Essays on the equitable distribution of healthcare

This dissertation investigates methods to incorporate societal preferences for equity in health economic decision making. Cost --effectiveness analysis (CEA) solves the problem of how to prioritize health programs so as to maximize health. However, CEA may not always agree with our social preferences for prioritizing health programs. For example, suppose for a cohort of persons, two health programs deliver at the same cost, the same aggregate health gain. However, the first program gives the health gain mostly to those poor in health and the second program gives it mostly to those rich in health. Individuals may strictly prefer the first health program to the second, yet CEA would consider these health programs equivalent. We call this preference behavior 'inequality aversion'. Inequality aversion may explain, in part, why there is sometimes negative reaction to policies prescribed by CEA.;In this dissertation, existing equity models are reviewed, potential framing problems in the elicitation process are analyzed, and finally a new model is proposed which extends the Rank-Dependent QALY model to reference dependence. Results of the framing study suggest that preferences for equality are volatile and the common way of asking for preferences for equality tends to violate the sure thing principle. When an additive social utility model is assumed, question frames that occasion preferences consistent with the sure thing principle are desirable because they are more likely valid when this is the case. Results of the reference-dependent equity study suggest that preferences for equity vary depending upon whether a policy maker is looking to expand existing health coverage or to curtail it. Respondents exhibited stronger preferences for equity in "loss" scenarios that curtailed existing health coverage. Two model types are incorporated: a power utility model and an equity weighting model. Results indicate that respondents have a diminishing marginal utility function for health. After adjusting for utility curvature, the median equity weighting function for both gains and losses were linear. Our results suggest that preferences for equity can be sufficiently measured by a utility function and that the equity weighting function adds little value.