Tom Murray, president of The Hastings Center, discussed how and why health reform should reflect our values in an interview on NPR’s Science Friday on November 6. “We wanted to start a conversation that takes a deeper look at values underlying health care and health reform,” he said. Murray made a case for universal participation—coverage for all, coupled with the responsibility of individuals to obtain it, andenabled by costs shared among individuals, employers, and government.

Click here for a full text transcript of the conversation.

Host Ira Flatow said in his introduction:

“Lost in the fray [of acronyms and actuarial tables] is the whole reason to have the health care debate in the first place…we’re going to try to reel it back in to talk about our values. What role do they play in shaping health care policy?”

Flatow noted that in its recent collection of essays, Connecting American Values with Health Reform, “The Hastings Center has tried to bring values back into the discussion.”

Len Nichols, health policy director at the New America Foundation, also participated in the show. Nichols, a health economist who wrote an essay on stewardship for the Hastings Center collection, said that passage of the final health care reform legislation is contingent on leadership that promotes shared values. “It is sometimes true is that those values seem to differ among political antagonists….but when you probe deeply and get in a dialogue you find out the values are actually shared,” Nichols said. “I believe most people share them and therefore we will end up with a bill that moves our country forward.”

The following was delivered as a speech to the Freedom Fest in Kansas City, MO on September 5 2009.

Why is it important to talk about health care at a rally for freedom?

Well, about 100 years ago, the government said it would ensure high-quality doctors. What they did was take away our freedom to get low-cost routine care from nurses and other clinicians, as well as our freedom to choose different types of health systems. In place of that freedom, they gave us higher health care costs, and lower quality medical care.

Then the government said it would ensure high-quality health insurance. What they did was take away our freedom to purchase health insurance from outside our own state. In place of that freedom, they allowed special interests to drive up the cost of health insurance with hidden taxes and coverage that we don’t want or need.

Then the government said it would make health insurance more affordable. Instead, they took away your freedom to control your earnings, choose your health plan, and buy secure health coverage. You know that $9,000 that your employer uses to pay for your family policy? It isn’t your employer’s money. It’s your money. But the government gave it to your employer. In place of the freedom to control our earnings and choose our health plan, the government gave us higher costs and health insurance that disappears the moment we get sick and can’t work anymore.

The government said it would make prescription drugs and medical devices safe and effective. What they did was take away your freedom to choose your course of medical treatment. And what took the place of your freedom? Every study that’s ever been done has found that we would save lives if government stopped regulating drugs so heavily.

The government said it would provide health care to the elderly. What they did was take away your freedom to save for and choose your own health plan in retirement. In place of that freedom, they gave us the Medicare program, which has cost far more than projected, and is the main reason why costs are so high. Medicare has required one tax increase every four years — and it’s still $80 trillion in the hole. As for quality, Medicare is the single largest reason that medical errors kill as many as 100,000 Americans each year. And it took Medicare at leastten years to improve mortality rates — if it has improved mortality at all, which remains an open question.

Finally, the government said it would provide health care to the poor. What they did was take away your freedom to provide charitable care as you see fit. In place of that freedom, they gave us government programs that provide medical care to millions of people who could afford it themselves. Your bill for those programs is more than $1,000 a year.

And now that government has:

• Taken away so much of our freedom,
• Reduced our health insurance choices and choice of providers,
• Driven health care costs skyward,
• Pushed quality downward,
• Given us health insurance that disappears when our jobs disappear, and
• Saddled us with entitlement programs that will cause income-tax rates to double by mid-century…

Now President Obama comes to us and says: Give me just a little more of your freedom, and I’ll make it all better. Let me force you to purchase health insurance. Let me decide what you’ll buy and use price controls to set the premiums. Let me add to your tax burden with yet another failing government program. Let government bureaucrats decide whether you and your loved ones get the treatment you want.

We can achieve so much, the president beams. All I need is just a little more of your freedom.

We’ve seen what the president wants to achieve. Politicians have already taken those freedoms away from the people of Massachusetts. And what did they get in return? Health insurance premiums are rising 40 percent faster than the national average. Waits to see a specialist are getting longer. And politicians are raising taxes like mad. All because it costs government almost twice as much to cover the uninsured as it costs the free market.

President Obama is not offering better, more affordable health care. He is offering us more of the same.

I sincerely believe that President Obama is a good man. But I propose we say, No thank you, Mr. President. We’re not going to trade in any more of our freedom. In fact, we’d like some of our freedoms back:

• Like the freedom to choose low-cost providers like nurse practitioners, and low-cost health systems,
• The freedom to control our earnings and choose our own health plans,
• The freedom to purchase health insurance across state lines, which could by itself cover 17 million uninsured Americans without costing taxpayers a dime,
• The freedom to choose our course of treatment with the advice of doctors we trust, and
• The freedom to provide medical care to the needy as we see fit.

Some will tell you: You don’t want those freedoms, those freedoms are dangerous. And you know what? They’re right.

To an insurance company that doesn’t honor its commitments, your freedom is dangerous. To a hospital that overcharges its patients, your freedom is dangerous. To the politicians, government bureaucrats, and special interests who play upon our fears to increase their power, your freedom is dangerous.

