I am encouraged by the national debate on health care. I hope that the Congress will pass a far reaching bill that will touch the lives of all Americans on the scales I have mentioned above. As a Presbyterian I am theologically interested in the issues that are being debated. At its heart I think the central theological issue is couched in the question: Is health care a right or a privilege? Like most questions with this sort of dichotomy I expect the answer will be found in an amalgamation of the two. For me, I think health care is a right. However, I can understand how those with significant financial means and varying theological perspectives might feel otherwise.

The notion of health care being a right emerges out of the theology of stewardship. Stewardship implies and connotes a sharing of one’s resources. In many religious communities stewardship is experienced in the sharing of money and time. The same notion applies in regard to health care. It is a sharing of resources. Some seem to fear that in that sharing quality, freedom, and quantity will be decreased or maybe even lost. I would suggest just the opposite. My experience is that the quality of health care is driven by those involved and the technology that is continually evolving. I see no reason for that to change for the worse because the brightest and best are still attracted to health care and the technology is on a continual upward climb. Clearly freedom will be enhanced and expanded as people have options that are not necessarily available to all at this time. The issue of quantity is a moot question, in that we currently are providing health care for many people unable to provide any financial support. When the emotionally and politically exhausting debates are over and the dust has cleared it is my contention that we will adequately move on with improved health care for all.

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.”

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.

There is some dissonance between these two planks of Menzel’s overall view. For if shifting the costs associated with unpaid emergency care simply involves having those who can pay (in the form of higher premiums) pick up the tab for those who cannot, why shouldn’t we count this as an instance of precisely the sort of fair sharing between citizens that Menzel endorses? Although his essay seems to suggest that he counts all such cost-shifting as unfair and in need of attention, perhaps Menzel wishes to make only the more modest claim that unfairness occurs only when those who receive unpaid care at emergency rooms are like the “young singles” who can afford insurance but forgo it because they see it as a bad financial bet. In these cases, the costs of one person’s unwise gamble are borne by her fellow citizens in the form of higher premiums.

But even in these cases we may have reason to think that an ideal of just social sharing would permit and perhaps even mandate shifting costs of care provided to the voluntarily uninsured. Let me note two reasons in particular for this.

First, and as Menzel acknowledges, the source of the shifted expenses is care provided by hospitals which are required by law to treat the acute health needs of anyone who presents in the emergency room. Yet as T. R. Reid points out in The Healing of America,

For the vast majority of sick people, the emergency room is not an option. Beyond that, you can’t go down to the emergency room for the physical exam or the blood test or the breast palpitation that could head off some disease before it threatens your life. You can’t go to the ER to refill the prescription for the pills required to keep you alive. (Reid: 30-31)

In contrast, the basic health care to which Menzel wants all to have access would surely include the preventive services that emergency rooms do not. But according to a recent literature review in the New England Journal of Medicine, “Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.” Even more recently, the nonpartisan Congressional Budget Office reported that “the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.” So it could turn out that it is less expensive to provide a restricted range of free emergency care even to those who make bad gambles than it is to fund, again via higher premiums, their expensive preventive care.

One might object here that if what we cared about most was others’ health, we would prioritize preventive care so as to reduce the likelihood of another’s winding up in the ER. But the argument of Menzel’s that I’ve been discussing seems concerned solely with the costs that are shifted from some onto others. It is thus unclear why a principle of social sharing enjoins us to pick up the costs associated with preventive services but not the costs associated with ER visits.

The second reason for thinking that a just sharing principle would permit shifting the costs of emergency care has to do with the typical attitude toward contribution held by proponents of universal health insurance. Whereas Menzel states that his critique of free-riders is based in the precept that “no one should get to ride the system without contributing to its upkeep,” most proponents of universal health insurance would not criticize those who would benefit without being in a position to contribute to its financing. Perhaps this attitude can be explained by a principle that requires contributions only if opportunities to contribute are readily available and not too burdensome. But then what do we say about a 25 year-old college graduate who adopts an itinerant lifestyle, living off the generosity of her friends, while pursuing what many know to be a hopeless career as an artist? Although she does not in fact have enough money to buy insurance, she could perhaps acquire it if she decided to “get a real job.” Is she contributing her fair share to the universal insurance scheme? If not, should her coverage be cancelled or her subsidies lessened?

