The Ethical Foundations of Health Care Reform
by William F. May
William F. May is Cary M. Maguire Professor of Ethics at Southern Methodist University in Dallas. This essay draws on some language and ideas generated by the author and others in the advisory work group on ethics for the White House task force on health care reform. The opinions expressed do not, however, purport to represent the positions of the Clinton administration, the task force or the ethics advisory group. The author accepts sole responsibility for the views expressed. This article appeared in The Christian Century, June 1-8, 1994, pp. 572-576. Copyright by The Christian Century Foundation; used by permission. Current articles and subscription information can be found at www.christiancentury.org. Article prepared for Religion Online by Ted & Winnie Brock.
Our health care system contains much of which we should be proud and much that we should conserve. It has enlisted the devotion of millions of professionals, created splendid hospitals, clinics and research institutions, and dazzled the world with its technical achievements. And it has allowed for some choice in doctors. Any reform of the system must preserve its virtues.
Yet our health care system is seriously flawed. It fails to reach many of us: at any given time, it excludes over one seventh of the population (about 40 million people) from health care insurance; it leaves another one-seventh underinsured. The consequences for individuals and families are devastating. When we exclude people from health care they suffer a triple deprivation—the misery of illness, the desperation of little or no treatment, and the cruel proof that they do not really belong to the community. We make them strangers in their own land.
When individuals lack health care, the promise of our common life together is also diminished. In relieving private distress, the nation enables its people to contribute more fully to its public life. The nation thereby serves its own public flourishing.
Our system also does not offer enough primary, preventive, home and long-term care, and it woefully neglects mental health coverage. We tend to be acute-care gluttons and preventive-care anemics.
Reflecting this lopsided emphasis, the system oversupplies us with specialists (some 70 percent of our doctors are specialists, compared with only 30 to 50 percent in comparable industrial countries) and undersupplies us with generalists whom we need for effective preventive, rehabilitative and long-term care.
The system pays for procedures performed rather than good outcomes achieved, and it exposes those who cannot pay to dramatically lower success rates for a given procedure. It often overtreats; yet insurance sometimes disappears when most needed. It exposes to financial ruin the person who has lost his or her job. It locks others into jobs they do not want because of pre-existing medical conditions, and it often establishes lifetime limits on care.
The system burdens health care practitioners and institutions with too many regulations and forms. A financial officer at one hospital reports that her staff has to handle some 3,200 different types of accounts receivable. The head of the major city hospital in Dallas says he needs 300 people to handle what, at a comparable hospital under the Canadian system, can be dispatched by three people.
Our system also costs more to operate than any other health care system in the world; no other country exceeds 10 percent of its GNP in health care costs, yet we are above 14 percent and rising further out of control. The system now consumes one-seventh of everything that we make or do. Even this figure does not fully measure the cost. The "fringe benefit" of health care is anything but a fringe cost of producing cars, computers, refrigerators and, for that matter, education. In some of our industries, health care is the second-largest cost after wages and salaries. This fact reduces the competitiveness of American businesses: Why should companies build cars in Detroit if their health care costs per worker are $500 to $750 less across the bridge in Windsor, Canada? Some commentators have argued that we have recently slowed down the increasing costs of medical care. But under three presidents we have undergone temporary slowdowns in costs only to see them speed up again. For our own sake and the sake of our children, we must be better stewards of our nation’s resources.
Further, our payment system is unfair. Businesses, insurance companies, hospitals, the government and patients engage furiously in cost shifting as they fob off on others their expenses. Hospitals jack up their prices to the insured to cover their costs in caring for indigent patients. Some doctors try to skim off the well-insured patients, while avoiding others. Insurance companies pick healthy customers to avoid making payouts to the sick. Companies shift to part-time, temporary or younger employees to reduce fringe-benefit costs. The government’s savings on Medicare and Medicaid patients sometimes comes at the expense of prices paid by insured patients. Some people are forced to stay on welfare because the low-paying jobs in the service industries do not provide the coverage they receive under Medicaid. All this artful dodging eventually dumps costs on workers and taxpayers, either through lower salary raises, higher taxes or higher insurance payments.
