences of a pandemic. The subject of the study were socio-economic, organizational and institutional processes of formation and effective implementation of strategies and models of crisis management in various areas of economic activity; substantiation of mechanisms for ensuring the competitiveness of economic entities and the formation new forms of entrepreneurship; development of modern information technologies; consideration of best practices in business process management and digitalization using world experience in various sectors of the economy caused by the COVID-19. (shrink)

Offers a commentary on the Report 'A Fair Path to Universal Health Coverage' from the perspective of the Director of the Ethiopian Ministry of Health.

Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with (...) ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D. (shrink)

This study attempts an exposition of different perceptions of obligation to medical treatment that have emerged from the Islamic theological understanding and how they contribute to diversity of options and flexibility in clinical practice. Particularly, an attempt is made to formulate an Islamic perspective on ordinary and extraordinary means of medical treatment. This distinction is of practical significance in clinical practice, and its right understanding is also important to public funded healthcare authorities, guardians of the patients, health and life (...) insurance institutions, and employers who provide health care coverage to their employees. Not only these parties, but also lawyers and justice administration functionaries such as public prosecutors and judges are in need of understanding this distinction to deal with relevant litigations. The distinction could be made regarding terminally ill patients and non-terminally ill patients separately. The essential factors that matter in making the distinction between ordinary and extraordinary means of treatment are: (1) patient capacity (2) expert advice, and (3) nature of medication. Regarding terminally ill patients, medical treatment can become extraordinary because of (1) patient capacity and (2) nature of medication. In both these case the deciding condition applies: the expert advice taken from a group of physicians. In regards to non- terminally ill patients, extraordinary medical treatment includes three cases: (1) treatment that is known to be useless and futile, (2) treatment that endangers the life or cause more harm than what it removes, and (3) useful treatment, but the patient is unable to bear the cost. (shrink)

Termination in international contracts is considered a harsh sanction that harms international trade for each breach of contract or its provisions. The interest of international trade is fulfilled in maintaining and completing performance of contract, even if with a breach rectifiable by remedy. The termination destroys the contract and results in returning goods after their dispatch in addition to the accompanying new freight and insurance expenses and administrative and health procedures necessary for the entry and exit of goods (...) and to pay then refund the price. Moreover, the goods are exposed again to damage and perishing risks. Furthermore, the international sale contract is inherently associated with other international contracts such as goods transport contract, insurance contract and documentary credit through which the price is paid. If the sale contract is terminated, its effect will apply to all other associated contracts, if not performed, which produces many issues and hardships. (shrink)

This project considers whether and how research ethics can contribute to the provision of cost-effective medical interventions. Clinical research ethics represents an underexplored context for the promotion of cost-effectiveness. In particular, although scholars have recently argued that research on less-expensive, less-effective interventions can be ethical, there has been little or no discussion of whether ethical considerations justify curtailing research on more expensive, more effective interventions. Yet considering cost-effectiveness at the research stage can help ensure that scarce resources such as tissue (...) samples or limited subject popula- tions are employed where they do the most good; can support parallel efforts by providers and insurers to promote cost-effectiveness; and can ensure that research has social value and benefits subjects. I discuss and rebut potential objections to the consideration of cost-effectiveness in research, including the difficulty of predicting effectiveness and cost at the research stage, concerns about limitations in cost-effectiveness analysis, and worries about overly limiting researchers’ freedom. I then consider the advantages and disadvantages of having certain participants in the research enterprise, including IRBs, advisory committees, sponsors, investigators, and subjects, consider cost-effectiveness. The project concludes by qualifiedly endorsing the consideration of cost-effectiveness at the research stage. While incorporating cost-effectiveness considerations into the ethical evaluation of human subjects research will not on its own ensure that the health care system realizes cost-effectiveness goals, doing so nonetheless represents an important part of a broader effort to control rising medical costs. (shrink)

