Medical care and public policy: the benefits and burdens of asking fundamental questions

This article questions two assumptions that regularly appear in discussions of what a fundamental discussion of medical care policy choices should inc lude. First, we review skeptically the presumption that explicit specificat ion of the scope of publicly financed medical services is a crucial step in improving policy-making in the health and medical care arenas. Second, we question the appropriateness, in many if not most contexts, of explicit rat ioning, the belief that being clear about who gets what (and who does not) constitutes proper public policy. The article proceeds by looking back on t he grounds for universal access to medical care, discusses the disputes abo ut how to set limits on care, and illustrates its argument with references to Dutch debates about explicit choice, the Oregon experiment with priority setting, and the appeals to 'healthy public policy' as a standard for sens ible policy reform. The article closes with a brief discussion of the sprea d of assumptions about health reform as they move across national borders. (C) 1999 Elsevier Science Ireland Ltd. All rights reserved.