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.”

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.

Subsidiarity found its first articulation in Catholic social teaching.  Basically it’s the investment of authority at the lowest level of an institutional hierarchy possible, essentially relegating centralized authority to a secondary or subsidiary role.  In other words, the group closest to whatever task or problem should tackle that problem first, and only when they’re not able to should a higher authority step in.  In social terms, this might break down something like this: first, individuals are responsible for their own social welfare, then families, then communities, then local governments, then state governments, and finally the federal government.

In many ways, subsidiarity flies in the face of the more universalist notion of solidarity.  Subsidiarity requires that small groups and individuals tackle problems, while solidarity demands that we all band together.

Nevertheless, if we’ve learned anything from the health care debate, it’s that for any meaningful reform to take place, we need to find ways to make competing ideas work together.  More people need to be covered for less money.  Somehow more government involvement in the health care industry also has to lead also to less of a financial burden on federal and state budgets.

The nature of health insurance is one of cost-sharing.  Lots of healthy people buy into a larger cost-pool in an act of voluntary, if unintentional, solidarity.  Insurers, at least in theory, compete against one another for customers, the competition leading to a decentralized system of coverage and care.

The American health care system, however, has instead erected a status quo which relies entirely on employment for health coverage.  Coupled with a ban on interstate sale of insurance, this has led to much smaller cost-sharing pools and very little actual competition, with one insurer often dominating entire cities or regions.  The sale of insurance is bound to each individual state and fifty different sets of rules and regulations govern insurance sales across the country.   Consumers of health care are almost always bound to their employer’s choice for health coverage – and worse, should they lose their job, find themselves suddenly without any insurance at all.  Essentially, the American system has eschewed both solidarity and subsidiarity, in favor of an ad hoc system found nowhere else in the industrialized world.  In the end, this has led to skyrocketing costs.

Beyond cost-control, solidarity is the driving force behind health care reform.  The argument that no modern, industrialized nation should be without universal coverage is compelling.  But other Western nations have found ways to take this principle of solidarity, and achieve it through far more decentralized means than Canadian-style single payer, or the expensive socialized medicine of the UK.  The Dutch have achieved universal coverage entirely through fierce competition between private insurers, and the Germans use a system of exchanges that allow German workers to move from job to job without losing insurance.  The Swiss, who have made an art of subsidiarity, have achieved universal coverage through competing non-profit insurance plans.

The problem with American politics is that so often our leaders view bipartisanship as a path to the worst of all possible outcomes – the uninspiring middle-road wherein nobody is happy and little is achieved.  What many European models have shown us is that competing values can actually be used to achieve effective compromise.  Perhaps conservative means can lead to progressive ends, or vice versa.  In the health care debate, competition and subsidiarity are the best tools to create quality, affordable health care for the most people, and with the right implementation they can be used to achieve universal coverage.  In this way subsidiarity, rather than a competing value, becomes a complimentary one, and we find our solidarity through competition and individual choice.  Universal coverage can be achieved from the bottom up rather than from the top down.

What could be more American than that?

As a society, we have a moral obligation to provide access to medical care for all of our citizens. When we frame healthcare as a “right,” we shift responsibility from society to the individual. It is up to him to demand his due. At that point, the word “entitlement” comes to mind, along with the conservative image (so artfully drawn by President Reagan), of an aggrieved, resentful mob of freeloaders dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy.

“We didn’t make them poor or sick,” some libertarians say. “Why should they have the “right” to demand so much from us?” And just how much care are they entitled to? Should they get the same care that wealthier Americans expect? Wouldn’t it be sufficient to give them care that is “good enough”?

Put simply, the language of individual “rights” doesn’t seem the best way to build solidarity. And I am convinced that social solidarity is key to improving public health.

A friend who lived in France for many years once explained to me: “Healthcare is so good in France because the French believe that nothing is too good for a fellow Frenchmen.” Unfortunately, in this country, many of us do not feel that way about each other.

But I am not willing to accept the notion that Americans are “different,” so incapable of such fellow-feeling. We are, after all, in this together. As humans we are vulnerable to disease and accident. As John F. Kennedy once put it, simply by having children we give “hostages to Fate.” This is what we have in common, our common humanity. This is why the citizens of developed nations willingly pool their resources to protect each other against the hazards of fate.

If healthcare is, in any sense, a “right,” I would argue that it is what the Declaration of Independence named an “inalienable right’” conferred on us, not by government, but by “Our Creator.” Inalienable rights are natural rights something we deserve simply by virtue of being human, so that we can be free to pursue life, liberty and happiness. These are affirmative right which empowers us to become part of society. Without our health, we cannot participate as members of a political community.

