HLTH 4530 Week 9 Rationing Argument Paper Example

Rationing in the Open: Defending a State Program's Rule Limiting a Costly Hepatitis C Cure to Advanced Liver Disease, Against the Quieter Rationing of Queues and Paperwork

Student Name

Walden University

HLTH 4530: Healthcare Economics From a Population Health Perspective

Instructor Name

Month Day, Year

Rationing in the Open: Defending a State Program's Rule Limiting a Costly Hepatitis C Cure to Advanced Liver Disease, Against the Quieter Rationing of Queues and Paperwork

The Restriction and the Position

A composite state health program, which covers low-income adults, has decided that a new direct-acting antiviral drug for chronic hepatitis C will be paid for only in patients with advanced liver scarring, stage F3 or cirrhosis, for the next two years. This paper defends that limit as the fairer of the available ways to ration a cure the program cannot yet afford for everyone, on the condition that it is published, time-limited and open to appeal.

Why Rationing Is Unavoidable Here

Direct-acting antivirals cure most patients with hepatitis C in a short course of pills, a major advance over earlier treatment. When the first of these drugs reached the market, its wholesale price was about $1,000 per pill, or $84,000 for a 12-week course (Hoofnagle & Sherker, 2014). A program with tens of thousands of infected enrollees and a fixed annual budget could not pay for every patient in the first year without cutting other services. Some form of rationing was going to happen. The only question was how.

This was not a hypothetical problem. Barua et al. (2015) reviewed state Medicaid policies for sofosbuvir in 2014 and found that 74% of the 42 states with known criteria limited access to people with advanced fibrosis or cirrhosis, and most also imposed restrictions based on prescriber type or drug and alcohol use.

Explicit and Implicit Rationing

Explicit rationing sets a published rule about who receives a service and applies it consistently. A fibrosis threshold is explicit: anyone can read it, see why a patient qualifies or not and argue that it should change.

Implicit rationing limits care without stating a rule. It works through waiting lists that grow until some patients give up, prior authorization forms so demanding that some clinicians never complete them, narrow approval windows and slow appeals. Every program that faces more demand than budget rations implicitly if it does not ration explicitly. The care still goes to some people and not others; the difference is that no one has to say why.

The Argument for the Explicit Rule

Explicit criteria are fairer than implicit ones for three reasons.

First, they can be challenged. Daniels and Sabin (1997) argue that limits on care are legitimate only if the reasons for them are public, relevant to meeting health needs fairly, open to appeal and revision, and enforced. A published fibrosis threshold can meet all four conditions. A waiting list that thins itself out cannot meet any.

Second, they direct scarce treatment to those at greatest near-term risk. Patients with advanced scarring are closest to cirrhosis, liver failure and liver cancer; treating them first prevents the most severe harm per course of treatment during the period when courses are scarce.

Third, implicit rationing tends to favor the advantaged. People with persistent clinicians, flexible jobs and familiarity with paperwork get through queues and forms; people without them do not. An explicit clinical rule does not depend on who can work the system.

The Strongest Objection

The best case against the restriction is that it makes people wait for their livers to be damaged before they can be cured. Hepatitis C causes scarring slowly but steadily. A patient at stage F2 today who is denied treatment may reach F3 in a few years, having suffered damage that early treatment would have prevented. The disease can also cause fatigue and other symptoms well before advanced scarring. And untreated patients can transmit the virus, particularly through shared injection equipment, so withholding a cure from people who inject drugs may sustain transmission that treatment would stop. National clinical guidance now recommends treatment for nearly all people with chronic hepatitis C, regardless of fibrosis stage (Bhattacharya et al., 2023). Barua et al. (2015) also concluded that the state restrictions they found did not conform with professional recommendations and appeared to conflict with federal Medicaid law requiring coverage consistent with a drug's label.

Reply: Concede the Harm, Defend the Form

The harm is real, and this paper concedes it. Waiting harms some patients, and a restriction that excludes people who inject drugs entirely would be indefensible on both health and transmission grounds. The defense here is narrower: given that the program cannot treat everyone this year, an explicit rule is a better way to decide who goes first than the implicit alternatives. Three conditions make the rule defensible rather than merely convenient.

It must be temporary. The rule should expire after two years and be reviewed annually as prices fall and budgets adjust. Prices for these drugs did fall after competitors entered the market, and a rule fitted to 2014 prices would not be justified today.

It must not exclude by behavior. Requirements of drug or alcohol abstinence, which most states imposed in 2014 (Barua et al., 2015), ration by social judgment rather than by clinical need, and they withhold treatment from the people most likely to transmit the virus.

It must allow appeal. Patients below the threshold with severe symptoms, other liver disease or high transmission risk should be able to request an exception through a fast, published process.

Who Decides the Threshold

The threshold should be set by the program's clinical advisory committee in public, with its reasons and evidence posted, and reviewed each year against the drug's price and the program's enrollment. Patients and advocates should have a formal way to submit evidence to that review, and the committee should publish its response to each submission so that the reasons for keeping or changing the threshold are on the record.

Conclusion

Every health program with a fixed budget rations. Hiding that fact behind queues and paperwork does not spare patients; it only hides who loses and why. An explicit, temporary and appealable rule limiting a costly cure to those with advanced disease is defensible as a transitional measure, provided it is revised as soon as the budget allows broader treatment and does not turn clinical rationing into moral judgment about patients.

References

Barua, S., Greenwald, R., Grebely, J., Dore, G. J., Swan, T., & Taylor, L. E. (2015). Restrictions for Medicaid reimbursement of sofosbuvir for the treatment of hepatitis C virus infection in the United States. Annals of Internal Medicine, 163(3), 215-223. https://doi.org/10.7326/M15-0406

Bhattacharya, D., Aronsohn, A., Price, J., Lo Re, V., & AASLD-IDSA HCV Guidance Panel. (2023). Hepatitis C guidance 2023 update: American Association for the Study of Liver Diseases-Infectious Diseases Society of America recommendations for testing, managing, and treating hepatitis C virus infection. Clinical Infectious Diseases. Advance online publication. https://doi.org/10.1093/cid/ciad319

Daniels, N., & Sabin, J. (1997). Limits to health care: Fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philosophy & Public Affairs, 26(4), 303-350. https://doi.org/10.1111/j.1088-4963.1997.tb00082.x

Hoofnagle, J. H., & Sherker, A. H. (2014). Therapy for hepatitis C: The costs of success. New England Journal of Medicine, 370(16), 1552-1553. https://doi.org/10.1056/NEJMe1401508