An approach that answers “no” to that last question might put universal health insurance in the same category as universal public education: you are entitled to it regardless of whether you end up contributing to its financing. In that case, the point of mandating insurance coverage might have less to do with guarding against free-riders than it would with ensuring that there are enough funds in the health system to protect and promote the health of all. And this is indeed one of the rationales cited by Menzel for the requirement that those who can afford it buy basic (and not merely catastrophic) insurance.

The analogy with universal education makes all the more salient the justification for universal health insurance Menzel associates with equality of opportunity. Here he follows the pioneering work of philosopher Norman Daniels in seeking to ground social justice claims to health care in what seems to be a squarely American ideal. But there is reason to doubt that this is in fact a winning strategy.

Daniels’ own inspiration for the equality of opportunity approach was John Rawls’s theory of justice. But that theory provides uneven ground for the extension Daniels proposed. Rawls’s equal opportunity principle is deliberately designed to redress only those inequalities of opportunity that are socially caused, such as inequalities in access to higher education that are the result of the impact of man-made economic arrangements on family income. Rawls therefore appears reluctant to endorse the claim, which is forwarded by Daniels, that all departures from full health that are nobody’s fault but nature’s are nevertheless prima facie unjust or unfair. Rawls’s stance here comports with a familiar strand in common morality that associates injustice with strong and assignable responsibilities for redressing it, and which assigns to one much stronger responsibilities for redressing disadvantages one had a hand in causing than to redress disadvantages caused by natural bad luck.

Like Daniels, Menzel adopts an expansive interpretation of equal opportunity that views naturally caused departures from full health as opportunity-limiting and thus prime facie unjust. Yet Menzel faces a second tension connected to the fact that he seeks a foundation in the ideas currently present “in U.S. moral and political culture.” For example, Menzel explicitly rejects the suggestion that equality of opportunity demands the universal provision of more than merely “basic” care. Why? Because “in a society committed to only modest measures of income redistribution generally, collective action will be out of balance if it guarantees everyone access to care above this line.” But then it seems utterly arbitrary to accommodate an American skepticism of “redistribution generally” while at the same time relying on an expansive interpretation of equality of opportunity that would likely be judged as overreaching from that same American perspective.

***

I am grateful to Paul Menzel for kicking off the discussion about justice and fairness in health reform by offering arguments to help orient our woefully inadequate national debate about the moral bases for reform. In the end, I share his confidence that there is a cogent rationale to be found in both common morality and U.S. political culture in favor of a government guarantee of affordable access to adequate health insurance. Although I have spent this post noting points on which I disagree with Menzel’s analysis, I hope the forgoing discussion proves as useful to moving the debate forward as his original essay.

(I thank Rob Streiffer for helpful comments on an earlier draft of this post.)

Many immigrants who lawfully entered the United States are working at low-wage jobs without health insurance. They struggle, as generations of immigrants to the United States did, to get by each day, to pay the rent and put food on the table. And they are often forced to go without the health care they need because they cannot pay a doctor.

Imagine what it would be like to wait five years to get a cancer screening. Think about what you might do if you had a sick child but could not afford to see a doctor. Or imagine having diabetes and waiting five years to get regular treatment. This is unacceptable.

Today in America, legal immigrants who qualify for Medicaid services are unfairly denied access to the program for five years even though they pay taxes like everyone else. If we value fairness as a society, we must provide children and adults with access to essential, preventive care that keeps people healthy.

Why? When we prevent legal residents who diligently pay taxes from accessing routine medical care, it leads to an inefficient, costly and wasteful system of treating patients who are forced to seek care in an emergency room. It’s an expensive and ineffective way to treat conditions that require ongoing management like diabetes, heart disease or even cancer.

Letting legal immigrants pay into the health care system and get access to the care they need will bring down health care costs for the entire nation. It will allow for true access to health care for everyone who needs it and save money for our health care system in the long-run. Taxpaying legal immigrants deserve timely access to essential medical care.

If our core values as a nation are the concepts of fairness and justice, we must reflect that in the reforms of our health care system. It’s time to do what’s right and end the wait for health care.

Deeana Jang, JD is the Policy Director of the Asian & Pacific Islander American Health Forum.  As head of the D.C. office, Deeana Jang leads APIAHF’s policy work which includes improving access to health coverage, improving quality of care including linguistically and culturally competent health care services, promoting a diverse health care workforce, improving data on Asian American, Native Hawaiian and Pacific Islander health, and increasing investment in community-driven health strategies.