An “inalienable right” is very different from a constitutional right (to free speech, for example ) which gives the individual the right to be free from interference by government or their neighbors—to be protected against unreasonable searches, cruel and unusual punishment, or invasion of privacy. Those rights are designed to protect us, as individuals, from society. Universal healthcare acknowledges each of us as equal members of society.

This means that it is essential to think about healthcare collectively. Asking, “What will reform mean for me and my family?” is not the way to achieve universal care. We should ask “What will it mean for all of us?” How can we allocate resources to achieve affordable, sustainable, high quality care for everyone? No movement that urges history forward has ever been built on narrow self-interest.

To some, the idea of “thinking collectively” might sound un-American. But if the rights of the individual are enshrined in our value system, so is the idea that all men are created equal. And liberty and equality go hand in hand. If we want a stable society, we must have equality with regard to the necessities of life. Without stability, my rights as an individual are in jeopardy. As the 1948 United Nations Universal Declaration of Human Rights puts it: “the recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.”

Thinking collectively also means understanding that the resources that we, as a society, have to spend on health care are finite. As a nation, we now spend well over $2 trillion on medical care and as costs continue to levitate healthcare is becoming unaffordable for many. If we want high quality care for all, we must husband our resources.

We know that today, our health care system is bloated with waste in the form of unnecessary tests, unproven treatments, and over-priced , cutting edge drugs and devices that, too often, are no better than the older treatments that they are trying to replace. More than two decades of research done at Dartmouth University (www.dartmouthatlas.org) tells us this. Moreover, this is hazardous waste. Every treatment carries some risk of side effects. If it is unnecessary, the patient is, by definition, exposed to risk without benefit.

The waste must be excised with a scalpel, not an axe. Individuals can make a difference. Both physicians and patients should think twice before ordering — or asking for – yet another MRI, a drug touted on TV, or angioplasty as a “quick fix” for chronic stable angina.

When a doctor recommends that you begin taking a sixth pill, a patient might ask: “Are you saying I absolutely should take this medication—or that it might be a good idea? I’m already taking five different drugs, and I’m a little concerned about becoming a walking pharmacy.” Your physician may well respond by saying “yes,” you do need this sixth pill. But the question could open up a conversation about whether you need the other five.

Similarly, before recommending routine PSA testing for prostate cancer, doctors should consider the advice of the American Cancer Society and discuss risks as well as the possible benefits of the test, giving patients an opportunity to make a informed choice.

All of us are responsible for trying to rein in needless spending, Washington can pass legislation, but change will happen on the ground if doctors step back and take a long look at their own ordering patterns.

This is what physicians and hospital leaders from Cedar Rapids, Iowa did when they decided to investigate the overuse of CAT scans in their community.

When they examined the data, they found that in just one year 52,000 scans were done in a community of 300,000 people. A large portion of them were almost certainly unnecessary, not to mention possibly harmful, as CAT scans have about 1,000 times as much radiation exposure as a chest X-ray. “I was embarrassed for us,” Jim Levett, a cardiac surgeon and the head of a large physician group in Cedar Rapids acknowledged. It’s just not likely that 1/6 of the population needed a CAT scan in a given year. Just by counting, these physicians became aware of the excess, and began cutting back.

The plain truth is that if we want to live in a society where everyone has access to care—and most of us do—then all of us must learn to share finite resources. This doesn’t mean that we must ration needed care. The over $2 trillion that we, as a nation, lay out for healthcare is enough to provide excellent care for all. But we must spend those dollars wisely.

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

Illness, we are often told, is a private matter. Accordingly, none must interfere in the medical decisions that emerge from the confidential relationship between physician and patient. Yet evidence of interdependence is ubiquitous in health care. One person’s malady can harm families, workplaces, clubs, churches, and sometimes entire communities. Similarly, a suffering patient must rely on many individuals, associational groups, corporate entities, and government agencies for support and assistance. It is, therefore, unsurprising that various social units claim an interest and a voice in maintaining health and treating disease.

However, explicit solidarity has long been out of vogue in America’s value system, despite persistent lack of af­fordable medical care. Instead, the public has prized sci­entific innovation, consumer sovereignty, and personal autonomy, and has installed physicians as benevolent oli­garchs to oversee these functions. The resulting system delivers idiosyncratic care at enormous expense to most Americans, while a sizable minority often goes without.

