Medical Need: Evaluating a Conceptual Critique of Universal Health Coverage

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional (universal, comprehensive) rather than a residual (minimalist, safety net) system. They argue that the concept (a) contradicts the idea of comprehensiveness; (b) leads to unsustainable expenditures; (c) is too indeterminate for policy; and (d) supports only a prioritarian distribution (and therefore a residual system). I argue (a) that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and (b) that UHC is a solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy (c) are not transparent about the source (ethical, semantic, political, or other) of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. I then argue that (d) the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option.