N I R E Y A L
H a r v a r d U . P E H & H a r v a r d M e d i c a l S c h o o l
P E H a n n u a l c o n f e r e n c e 2 0 1 3

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It is usually assumed that, because it is so unfair, trading off Population (=“breadth”) is off the table.
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You can cover some of the people all of the time, or all of the
people some of the time. Most consider the latter fairer.
This talk proposes: Rationing along Population isn’t always bad, or a “trade-off”. It can be fair and good.
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I shall call that way to ration selective facilitation.

 = Phasing off public (=by government, donor, union)
facilitation (provision, financing, special administrative support) of medically-needed low- and middle-cost services, around the income % that gives the person full access to these services.
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“Full access” = private insurance market for the service is functional and the person is able to buy it and paying would not impoverish or bankrupt her.
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E.g. provide (cheap) cataract surgery for all poor populations, no matter how remote—not to middle class and rich.
E.g. fund (mid-cost) leukemia Rx for poor and middle class—not to rich.
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Note: This proposal pertains to low- and middle-cost services. High-cost services require an independent solution anyhow.

1.
By saving on insurance for those who can afford to pay out of pocket, we can protect the health of those who cannot, more.
2.
We can also protect their income more.

 By saving on insurance for the rich, we can protect the health of the poor more.
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Because we keep more money for assisting the poor.
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E.g. if annual health service budget for the entire population is $16 per person, for needier half it is roughly $32 per person.
So e.g. we may be able to fund childhood leukemia Rx for needy.
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Because if insurance universal, rich use it more than others.
 This is also a matter of fairness
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Selective facilitation would somewhat equalize health service access, access to health, and health.

 By saving on insurance for the rich, we can protect the income of the poor more.
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Because we can lower the user fees that the poor pay.
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E.g. when population-wide services require user fees at ½ the cost, funding needier population half exclusively allows scrapping fees.
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Because the rich then take back less of whatever they gave in taxes and premiums.
 Again, this is also a matter of fairness.
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Selective facilitation would somewhat equalize income.

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WHO uses “coverage” to mean “access to key … interventions … at an affordable cost.” (WHR 2010;
WHA resolution 58.33).
But that’s not what “coverage” means in English.
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E.g. in the NHS, Alex Voorhoeve has “coverage” for medical expenses not dental expenses, because he maintains his access to dental care through own-pay—even without coverage.
That linguistic muddle obfuscates important ways to achieve universal access without universal provision of services or funds.
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…which is roughly what service “coverage” means in English.

Brazil’s sistema único de saúde

“Universal coverage”
= universal public finance (UPF)

“But what does universal coverage cost? Universal coverage is not a one-size-fits-all concept; nor does coverage for all people necessarily mean coverage for everything. …moving towards universal coverage means working out how best to expand or maintain coverage in three critical dimensions: who is covered from pooled funds; what services are covered; and how much of the cost is covered. Within that broad framework, policy-makers must decide how funds are to be raised and administered.
Thailand offers prescription medicines, ambulatory care, hospitalization, disease prevention and health promotion free of charge to patients, along with more expensive medical services... But Thailand does not cover everything…” (WHR 2010, p. 22)

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“The necessary means testing and monitoring would be expensive, inefficient, intrusive, distrustful, shaming.”
“Services for poor-only get stigmatized, underused.”
“The rich won’t support programs for others, so
selectivity would lead to underfunding.”
“The rich will “poach” the health workers.”
“This will create a poverty trap.”
“In a sense, this doesn’t “treat” all equally.”

 “The necessary means testing and related monitoring would be expensive, inefficient, intrusive, distrustful, shaming.” (compare Wolff 1998)
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Making leukemia treatment etc. possible matters more.
For the middle class, we can often read income off of tax forms.
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To reduce shaming, we can simply recruit rich less vigorously
(Seguro Popular does not reach out to the rich self-employed).
To reduce shaming, we can also use rough proxies of poverty:
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 e.g. not facilitating services in some (rich) geographical areas.
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In Brazil’s sistema único de saúde, “a positive association between income and public doctor visits … becomes negative when we include local area fixed effects” (Cataife & Courtemanchez 2011).
e.g. not covering the remaining diseases of the rich (oyster poisoning?
Ski/safari accidents?).
Thanks to Gustavo Nigenda

 “Services for poor-only get stigmatized, underused.”
(compare Van Parijs 1995)
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Presumably, most key health services would be utilized.
Little stigma when services help poor and middle class not rich
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E.g. de facto some Medicare services.
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E.g. mixed housing.
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E.g. US food stamps in this recession (DeParle & Gebeloff, 2010).

 “The rich won’t support programs for others, so
selectivity would lead to underfunding.”
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But so far, Seguro Popular only expanding (Knaul et al 2012).
But politically, it may also be easier to convince voters to facilitate health services that all beneficiaries badly need.
But the “sharp-elbowed middle classes” will often remain inside (Le Grand & Winter 1987).
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But the target can be set more expansively than the real goal.

 “The rich will “poach” the health workers.” (G. Sen)
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But the rich would hire many health workers privately in any
case—even if they received free services or insurance.
So selective facilitation is not the source of this hard problem.

 “This will create a large poverty trap.”
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Seguro Popular hasn’t done that (Knaul et al Lancet 2012).
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Gradual phase out can further prevent that.
Nor need this create a “middle-class trap:”
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Becoming upper class is usually more attractive than few low/middle-cost health resources lost.

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“In a sense, this doesn’t “treat” all equally.”
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But what matters ethically is equal concern, not “equal treatment” in that sense (Dworkin 1978).
Admittedly, equal “treatment” might have palpably communicated equal citizenship.

 Selective facilitation is often the best and fairest way to achieve universal access.
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It makes sense not to fill the box’s Population dimension fully.

 If your goal is generous selective facilitation in the interests of universal access, you might still want to set something else as your stated target:
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Perhaps excessively-selective facilitation:
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The middle class will demand what you provide the poor.
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Or perhaps even universal facilitation:
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Despite de jure and de facto access to good services, the rich might not utilize services, out of snobbism: “auto-rationing” (L. Price).
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Then you get the symbolic benefits of universal insurance at a fairly similar financial cost to selective facilitation.

 Universal access to the social determinants of health is no less important.
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So can we legislate a related human right?
 e.g. a human right to the most powerful (=strong evidence shows largest impact) social determinants of basic health?
 e.g. a human right to early childhood development programs?
To economic equality?..