A major reform of our health care system will rank as the most comprehensive piece of social legislation since the establishment of the social security system. We cannot engage in so grand an undertaking without being clear about its moral foundations In my judgment, those foundations are three: 1) health care is a fundamental good; 2) health care is not the only fundamental good; and 3) health care is a public good.
To say that health care is a fundamental good means that health care is one of the necessities of life. It is not an optional commodity, like a Walkman, a tie or a scarf. Mothers instinctively affirm this truth when they concentrate their hopes on just this: the birth of a healthy baby—ten fingers, ten toes, a good heart, robust lungs. Why this single, humble, anxious wish? The mother prizes her baby’s health because of the promise it holds for the child’s life and flourishing. Healthy children, and therefore health care, are part of a nation’s covenant with its future.
Because health care is a fundamental good, the American system must honor and reflect the following five moral principles.
The system must offer universal access. Health benefits should reach all of us without financial or other barriers. Citizens should not fear that part-time or temporary employment, or a change or loss of a job, will block health care coverage. No one should lose access to health insurance due to pre-existing conditions, or to age, race or genetic background. Barriers to access arising from linguistic and cultural differences, geographical distance, and disability must also come down.
Why should Americans especially insist that a basic good, such as health care, ought to reach all citizens? Our three major religious traditions—Protestant, Catholic and Jewish—are communitarian. They have all insisted that no one should be left out in the cold when it comes to the basics in life. Some individualists may counter that our revolutionary emphasis on individual liberty made a break with this communitarian heritage. This view of our past, however, overlooks the first words we spoke as a nation: "We the people." The Preamble to the Constitution does not proclaim, "We the factions of the United States" or "We the interest groups of the United States" or "We the individuals of the United States," but "We the people." That declaration was tested and affirmed through the bitter ordeal of the Civil War. We could not survive, half slave, half free. Neither can we stand divided between the sick and the well, the protected and the uninsured. Our flourishing as a people rests upon our ability to create a health care system that binds us together as a nation. The principle of universal access goes to the soul of reform. Currently, we are the only industrial nation, other than South Africa, that fails to offer universal access.
The system must be comprehensive. Benefits must meet the full range of health care needs. We should offer primary, preventive and some long-term care as well as acute care; home, as well as hospital care; treatment for mental as well as physical illness. An observer once saw through our lopsided allocations in the U. S. when he wrote, "Our system’s philosophy might be condensed in the motto, ‘Millions for [acute] care and not one cent for prevention!"’ -Those lines were written in 1886. When we attend too little to primary, preventive and mental health care, the cost of acute care increases: we mistarget funds, and we fail to empower people to take responsibility for their own health.
When we do not offer comprehensive coverage, we also fail to offer universal coverage. We discriminate against whole classes of the afflicted, such as the mentally ill or those in need of long term care. We would find it strange to treat renal disease but not heart attack victims. But currently many plans lavish care on the physically ill but discriminate against the mentally ill. A scheme that aspires to universal coverage must offer a comprehensive package.
The system must be fair in that it does not create a two-nation system—dividing the nation over this fundamental good—and fair in that the costs and burdens of meeting health care needs are spread across the entire community. Some might respond: don’t the uninsured receive the benefit of care through the emergency room? Unfortunately, their care does not match that of the insured. Their mortality rate for a given procedure is 1.8 times higher than the rate for the insured. The astronomical costs of some acute and long-term services can impoverish the sick and the disabled and their families, and the prospect of these costs imperils the security of those of us who have not yet been stricken.
We would find it absurd to limit the protection of defense—another fundamental good—only to those who could afford a private army. We ought not limit access to medical care only to those who can hire a platoon of doctors. We also need a system that fairly shares the cost of health care. We must secure contributions from all and eliminate the widespread patterns of cost shifting and free loading. A fair sharing, of benefits and burdens draws the community together and ties the generations to one another.