Calls for solidarity in American health care reach re­ceptive ears mainly when spoken in fear—recently of pandemic disease, bioterrorism, and natural disaster. Al­though crisis is a perpetual and therefore meaningless ad­jective in health policy debates, calamity seems to breed togetherness. Foxholes tend to convert libertarians into communitarians as well as atheists into believers. Special concern is provoked by novel pathogens, runaway tech­nologies, and random, large-scale events.

The economic downturn, with its emerging consensus that something must be done to universalize the U.S. health care system, presents an unexpected opportunity to revisit health solidarity. Whether hard economic times are sufficiently calamitous to become a unifying force re­mains to be seen. If so, we should be grateful that the streets are littered merely with dead businesses, not with dead bodies, and that toxic assets rather than toxic agents are responsible.

Beyond these base emotions, one can identify three sources of solidarity that reflect American society’s better nature. I shall call them mutual assistance, patriotism, and coordinated investment.

Mutual Assistance

utual assistance rooted in both compassion and ex­pectation of reciprocity accounts for the bulk of U.S. health solidarity. Misfortune attributable to chance or resulting inevitably from the passage of time—not temptation or moral failing—typically triggers collective support to prevent avoidable deaths, ameliorate suffering, and save victims’ families from impoverishment.

Sharing the financial risk of poor health can be ac­complished through processes of varying formality, rang­ing from charitable campaigns (such as donations to hos­pitals) to means-tested entitlements (Medicaid) to full-blown social insurance (Medicare Part A). These efforts openly redistribute wealth but greatly assist recipients and, at least for voluntary charity, en­hance the well-being of donors. Health is a natural area for mutual aid because those contributing be­lieve that those receiving aid are seri­ously ill and thus have no higher use for resources than medical care. This mitigates concerns that aid might dis­courage self-help and promote wel­fare dependency. Mutual assistance is strongest when donors can identify with potential beneficiaries; nations with the most generous social insur­ance programs tend to be those that are demographically homogeneous.

Mutual assistance occurs in private health insurance as well as public pro­grams. Group rates for employment-based coverage redistribute resources from healthier to sicker members of workplace risk pools. Americans readily accept this mode of mutual support because they identify with fellow workers. It is undoubtedly made more palatable by the selective subsidy awarded employee benefit plans under the federal tax code, by lack of transparency regarding the magnitude of the transfer, and by the widely credited fiction that the money involved is the employer’s rather than the employees’.

Similarly, Americans routinely empower health care providers to make decisions about how to distrib­ute shared resources because they can imagine lives being saved. A seldom-noted aspect of the backlash against managed care derived from percep­tions that HMOs were converting otherwise acceptable cross-subsidies into corporate profits and thereby de­priving the health care system of needed funds. Historically, physicians charged higher fees to wealthy pa­tients and offered free service to poor ones, a practice that eventually yield­ed to the bureaucratic constraints of government programs and lack of equal charity from suppliers of neces­sary diagnostic and therapeutic com­plements. Nonprofit hospitals con­tinue to redistribute in this fashion, reflecting the social mission assigned them by their constituents and the insistence of the taxing authorities that charity care should be the touch­stone for “community benefit.”

Patriotism

Patriotism is a less common source of interconnectedness in American health care. America’s commitment to tolerance and liberal pluralism is very effective at creating associational groups with shared values, which in health care spawns agendas as diverse as those of the American Cancer Society, the Hemlock Society, Physicians for Human Rights, and the Association of American Physicians and Surgeons. But it is not very effective at motivating large national projects during peacetime.

Building loyalty to centralized governments, fostering political stability, and avoiding class warfare— the conventional explanations for the welfare states of Western Europe— seem unnecessary given our long-standing federal union, our melting-pot heritage, and our belief that continued upward mobility serves as a social safety valve. Even in post–cold war America, compulsory redistribution to achieve explicit ideological goals of equality in health care access sounds disturbingly Soviet (“from each according to his ability, to each according to his need”). Accusations of “socialized medicine,” most recently hurled by former New York City Mayor Rudy Giuliani during his brief 2008 presidential campaign, retain rhetorical impact because we continue to fear state intrusion into intimate personal and family decisions.

America’s preference for low taxation further discourages a collectivist political orientation. Proposals for government to assume responsibility for health care are widely perceived as fiscal power plays—schemes not only to raise revenue, but also to divert private spending on health into other, unspecified government projects. Many Americans suspect that the inevitable result would be reduced investment in facilities and innovation, quality reductions, supply constraints, and rationing. These concerns are reinforced by the American medical profession—a grass roots army of talented small businesspeople who, with fierce conviction if little historical justification, continue to construe their social prominence and financial success as the result of rugged individualism rather than sheltered competition and lavish public subsidy.