Single Payer

Single-payer advocates in the U.S., such as Physicians for a National Health Plan, to take just one example, argue that present health reform efforts ought not even to be considered “reform.” Steffie Woolhandler of PNHP, for example, testified at a hearing at the President’s Council on Bioethics in 2008 that most of the health reform proposals being floated during the 2008 elections constituted “placebo” reform. For PNHP, the issue is that we’ve got nearly 50 million Americans who are uninsured, and who disproportionately suffer and die because they’re uninsured, in this country. Yet others get far more care than they need, and in fact more care than can do them any good. Coverage is not stable for most Americans. Private individuals and companies profit off the illness of others. As a result, we spend far more on health care than any other developed nation, yet fail to profit from it sufficiently, and in fact do much worse in many basic measures of public health than most other wealthy nations. Dr. Woolhandler believes that all necessary and effective health care should be free for everyone who needs it, and that it should be paid for via a nonprofit, national health plan.

Single-payer health care can look different depending on its foundational principles and how it’s instantiated. PNHP, for example, advocates universal access to comprehensive, publicly funded health care, free of additional charge to the public, provided by one’s own choice of providers, with policies set through democratic means. Many of its goals are similar to the goals of Canada’s Medicare program, which are public administration, comprehensiveness, universality, portability, and accessibility. PNHP, focusing on its American audience, pays particular attention to emphasizing free choice of private providers – a feature which, in this land that otherwise emphasizes choice, most insured Americans don’t currently enjoy through their coverage.

Incongruous Values

If you believe that everyone ought to have access to health care, that everyone will benefit by having universal access, and that we have a duty to ensure such access by stewarding dollars in the most effective and efficient means possible, then single payer looks like a pretty reasonable way to go. Indeed, it – or, perhaps, another form of universal coverage, such as one that uses a heavily-regulated system of nonprofit insurers who set provider payment rates through all-payer negotiation and who accordingly also do not restrict their beneficiaries’ choices of providers – would be just about the only reasonable way to go. As Joseph White and others have detailed, we have little evidence that the private market has improved health care costs and delivery in this country in recent decades.

But, if you do not assume everyone has an equal right to health care, regardless of ability to pay, and if you give less priority to the role of social solidarity, and perhaps also regard health care primarily as a consumer good, then single payer can start to look rather problematic. This is where we find ourselves in this country, where a distinct subsection of the population believes that justice, or at least distributive justice, in the case of health care among other items, entails allowing each person to keep the fruits of his or her own labor and accomplishments, without redistribution of the wealth.

In the United States, the values that we tend to prize are not ones that would at first glance favor a single-payer, Canadian-style system, but rather something far more like what we’re presently seeing going through Congress – an at-times incongruous amalgam of conflicting values and ends. Distributive justice in health care in the United States is a curious notion. On the one hand, most would agree in principle that health care should be equally available to all, and that we should strive to make it so. We do provide a substantial amount of care through public means or charity, and most of our coverage is tax-subsidized or -advantaged. Yet few of us have guaranteed coverage, and if we go without, the public often considers this to be our own fault. The substantial role of the government in the provision, financing and regulation of coverage tends to be obscure to most casual observers. Additionally, most of us obtain our health insurance through work, which appeals to our notion, whether real or fictional, of equality of opportunity and meritocracy in action. According to these notions, those of us who have coverage through employment do so by dint of hard work, intelligence, perseverance or other traits, and many of those who lack it do so because of a failure of effort, will, or other issue.

This becomes clearer through an examination of polls asking the public about health coverage. A recent Gallup poll, for example, found that 61% of Americans believed that individuals, rather than the government, should be primarily responsible for ensuring that they and their families have health coverage. And while a plurality or majority of Americans, when polled, support national, tax-financed health insurance, the number drops substantially – to about 40% – when asked whether their support would continue if this entailed that all Americans would get their coverage from a single government plan.

These incongruous values and beliefs pose a problem in implementing any health coverage system with a relatively homogeneous set of underlying values. We can’t simply decide that a given form of coverage is abstractly best suited to accomplish certain policy and ethical goals, and then implement it accordingly. Rather, like Daniel Callahan noted in a somewhat different context, we need also to look to the structure and values of the society in which we’re proposing that such a change come about. What we presently do, and what we ultimately decide to do with respect to health reform, as the late Senator Kennedy observed, says much about us as a society. We can continue on our present path, or we can choose to more clearly opt for one set of values over another.

