Changes in health system financing and delivery have the potential to save thousands of lives and billions of dollars. The overarching value system embedded in these new models for payment is a rough utilitarianism with origins in economic analysis. These models use financial incentives to change the behavior of physicians, hospitals, and patients. In addition, many of these policy approaches are also based in other normative approaches to medical care with links to liberal economic theory. While these utilitarian-based innovations in insurance and payment policy have often proven to improve access and quality of care in the aggregate, they have frequently been shown to have less benefit or even cause harm to vulnerable populations. This chapter demonstrates how improvements in quality of care frequently have the unintended consequence of widening disparities, either because the populations who had the worst outcomes to start with are more difficult to reach with improved-care models, or because the mechanisms designed to increase access and quality actually destabilize institutions that have long served the poor. As health reforms are implemented, attention to their impact on poor patients and the institutions that serve them will be essential.
The quality of care delivered to Parkinson's disease patients in the U.S. Pacific Northwest Veterans Health System