Nevertheless, patriotism partially motivates several core features in the U. S. health care system. Those who render military service to the nation are repaid in part with health care: the Veterans Health Administration is the largest component of the Department of Veterans Affairs and provides lifetime benefits to millions of individuals. The enactment of Medicare can be viewed similarly, as health security to compensate generations of Americans who worked through two world wars and the Great Depression and who became old and infirm during the sustained period of peace and prosperity that followed. As evidenced by the temporal connection between Medicaid and the civil rights movement, patriotism to redress prior regional and national discrimination can also generate health solidarity.

Coordinated Investment

A third source of health solidarity is a loosely organized but potentially powerful array of coordinated investments that Americans can make to safeguard and advance their futures. The objective of these activities is to increase overall welfare, not to define citizenship or to redistribute resources from better- to worse-off. Traditional public health functions fall into this category. Epidemics and disasters generate widespread willingness both to contribute funds and to submit to physical restrictions in order to prevent additional physical harm and to keep critical infrastructure functioning.

Equally important is reducing spillover economic harm through prevention and control of noncommunicable chronic diseases—many of which derive from smoking, poor nutrition, and lack of physical activity. Unconstrained government spending on chronic disease crowds out other productive uses of public funds. The burden of chronic disease also diminishes both near-term workplace productivity and long-term prospects for overall economic growth. This collective project is a more controversial exercise of government authority because, at first glance, interventions appear aimed at protecting individuals from the consequences of their own conduct rather than someone else’s. However, research on social networking reveals that many chronic health conditions are “communicable” through shared norms, and that improved design of workplaces, schools, and communities can alter common environments and reduce risk factors.

The production of medical knowledge as a public good is another established form of coordinated investment, as is support for hospital construction, education of health professionals, and patenting of biomedical technology (at least following the enactment in 1980 of the Bayh-Dole Act, which encouraged commercialization of publicly supported research). Surprisingly, far fewer resources have been directed at improving the productivity of health care providers on the assumption that professional self-governance and market discipline are sufficient to generate and disseminate best practices. Recently, however, policy-makers have come to understand that decades of regulation and subsidy have artificially fragmented health care delivery and rewarded unproductive behavior, rekindling interest in public support for health informatics and comparative effectiveness research.

A final, widely accepted justification for coordinated investment in health care is the elimination of waste. Reducing “waste, fraud, and abuse” in Medicare has maintained universal political appeal for decades while, unfortunately, providing little actual relief from persistent growth in expenditures. Today’s proponents of tax-financed universal health coverage argue, somewhat more persuasively, that leaving a large percentage of the U.S. population uninsured reduces access to cost-effective primary care, wastes expensive emergency services, and misses opportunities to prevent, detect, and offer timely treatment for disease. In Texas, for example, the most marketable argument for health reform among the general public is that roughly $1,500 of the annual premium paid by each insured family is spent on care for the uninsured. The risk of this approach, of course, is that voter sentiment could turn from “please spend my money more wisely” to “please give me my money back.”

Policy Implications

Many strands of social solidarity exist in American health policy, even if an explicit commitment to universal health coverage continues to elude us. The severity of the economic downturn—and the aggressive response it has provoked—create an opportunity to overcome entrenched political positions and recalibrate public values in support of solidarity. In my view, however, three barriers must be removed in order to create a more accessible, affordable, and productive health care system.

First, federal fiscal politics cannot continue to impede collective investment in restructuring health care— an investment that will almost certainly have a large long-term payoff. In addition to funding the marginal costs of expanding coverage, the trillion dollars or so that have been committed as economic stimulus can provide the activation energy (in both knowledge and infrastructure) necessary to transition the health care delivery system to a new, more efficient equilibrium.

Second, “medical individualism” cannot be allowed to paralyze the debate. Americans have built a mental wall between supporting aggregate change and resisting personal change that entrenched interests exploit by portraying every serious reform proposal as a threat to one’s own care or the care of one’s family. Effective reform must connect individual services to population health at as many junctures as possible.

Third, health is a major component of America’s long-term creditworthiness and prosperity in both our public and private sectors. Industry stakeholders must accept that those who receive government support in these difficult times cannot merely continue business as usual, and the general public must agree that the stakes justify shared sacrifice and require sustained commitment to a common purpose.

William M. Sage, MD, JD, is vice provost for health affairs and James R. Dougherty Chair for Faculty Excellence at the Universi­ty of Texas in Austin.

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.