Most people are completely oblivious to the danger that their medical data undergoes as soon as it goes out into the burgeoning world of big data. Medical data is financially valuable, and your sensitive data may be shared or sold by doctors, hospitals, clinical laboratories, and pharmacies—without your knowledge or consent. Medical data can also be found in your browsing history, the smartphone applications you use, data from wearables, your shopping list, and more. At best, data about your health (...) might end up in the hands of researchers on whose good will we depend to avoid abuses of power.2 Most likely, it will end up with data brokers who might sell it to a future employer, or an insurance company, or the government. At worst, your medical data may end up in the hands of criminals eager to commit extortion or identity theft. In addition to data harms related to exposure and discrimination, the collection of sensitive data by powerful corporations risks the creation of data monopolies that can dominate and condition access to health care. -/- This chapter aims to explore the challenge that big data brings to medical privacy. Section I offers a brief overview of the role of privacy in medical settings. I define privacy as having one’s personal information and one’s personal sensorial space (what I call autotopos) unaccessed. Section II discusses how the challenge of big data differs from other risks to medical privacy. Section III is about what can be done to minimise those risks. I argue that the most effective way of protecting people from suffering unfair medical consequences is by having a public universal healthcare system in which coverage is not influenced by personal data (e.g., genetic predisposition, exercise habits, eating habits, etc.). (shrink)

Despite the recent advances in information and communication technology that have increased our ability to store and circulate information, the task of ensuring that the right sorts of information gets to the right sorts of people remains. We argue that the many efforts underway to develop efficient means for sharing information across healthcare systems and organizations would benefit from a careful analysis of human action in healthcare organizations. This in turn requires that the management of information and knowledge within healthcare (...) organizations be combined with models of resources and processes of patient care that are based on a general ontology of social interaction. The Health Level 7 (HL7) is one of several ANSI-accredited Standards Developing Organizations operating in the healthcare arena. HL7 has advanced a widely used messaging standard that enables healthcare applications to exchange clinical and administrative data in digital form. HL7 focuses on the interface requirements of the entire healthcare system and not exclusively on the requirements of one area of healthcare such as pharmacy, medical devices, imaging or insurance transactions. This has inspired the development of a powerful abstract model of patient care called the Reference Information Model (RIM). The present paper begins with an overview of the core classes of the HL7 (Version 3) RIM and a brief discussion of its “actcentered” view of healthcare. Central to this account is what is called the life cycle of events. A clinical action may progress from defined, through planned and ordered, to executed. These modalities of an action are represented as the mood of the act. We then outline the basis of an ontology of organizations, starting from the theory of speech Acts, and apply this ontology to the HL7 RIM. Special attention is given to the sorts of preconditions that must be satisfied for the successful performance of a speech act and to the sorts of entities to which speech acts give rise (e.g. obligations, claims, commitments, etc.). Finally we draw conclusions for the efficient communication and management of medical information and knowledge within and between healthcare organizations, paying special attention to the role that medical documents play in such organizations. (shrink)

Background: Despite the at least decades long record of philosophical recognition and interest, the intricacy of the deceptively familiar appearing concepts of ‘disease’, ‘disorder’, ‘disability’, etc., has only recently begun showing itself with clarity in the popular discourse wherein its newly emerging prominence stems from the liberties and restrictions contingent upon it. Whether a person is deemed to be afflicted by a disease or a disorder governs their ability to access health care, be it free at the point of (...) use or provided by an insurer; it also influences the treatment of individuals by the judicial system and employers; it even affects one’s own perception of self. -/- Aims: All existing philosophical definitions of disease struggle with coherency, causing much confusion and strife, and leading to inconsistencies in real-world practice. Hence, there is a real need for an alternative. -/- Materials & Methods: In the present article I analyse the variety of contemporary views of disease, showing them all to be inadequate and lacking in firm philosophical foundations, and failing to meet the desideratum of patient driven care. -/- Results: Illuminated by the insights emanating from the said analysis, I introduce a novel approach with firm ethical foundations, which foundations are rooted in sentience, that is the subjective experience of sentient beings. -/- Discussion: I argue that the notion of disease is at best superfluous, and likely even harmful in the provision of compassionate and patient-centred care. -/- Conclusion: Using a series of presently contentious cases illustrate the power of the proposed framework which is capable of providing actionable and humane solutions to problems that leave the current theories confounded. (shrink)