Social welfare and the Affordable Care Act: Is it ever optimal to set aside comparative cost?

The creation of the Patient-Centered Outcomes Research Institute (PCORI) under the Affordable Care Act has set comparative effectiveness research (CER) at centre stage of US health care reform. Comparative cost analysis has remained marginalised and it now appears unlikely that the PCORI will require comparative cost data to be collected as an essential component of CER. In this paper, we review the literature to identify ethical and distributional objectives that might motivate calls to set priorities without regard to comparative cost. We then present argument and evidence to consider whether there is any plausible set of objectives and constraints against which priorities can be set without reference to comparative cost. We conclude that – to set aside comparative cost even after accounting for ethical and distributional constraints – would be truly to act as if money is no object.

► The Affordable Care Act has set comparative effectiveness research at centre stage of US health care reform.
► Comparative cost analysis has remained marginalised.
► Distributional objectives may justify down-weighting comparative cost in coverage and treatment decisions.
► To set aside comparative cost even after accounting for distribution would be truly to act as if money were no object.