Values in Major Current Coverage Reform Proposals

Current health reform efforts in Congress – or at least the ones getting all the publicity – prioritize many if not most of the same goals we presently further through our health coverage system. We all know what’s going on in Congress right now. All the health coverage reform bills under serious consideration now in Congress build and expand on our present, fragmented, and largely private but substantially publicly funded health coverage system. They would require everyone to obtain coverage, largely through the private market, give subsidies to lower- and middle-income Americans, and expand Medicaid. While a public plan option for Americans who don’t have coverage through work appeared dead as of August, chances are looking slightly – _slightly_ – better for its passage, though it’s still likely that it won’t make it in any final bill that might be enacted.

Under any of these proposals, justice in both of the senses I outlined earlier will continue to be only partially served: while more people will have access to coverage, in part through redistribution of the wealth, many others will not due to inadequate subsidies in a market that will continue to be private and for-profit. Social responsibility will exist via copious tax subsidies and public program expansions, but the labyrinthine nature of the system will continue to obscure the effect this could otherwise have on fostering solidarity, instead allowing many to continue to believe, whether correctly or incorrectly, that coverage is provided for the most part via one’s own efforts and financing. Lastly, the treatment of health care as a commodity from which to profit will continue with little if any abatement.

So to what extent, if at all, could a pragmatic single-payer advocate support the major features of the primary congressional bills under consideration, as making sufficient improvement, however flawed, to the present system while also laying at least some groundwork, if not a foundation, on which to ultimately achieve their goals?

Obama and the Democrats who wrote the major House and Senate bills deliberately chose to keep the current system more-or-less intact. They feared that, if they attempted wholesale change, Americans who presently have coverage – the majority – would oppose them and kill reform altogether. It was a pragmatic move, as many have observed. But almost no matter how one defines what it means to have an adequately functioning health coverage system, the one thing nearly everyone, on any side of the political spectrum, can agree on is that our present system isn’t working. If the reform fails to make certain key changes or additions to the system, particularly regarding benefit plan and capital investment regulation, provider payment reform, and security and affordability of coverage, then a tremendous opportunity will have been lost.

All the major bills under consideration include a mandate that individuals obtain health insurance, or else pay a penalty. Additionally, all of them except the Senate Finance bill also contain some form of mandate that employers provide coverage for their employees. While the House bill penalties have some teeth, the Senate penalties for failing to obtain coverage for oneself or provide coverage for one’s employees are minimal in comparison to the price of insurance. In exchange, they require insurers to guarantee issue and renewability, to institute modified community rating, and to set minimum benefit standards for the individual and small group markets. They also provide subsidies for people buying coverage on the nongroup market to ensure that coverage costs for them don’t exceed a certain percentage of their gross income, say between 2 and 12%, depending on the bill.

Now, these mandates could be quite reasonable if, for example, health insurance plans were tightly regulated in the benefits they offered, if plans jointly negotiated provider payments, and if prices were kept within the legitimate means of all Americans, whether through subsidies or otherwise. After all, in the absence of universal, government-provided coverage, we would need some way of ensuring that everyone obtains coverage, thereby spreading the risk most broadly and, ideally, helping to avoid financial disaster for those who incur substantial medical costs. But the proposed subsidies are pretty meager for middle-income Americans. The expectations regarding the maximum appropriate percentage of income for individuals to pay for health coverage are not reasonable, and they don’t include all out-of-pocket expenses. Administration of the credits will not be simple, and will require Americans seeking them to also seek and undergo eligibility determinations. All-payer negotiations aren’t under consideration. And the ability of risk-spreading mechanisms to accomplish what they’d need to do is questionable at best. If you advocate universal, single-payer health coverage, and believe that, as a pragmatic minimum, coverage must be genuinely affordable, cover most reasonable and necessary medical expenses without substantial out-of-pocket expense, and must provide relatively uniform and stable access for everyone, then these provisions simply don’t do the job.

