Patients' rights after health care reform: who decides what is medically necessary?

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers.

Patients' rights to care under Clinton's Health Security Act: the structure of reform

Like most reform proposals, President Clinton's proposed Health Security Act offers universal access to care but does not significantly alter the nature of patients' legal rights to services. The act would create a system of delegated federal regulation in which the states would act like federal administrative agencies to carry out reform. To achieve uniform, universal coverage, the act would establish a form of mandatory health insurance, with federal law controlling the minimum services to which everyone would be entitled. Because there is no constitutionally protected right to health care and no independent constitutional standard for judging what insurance benefits are appropriate, the federal government would retain considerable freedom to decide what services would and would not be covered. If specific benefits are necessary for patients, they will have to be stated in the legislation that produces reform.

Anticipated changes in the doctor-patient relationship in the managed care and managed competition of the Health Security Act of 1993

The doctor-patient relationship is the cornerstone of medical ethics, yet the relationship will change significantly under the Health Security Act of 1993. In a way, managed care and managed competition are a return to the old medical ethics: doing everything reasonable and probably beneficial for all, instead of going all out for each. Five central questions may help physicians and policy makers anticipate a paradigm shift in ethics. An analysis of these questions suggests that managed care and managed competition challenge physicians' roles as trustworthy patient advocates. Fortifying doctor-patient relationships in managed care would be prudent and wise and would help to achieve the ethical allocation of limited resources. By protecting patients' personal medical interests and empowering patients to do the same, doctors can attempt to safeguard trust. Both doctors and patients want to have strong, personal, values-oriented relationships. Whether such relationships are possible under the Health Security Act remains to be seen.

Health care reform and the right to health care

Where is the right to health care in the national debate? The Clinton health care plan would translate moral commitment to equitable access to a decent minimum of health care into a legal right to health care. This article reviews health care reform from the perspective of a right to health care.