Fair Enough? Inviting Inequities in State Health Benefits — NEJM

Fair Enough? Inviting Inequities in State Health Benefits — NEJM:

How much leeway should HHS allow in benefits programs?

I believe that the HHS proposal reflects an inadequate view of equality. A better approach would be to establish uniform standards so that all Americans would have access to the same high-quality goods and services.5 Such a policy could mean the difference between life and death, and it has been well tested and long debated. Indeed, this solution is grounded in the Aristotelian principles of vertical and horizontal equity. Vertical equity calls for different quantities and intensities of goods and services for persons with different needs. For example, patients with conjunctivitis and those with glaucoma need different treatments to restore normal ocular function. Horizontal equity demands that persons with the same needs receive the same treatment. Providing such persons disparate care — as might well happen under the flexible system established by HHS — represents horizontal inequity.

Those who object to the uniform-standards solution will counter that it idealistically and naively seeks, as measures of fairness, the same health outcomes and the same amounts of care for everyone. In fact, however, it is based on the principle of proportionality — the notion that similar cases should be treated similarly and different cases differently, in proportion to their differences. Medical cases in which the health needs are the same are deemed alike; those in which the health needs are different are considered unalike. Such a solution would also require that health care be provided in keeping with medical necessity and medical appropriateness and that patients and their doctors — not state insurance exchanges, state governments, or private health plans — be the ones to make such assessments, within the scope of national standards.

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