The Medicaid expansion poses other issues. On the one hand, the proposed expansion eliminates eligibility categories and protects the lowest-income Americans from the heavy out-of-pocket expenses they’d otherwise incur if they were instead forced into the private market for coverage. Both make sense, and deserve support, particularly from supporters of universal coverage of nearly any form. However, nothing will be done to ensure adequate provider payment. Given that the Medicaid expansions will ultimately cost states substantially more money, because the population covered will expand dramatically in most states, this practically guarantees that providers will continue to be poorly reimbursed in relation to other plans, and hence likely reduce access for Medicaid beneficiaries. The disparate access it will likely engender would be difficult for even the most pragmatic and compromising single payer advocate to swallow.

Then there’s the public plan. Not only did the Senate Finance committee not include a public plan option in their bill, but the White House went to some lengths over the summer to indicate that, while it supports a public plan option, it doesn’t consider it to be an essential part of any legislation that might ultimately pass. If you’re a single-payer advocate, then a robust public plan option, one with cost controls and that’s available to a wide range of Americans, is essential. If the public option were successful in providing decent, stable and affordable coverage, it could provide a basis on which ultimately to expand. This, of course, is precisely what single-payer opponents fear, and why they’ve vociferously blocked such an option. Then again, this is what was originally said about Medicare, and it’s been nearly 45 years now without such a transformation. Nevertheless, a public option won’t likely make it into any bill that’s ultimately passed, even if only Democrats are on board, except perhaps in a very attenuated form.

So where does this leave our pragmatic single-payer advocate? Community and solidarity are little to be found in any of the bills under consideration. While they do reform some particularly ugly features of our present health coverage system – and this is a good thing – they largely retain the fragmentary nature of our system, and give Americans little reason to feel jointly invested in it. While they improve the ability of many, particularly lower-income, Americans to obtain coverage, they hardly guarantee health security. People can still lose their coverage in any number of ways, and they can still go broke paying for medical care. Perhaps a very, very pragmatic advocate of universal, single-payer coverage could hold his or her nose and support at least the Senate HELP bill or two of the three House bills. But these bills run far astray from the principles such an advocate holds dear.

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

Convictions about justice are a deep and persistent force in health care. It seems distinctly unjust and unfair, for example, that one victim of a disease dies or is permanently impaired and financially devastat­ed, while another with the same disease is readily cured and lives financially unscarred.

Yet convictions about what is unjust do not necessari­ly steer us quickly toward universal access to basic care. Beyond political and economic self-interest, conflicts be­tween justice and allegedly competing values like liberty may intrude. Also, there are different senses of justice it­self, varying widely across the moral and political spec­trum. Those who think it unjust that one person can be ruined by an illness that leaves somebody else, who has greater resources, unscathed, are looking to a relatively egalitarian sense of justice. That sense pushes toward uni­versal access and its equitable financing. Some libertarian views of justice, on the other hand, contend that those who have no contractual or special relationship with the unlucky victim of disease—and have not themselves ex­acerbated her plight—have no obligation to assist her.

Despite these complications, several claims about jus­tice and fairness may be based broadly enough in U.S. moral and political culture to guide society’s debate. A case for mandated universal coverage built on seven such claims is outlined below, followed by a discussion of how such a policy embraces the values of liberty and justice.

Why Mandated Universal Coverage is Just and Fair

We have already collectively decided to prevent hospitals from turning away the uninsured. In such a context, allow­ing insurance to remain voluntary is unfair to many of the insured. The obvious way to alleviate this unfairness is to mandate insurance.

Since 1989, by federal law (the Emergency Treatment and Labor Act), hospitals have been prohibited from re­fusing acute care to those who cannot afford to pay. Con­sequently, $100 billion of care is annually “cost-shifted” onto patients who can pay, almost all of whom are in­sured. This shift raises the average annual health insur­ance premium roughly $1,000 for every insured family. Some of the uninsured are working families and young singles; when they need emergency care and get it at little cost, others who are economically similar but have chosen to insure end up invisibly footing part of the cost. Ar­guably, those uninsured who so benefit without bearing any share of cost are unfairly free-riding. Only two ac­tions can avoid this: either repeal the rescue requirement on hospitals, or mandate insurance. Few support the for­mer, so let’s face the matter and mandate insurance.

A mandate that everyone be insured is unfair unless in­surance is affordable, but in any multipayer system, afford-ability requires both income-related subsidies and restrictions on the behavior of insurers.

Given the cost of even basic insurance, many people of modest means who do not qualify for Medicaid cannot reasonably afford insurance without a subsidy. In addi-tion, insurance will not be affordable for anyone who already has health conditions likely to require higher-than-average annual expenditures un­less insurers are prevented from carv­ing out their favored clientele by means of preexisting condition exclu­sions and “risk-rated” premiums.

