Policy Challenges in Modern Health Care

By David Mechanic; Lynn B. Rogut et al. | Go to book overview
Save to active project

Accountability for Reasonable
Limits to Care


All health systems, whether public or private or rich or poor, limit access to medical care. Occasionally, this limit setting takes the form of a public melodrama focused on the “heartless” denial by an “evil” insurer or bureaucrat of a “last-chance” treatment for a dying patient. Such drama leaves little room for the limit setter to claim moral authority. For example, when Medicaid denied coverage for a bone marrow transplant to young Coby Howard in Oregon, the script of the public drama barely mentioned the fact that he was not in remission from his leukemia and therefore was not even eligible for a transplant.

The backlash against this case propelled the state to evaluate its Medicaid coverage through a process that attracted international attention. Yet most lightning-rod cases yield no such positive, if unintended, side effects. In Fox v. Health Net (Sup. Ct. 219692 [1993]), for example, a California jury decided that a private insurer's initial denial of an unproven bone marrow transplant contributed to the patient's death. The resulting $89 million judgment, combined with lobbying by interest groups, helped make bone marrow transplant the standard of care for advanced breast cancer—delaying discovery that such treatment was ineffective.

Public melodramas generally mislead people about efforts to set limits on health care, for most such efforts do not involve last-chance rescues. Avoiding these dramas—and viewing extreme situations more critically and dispassionately— requires that we learn how to set limits fairly and well in more typical settings.

Consider a case that entailed more established treatments and no life-saving rescue. When Massachusetts Medicaid recently faced cuts owing to steep declines in state revenue, the high cost of psychiatric drugs became a target (Sabin and Daniels 2003a). The agency established a process through which key stakeholders would develop a cost-reducing coverage policy acceptable to psychiatrists and patient advocates. Despite opposition by the American Psychiatric Association (APA) to limits on drug coverage, including requirements that providers obtain prior approval, the decision-making process secured acceptance of the plan among local psychiatrists and patient advocates.


Notes for this page

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
Loading One moment ...
Project items
Cite this page

Cited page

Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

Cited page

Bookmark this page
Policy Challenges in Modern Health Care


Text size Smaller Larger
Search within

Search within this book

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

While we understand printed pages are helpful to our users, this limitation is necessary to help protect our publishers' copyrighted material and prevent its unlawful distribution. We are sorry for any inconvenience.
Full screen
/ 276

matching results for page

Cited passage

Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

Cited passage

Welcome to the new Questia Reader

The Questia Reader has been updated to provide you with an even better online reading experience.  It is now 100% Responsive, which means you can read our books and articles on any sized device you wish.  All of your favorite tools like notes, highlights, and citations are still here, but the way you select text has been updated to be easier to use, especially on touchscreen devices.  Here's how:

1. Click or tap the first word you want to select.
2. Click or tap the last word you want to select.

OK, got it!

Thanks for trying Questia!

Please continue trying out our research tools, but please note, full functionality is available only to our active members.

Your work will be lost once you leave this Web page.

For full access in an ad-free environment, sign up now for a FREE, 1-day trial.

Already a member? Log in now.

Are you sure you want to delete this highlight?