Universal Coverage and Social Justice

1. Universal Coverage and Social Justice • Norman Daniels, HSPH • PEH Conference on Universal Coverage • April 19, 2013

2. Overview • Rationale for Universal Coverage • Some Issues and Objections • Reasonable disagreements about UC • Bearing of conference on these points

3. 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)

4. 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)

5. 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

6. 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

7. 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

8. 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?

9. 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

10. 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

11. 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