Unless insurance is mandatory, it is unfair to bar insurers from using preex­isting condition exclusions, waiting pe­riods, and risk-rated premiums.

Feasible access to insurance for the people who most need it suffers greatly when voluntary insurance that permits the healthiest to go without coverage gets combined with wide latitude for insurer strategies to re­cruit optimal subscribers. The effec­tive path to access, however, is not merely to bar insurers from using such strategies. To do so would ex­pose them to potentially lethal eco­nomic risk (through “adverse selec­tion”). It would also raise premiums for healthy young people, who in turn would be even less likely to in­sure; thus the number of uninsured might actually increase! People who want to postpone insurance, thinking its expense to be a poor bargain given their current good health, should not be allowed to pick their time to get insured. To receive benefits in times of crisis, people need to pay in all along.

Justice between the well and the ill requires that they share most of the fi­nancial burdens of illness, as well as in­surance.

Mandating insurance together with sharply restricting insurers’ prac­tices is not only practically necessary to achieve access. It also fundamen­tally aligns with justice between the ill and the well. Some principle of just sharing between them emerges from widely held convictions about the importance of assuring equality of opportunity. One attractive ver­sion of such a principle is that the fi­nancial burdens of medical misfor­tune ought to be shared relatively equally by well and ill alike, except when people can be reasonably ex­pected to minimize those burdens by their own choices—by avoiding overeating that exacerbates (or even creates) diabetes, for example. It fol­lows that the cost of insurance should seldom depend heavily on a person’s health conditions.

We can’t have it all: setting hard pri­orities among different health care ser­vices (“rationing,” if you will) is not un­just or unfair to patients who would have regarded such limits as wise and prudent prior to becoming ill.

Everyone has reason to worry about the expenditures providers and patients will run up. Once insured— and once ill—patients will want to get and providers will want to pro­vide all the care that has any prospect of net benefit, regardless of how small the benefit is, or how expensive its cost. Every system of insurance thus needs to police the care it provides, restricting care at the margins of (low) benefit and (high) expense. Call those limits “priority setting,” “prac­tice guidelines,” “rationing,” or what­ever: they are absolutely necessary to wise and prudent insurance be made? Arguably, the person of modest means. The first demand of justice in health care is for universal access to care that has been proven effective and whose expense-to-benefit ratio is not so high that it leads thoughtful, middle-class subscribers to pull it from the package they are willing to fund. The compelling obligations of those who are well to help fund care for the sick, and of the relatively wealthy to help fund insurance for the relatively poor, stop at this line. People can continue to argue about whether health insurance should be more insulated than this from varia­tions in affordability, but in a society committed to only modest measures of income redistribution generally, collective action will be out of bal­ance if it guarantees everyone access to care above this line. Of course, some will wish to include greater cov­erage, including unproven care of highly speculative benefit. So be it: they are free to buy up to it with their control costs in a system of insured care. They are not unfair to patients just because the patient might have benefited from the marginal care withheld. If knowledgeable sub­scribers, in selecting insurance before­hand and having to pay for it with premiums or taxes, would have de­cided that such care was not worth its higher premium cost, then sub­scribers’ own values are the source of the limitations that define “wise and prudent” insurance.

Justice does not require universal ac­cess to all care, but only to “basic” care. Justice can tolerate additional, more ex­pansive tiers of health care for those who choose to pay for it with their own ad­ditional means.

From whose perspective—the rel­atively wealthy subscriber, or the per­son of more modest means—should the decision about the boundaries of own devices. Keeping the package of basic care relatively lean and thus af­fordable to subscribers and sustain­able for taxpayers will never be easy, and pressures from particular interest groups will often need to be resisted.

Financing insurance through the current taxable income exclusion for employer-paid premiums is highly re­gressive and hardly just. If purchased insurance continues to play a major role in health care, a less regressive, fairer subsidy for access is required.

Currently, roughly half the popu­lation is insured through employer-sponsored plans, whose premiums are excluded from the employee’s taxable income. This roughly 40 percent tax subsidy (when the employer’s and employee’s FICA and Medicare taxes are included) is distinctly regressive, benefiting those in the higher tax brackets the most. Such a structure for the society’s primary incentive for purchasing insurance is hardly fair. A second questionable aspect is the sub­sidy’s lack of any limit on the premi­ums excluded; cost control in health care is thus discouraged, and general affordability aggravated further. Even if health insurance remains signifi­cantly based in individual or employ­er subscription, a capped tax credit is fairer. It would also likely be more ef­fective in persuading lower-income employees and low-payroll employers to insure.

