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Horizontal Inequality in Rationing by Waiting Lists
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Linköping University, Department of Management and Engineering, Economics. (The National Center for Priority Setting in Health Care, Linköping University, Linköping, Sweden)ORCID iD: 0000-0002-8159-1249
Linköping University, Department of Science and Technology. Linköping University, The Institute of Technology.
Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences. (Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden)
Department of Economics, Lund University.
2014 (English)In: International Journal of Health Services, ISSN 0020-7314, E-ISSN 1541-4469, International Journal of Health Services, ISSN 0020-7314, Vol. 44, no 1, 169-184 p.Article in journal (Refereed) Published
Abstract [en]

The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Östergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%,p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.

Place, publisher, year, edition, pages
Baywood Publishing Company, Inc., 2014. Vol. 44, no 1, 169-184 p.
Keyword [en]
Rationing, waiting list, horizontal equity, elective surgery, Sweden
National Category
Medical and Health Sciences Philosophy Health Care Service and Management, Health Policy and Services and Health Economy
URN: urn:nbn:se:liu:diva-65396DOI: 10.2190/HS.44.1.jISI: 000331060500010OAI: diva2:395440
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2015-09-22Bibliographically approved
In thesis
1. The Art of Saying No: The Economics and Ethics of Healthcare Rationing
Open this publication in new window or tab >>The Art of Saying No: The Economics and Ethics of Healthcare Rationing
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

It follows from resource scarcity that some form of healthcare rationing is unavoidable. This implies that potentially beneficial medical treatments must be denied to patients to avoid unacceptable sacrifices in other areas of society. By focusing on four, core, conceptual themes – individual responsibility, paternalism, incentives, and inequality – this thesis explores the matter of finding justifiable grounds for saying no in the context of health care.

By combining the perspectives of welfare economics and population-level ethics, the author explicate and discusses conflicting moral values involved in healthcare rationing. Four papers form the foundation for this thesis. Paper I articulates the potential role of individual responsibility as a welfarepromoting, rationing tool by exploring when healthcare services exhibit characteristics that facilitate individual responsibility for private financing. Paper II explores the normative relevance of individuals’ time preferences in healthcare rationing and when paternalism can be justified in the context of individuals’ intertemporal health choices. Paper III examines the compatibility between incentive-based organ donation and the ethical platform for setting priorities in Sweden. Paper IV empirically  investigates the existence of horizontal inequalities in using waiting lists to ration care.

From the discussion it is suggested, inter alia, that: I) Prospective responsibility as opposed to retrospective responsibility is a more productive notion of responsibility when discussing actual policies. However, potential positive effects need to be weighed against the increased economic inequality that it is likely to invoke. II) Although cost-effectiveness analysis provides valuable input when making rationing decisions it should not be viewed as a decision rule, since it is based on utilitarian values that constantly need to be balanced against other nonutilitarian values. III) Potentially, increased health could negatively affect individuals’ well-being if it creates opportunities that they are unable to take advantage of. This needs to be taken into account before embarking on paternalistic policies to improve health – policies that often target the lower socioeconomic segment.

The author concludes that decisions on rationing cannot be computed through a simple formula. Moreover, given that rationing is bound to be associated with reasonable disagreements we are unlikely to ever fully  resolve these disagreements. However, by explicitly stating conflicting moral values we are more likely to narrow the disagreements and achieve a healthcare system that is both fairer and more efficient.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 91 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1215
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-65397 (URN)978-91-7393-282-0 (ISBN)
Public defence
2011-02-04, Berzeliussalen, ingång 64, plan 9, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2015-09-22Bibliographically approved

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Tinghög, GustavAndersson, DavidTinghög, Petter
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