We have surrendered so much of our freedom that it’s no wonder one-third of U.S. health care spending — more than 5 percent of GDP — is completely wasted.

When we reclaim these freedoms, we will see an explosion of innovation that will make health care better and more affordable for everyone — especially the needy.

When we reclaim these freedoms, we will become a healthier nation, a wealthier nation, and most importantly, a freer nation.

This is the second part of Paul Kelleher’s two-part submission.  The first part can be found here.

In a previous post, I used Paul Menzel’s provocative contribution to the Hastings Center’s Values and Health Reform Connection as a touchstone for getting clearer on what implication the values of fairness and equality of opportunity might have for health care reform. Since that post was mostly critical in nature (I argued that they do not have the implication Menzel describes), I wanted to offer a constructive suggestion that, while not novel, might provide some reason to think that seemingly conflicting strands in contemporary political philosophy can provide mutually supportive grounds for a government guarantee of affordable access to adequate health insurance.

One thing I tried to argue in that first post was that the Rawlsian ideal of equality of opportunity does not provide the momentous rationale for justice in health care that some, including Menzel, think it does. Although Rawls is a well-credentialed liberal, he deliberately avoided the question of health justice, and it is not clear which, if any, plank of his theory could be broadened or reinterpreted to yield the pro-reform conclusions that Menzel and I stand together in endorsing.

There may, however, be a characteristic of Rawls’s view that could provide the germ of a constructive expansion. Although Menzel characterizes as “libertarian” the view that duties of justice are largely grounded in the features and consequences of special relationships, I explained in the earlier post how Rawls’s liberal interpretation of equality of opportunity stresses the ways in which features of one’s situation are the man-made result of collective decision-making by one’s society. So the distinctive features of the citizen relationship are also central to Rawls’s account. But Rawls departs from libertarianism insofar as he recognizes that the myriad social and economic choices we as a society make have such profound effects on others that they often generate strong duties of fair sharing, compensation, and fraternity. Thus even if Menzel’s conception of equality of opportunity is not itself a basic component of justice, perhaps many of its demands can be vindicated—both philosophically and, eventually, politically—in light of the special ways citizens’ lives are influenced and shaped by prevailing social and economic institutions.

Ironically, the path to such a vindication can be illuminated by none other than the most important philosophical defender of libertarianism, Robert Nozick. To be sure, Nozick is widely remembered for his bold claim that “taxation…is on par with forced labor.” But in a brief discussion of polluting activities—i.e. activities that impose “negative effects on other people’s property such as their houses, clothing, and lungs”—Nozick says that the proper response to unintentional pollution may be to “spread the cost [of addressing the negative effects] throughout society,” or, if feasible, to “place [the costs] on those who benefit from the activity.”

At this point we can follow Merrill Goozner’s lead and refer to the “vast literature on the social determinants of health” that describes the “real and enduring determinants of ill-health in our society—poverty, income inequality, social insecurity, and status anxiety.” If what the epidemiologists say is true, that is, if a central cause of poor health and health disparities is the pattern of social and economic choices made by society at large (and not by individuals on their own), then there is an argument, potentially compelling to the liberal and the libertarian alike, for coercive social measures that spread the costs of addressing consequent ill health throughout society.

We can now see that the objection on the part of the well-off to subsidizing the premiums of the poor or the care of the ill might have a conclusive rebuttal. If economic arrangements that generate inequalities also contribute significantly to the poor health of those who are ill, then it seems reasonable to require those who have benefited most from these arrangements to contribute to health care of those who benefit least and who turn out to be actively harmed by those same arrangements. In the search for rationales that might win wide consensus, then, there is some reason to hope that empirically informed arguments that are good enough for both Rawls and Nozick could be good enough for the American people.

Unfortunately, a recent study soon to be published in the American Journal of Public Health gives us reason to believe that cogent arguments will not be enough by themselves. The study finds that when presented with news stories explaining that individuals’ Type 2 diabetes is genetically caused, both Republicans and Democrats respond with some willingness to use public funds to address the medical problem. But, when presented with news stories explaining that social and neighborhood factors beyond an individual’s control cause diabetes, Republican—but not Democratic—support for public intervention wanes. So a person’s political leanings seem to have an effect on his or her receptiveness to normative arguments that should be resonant with both left-leaning and right-leaning political philosophies.

Does this mean that we philosophers must go back to the drawing board, normatively speaking? It does not. It does mean that we should be mindful that philosophy isn’t politics or advertising, and that some well-meaning advocacy campaigns may have unintended consequences. But this is likely true for virtually any cogent argument strong enough to justify robust government action where it was previously lacking and where some adamantly believe it should not exist. Fortunately, some of the very social scientists that first taught us about the social determinants of health have already begun to think systematically about how to design messaging strategies to educate the population about the many social causes of ill health. This confirms that whatever happens during this current round of reforms, it will be absolutely essential that philosophers and social scientists strengthen and extend their cooperation. Neither group can succeed without the other, but with a little luck we can together translate the rather ecumenical case for progressive health reform into political action supported by those whose values comport with this case, but who were nonetheless previously reluctant to support it.