How Mandated Universal Coverage Supports Liberty

Some claim that individual liberty and responsibility conflict with both universal access and any form of mandatory or societal insurance. Mandating insurance may be just and fair, but it certainly appears to limit liberty, and whatever relatively uni­form level of “basic care” is used to define universal access rides roughshod over the often very differ­ent views individuals have about what health services merit funding. The challenge in countering such a view is to consider liberty in its fuller context, as bound up with responsi­bility—where both are connected to justice and fairness:

• Lack of access to basic care se­verely undermines people’s abili­ty to be responsible for them­selves and their families. Un­treated illness has this effect, and so does the financial hardship (even bankruptcy) often caused by uninsured medical expenses.
• The prevention of unfair free­riding—a driving force behind the move to mandatory insur­ance—is itself based in the value of individual responsibility: no one should get to ride the system without contributing to its up­keep.
• The principle of just sharing between the well and the ill is key to the argument for universal access to basic care, but it is grounded on convictions about equal opportunity for human well-being. That focus of justice on equal opportunity, not on equal well-being itself, inherently includes liberty and responsibili­ty. The enterprise of achieving justice is therefore not a matter of “leveling,” but of expanding and energizing.
• Even limitations on covered services—that curse of health care politics, “rationing”—may at bottom be tied to the concept of liberty, insofar as these limita­tions reflect our liberty as citi­zens to determine what and how much will be spent on health care, using our values.

Arguments for universal access and mandatory insurance that invoke jus­tice and fairness can thus be based in fundamentally liberty-friendly values. There is broader room for moral and political agreement than at first meets the eye.

Policy Implications

• Insurance for basic care must—at least eventually—be mandatory and universal.
• If the system retains employer or individual premiums, they must not be significantly higher for people who are likely to be chronically ill than for those who are likely to be well.
• Guaranteed, universal access should be to a limited scope of care that is of proven effective­ness and reasonable cost-effec­tiveness. Costs must be con­trolled, even if this requires set­ting priorities and excluding some kinds of care. People should be at liberty, however, to buy more inclusive insurance.
• Both single- and multipayer systems can be just. Any multi-payer system will have to set a common framework for basic in­surance and sharply restrict in­surers’ efforts to recruit the most profitable subscribers. Financial incentives should promote fair competition both among private insurers and between private and public insurance.

The current tax subsidy for pri­vate insurance—the uncapped exclusion of employer sponsored premiums from taxable in­come—should be changed to a subsidy that is less regressive and more effective at controlling costs.

Paul T. Menzel, PhD, is professor of philosophy at Pacific Lutheran University and has published widely on philosophical questions in health economics and health policy.

]]> http://valuesconnection.thehastingscenter.org/2009/09/29/justice-and-fairness-mandating-universal-participation/feed/ 5 http://valuesconnection.thehastingscenter.org/2009/09/29/values-the-beating-heart-of-health-reform/ http://valuesconnection.thehastingscenter.org/2009/09/29/values-the-beating-heart-of-health-reform/#comments Tue, 29 Sep 2009 13:42:39 +0000 Thomas H. Murray http://valuesconnection.thehastingscenter.org/?p=39 With liberty and justice for all.
—The Pledge of Allegiance

This is the introductory essay in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner.  The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

Our mandate was to provide recommendations about what health insurers should and should not do with genetic information. This was the early 1990s; there wasn’t much information available about an individual’s genes, but the avalanche of genetic information was gathering strength. The first few pebbles had arrived recently, and ever larger ones, such as the tests for genes linked to breast and ovarian cancer, would appear soon. We had time—not a lot, but some—to plan for how private health insurers would deal with information about our genetic risks for diseases, from the rare and inexorable progression of Huntington’s disease to far more common ones such as Parkinson’s, diabetes, and heart disease. Health insurers were accustomed to shaping policies according to the risks people presented. If someone with cancer was like a house afire, someone with a genetic risk of cancer was a house with a smoldering pile of rags in the corner.

