Justice, HMOs, and the invisible rationing of health care resources

Fleck divides his paper on health care rationing into three parts. In the first part, he presents and critically assesses the moral problems posed by invisible rationing mechanisms. He claims that such mechanisms, by being localized, privitized, and unofficial, violate Rawls's publicity condition that is an essential part of our concept of justice. In the second part, he analyzes and criticizes the role that prospective payment mechanisms such as health maintenance organizations (HMOs), diagnosis-related groups (DRGs), and Great Britain's National Health Service play as invisible rationing mechanisms. He suggests that if HMOs could be structured so as to satisfy the publicity condition, a national system of HMOs could achieve cost containment objectives. In the third part of his paper, Fleck describes such a system of HMOs in detail, and assesses it from the perspective of justice.