The standoff in that room, though, was puzzling. We asked the insurers if they believed that everyone should have access to insurance whatever their risks: Yes, they agreed, everyone should have access to insurance. So, they were in favor of universal access, right? No, they adamantly insisted, universal access would be the death of the  industry. Finally, we understood what frightened them: to insurers, universal access meant that people could sail along without any insurance coverage until the day they became ill, when they could march into the insurer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Everyone should have to pay their fair share and, when they needed care, their health insurance would be there to cover the cost. We described it as universal participation.  Fine, said the insurers, we can agree with that.

Among the lessons I learned from chairing the task force (including: Don’t fly from England to San Francisco and expect to control a contentious meeting), one stands out for this collection of provocative essays: understanding what’s at stake in a public policy debate is as vital as it can be elusive.

Connecting American Values with Health Reform is our effort to identify what is at stake amidst the swirling confusion of proposals for delivery systems, financing, cost control, and other details necessary for any practical reform. These details, though, are instruments carrying with them the impedimenta of history, habit, and interests.  To see things afresh, it helps to return to foundational questions: What do we want health reform to accomplish? What values should our institutions and practices be built upon, embody, and achieve?

The language of values has another virtue: Unlike health policy mavens, most Americans are baffled by the alphabet soup of program acronyms, economic models, and the difference between cost-benefit and cost-effectiveness analyses. Heck, most of us can’t explain the difference between Medicare and Medicaid. But we all understand what values are, and we can defend our preferences among them. Which leads to another reason The Hastings Center undertook this project.

Values can be wielded like cudgels to batter your opponents. That, unfortunately, has been all too common in recent political discourse. But values worth taking seriously — including all the values addressed in this collection of essays – are far more subtle, multifaceted, and interesting ideas that can cross political boundaries. Liberty, Bruce Jennings reminds us in an echo of Isaiah Berlin’s classic formulation, includes both freedom from and freedom to — and each of those meanings of liberty deserves attention in health reform. Liberty can mean the freedom from the imposition of a particular health plan and physicians; but it also demands a health care system that does not deny a would-be entrepreneur the freedom to pursue her vision, a freedom not available to the parent of a child with diabetes, for whom health insurance would be unaffordable outside the protective umbrella of a large group policy.

We chose the authors of these essays to represent a broad spectrum of beliefs. We assigned each of them a particular value to address, but we did not tell them what to say about it, other than to display the complexity residing within each value and spell out the policy implications of taking that value seriously for American health reform.

In reading these essays, I found moments of great illumination and insight along with occasional areas of disagreement; familiar ideas displayed in new and revealing aspects; new arguments, distinctions, and concepts. I was provoked, enlightened, and occasionally surprised. I hope that other readers will have a similar experience.

Most of all, I came away convinced that values are the beating heart of health reform, that these authors have begun a marvelous conversation about those values, and that the implications for American health reform are concrete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice.  Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform.

Second, when we acknowledge, as we must, that our goal is health, we are obliged to think much more broadly than our patchwork system of health care. Healthy children, healthy adults, and healthy communities are the outcome of many factors—from decent housing and safe areas for play and exercise to good jobs and schools.  Health care, crucial for episodes of acute illness and for the care of chronic diseases, is a significant but not dominant determinant of a community’s health. As responsible stewards of community resources, we should invest our finite public funds according to where they will do the most good. At times the best investment for health may be in education, job creation, or environmental protections, not in health care.

Third, the practice of individual underwriting in health insurance—making it harder to get the sicker you are — should be given a prompt funeral and buried with a stake through its heart. A concept such as actuarial fairness — which makes good moral sense in commercial insurance where risks are voluntary and the losses measured in money — has no place in deciding who gets access to the health care they need.

Fourth, efficiency and communal responsibility are essential if we are to have an affordable, effective, and sustainable health care system. This will require, at a minimum, systematically studying and improving the quality
and effectiveness of what we do in the name of health care. It will also require restructuring incentives so that providers are rewarded for results rather than for the numbers of procedures or tests they perform. There is good evidence that such changes would also lead to a higher quality of care.

Finally, the concept the task force developed more than fifteen years ago—universal participation—may be one whose time has finally come. The core idea is simple enough: everyone should be responsible for participating in whatever way is appropriate; when anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them. I was delighted to find the concept, if not the term, endorsed so often in these essays.

Whatever combination of private and public programs we choose, it’s a good time to connect American values with American health reform.

Thomas H. Murray is the President of the Hastings Center.