The System must be of high quality. Health care is too important a good not to be good. Fostering good quality requires providing health care professionals with an environment that encourages their best work, protects the integrity of professional judgment, delivers effective treatments and weeds out unethical and incompetent practitioners. It also means providing patients with sufficient information about the outcomes achieved by different plans to help them make informed, rational choices.
Ordinarily, consumers in the marketplace can enforce quality through their ability to compare products knowledgeably. But patients today do not have the information to make those judgments about doctors, hospitals and health care plans—and it is difficult to acquire this knowledge in the midst of a medical crisis.
Health care is also too important a good not to get better. Therefore, the system must also support research for improving the full range of health care services, including research on the outcomes of health care and more research directed to preventive, rehabilitative and terminal care. Without the assurance of quality in the basic health care package, the well-to-do will buy up and out, returning the country to a two-nation system.
The system must be responsive to choice. Health care is too fundamental a good, affecting each of us too intimately and fatefully, not to give us some measure of freedom to choose our doctors, the treatments we receive and the health care plans in which we receive them. Too many people lack choice altogether or enjoy choice on only one of these matters. Honoring choice in the health care system not only respects liberty; it also engages the patient in the activity of preventive, acute, rehabilitative and long-term care.
While health care is a fundamental good, it is not the only fundamental good. We must also defend the nation, provide housing and educate our children. Thus we need a system that allocates wisely and manages efficiently so as to accommodate other basic goods.
To enable us to allocate wisely, the health care system must let us compare and balance what we spend on health care against other national priorities and evaluate and choose among diverse health services. In the past, the structure and funding of the health care system has not given us enough information about costs to make clear choices among these priorities. We need this information to put ourselves in a better position to meet all our social needs and also to decide more wisely among competing health care needs. Efficient management is a moral, not just an economic, imperative. Ethics is not one sphere and economics another. The British universities had it right when they linked the study of economics, politics and philosophy. Ethics, politics and economics are interconnected.
The health care system should also be simple to use, without bureaucratic roadblocks to the delivery of care. I have two daughters who are physicians, and they find it discouraging, to say the least, to talk to a person at the other end of an 800 line, someone who has power to approve or refuse a treatment, and be asked, "How do you spell ‘manic depressive’?" Senator Robert Dole criticized the Clinton plan for its complexity by showing an organizational chart of the plan on TV; he did not mention that the current system is so complex that one could not even bring it into view on a TV camera. Nevertheless, he had a point. Whatever the reform plan, it must offer simple access for patients and ease of management for doctors and other caregivers. The Clinton administration, sensitive to this issue, would locate responsibility for individual patient care in the provider organizations rather than in the National Health Council or the statewide purchasing alliances.
The new system will also need to reduce administrative costs. Today 1,500 insurance companies compete for our health care dollars, producing huge redundancies and complexities in administration and advertising costs. Moreover, these companies largely compete not in matters of price and quality, but in the art of designing benefits packages so as to avoid claims from people when they fall sick.
Efficiency must be defined with a wise heart, not just a calculator. Providers should not be bound by medical cookbooks but should be encouraged to adopt wise treatment guidelines. Inevitably, controlling costs requires distinctions between needs and wants, effectiveness and futility, and setting priorities among health needs. Efficiency in the service of universal access is a virtue, not a limit. It can offer choices and opportunities for health care for all people, instead of denying choice to millions. We must allocate our resources wisely so that we can achieve the goals of our health care system and address our other national needs.
Health care is a public good, and a good system must help increase our sense of responsibility, both as providers and as consumers. A huge social investment has helped to educate health care professionals and sustain the good which they offer. Federal outlays for research and medical education, patients who offer their bodies to let young residents practice, community chest drives, foundation gifts, corporate grants, municipal taxes, bonds floated to build hospitals— all these aspects of health care confound the notion that health care is exclusively a private skill or a commodity up for grabs to the highest bidder. A society that carefully reckons with the social derivation of health care cannot plausibly reduce the distressed patient merely to a profit opportunity or an object of occasional charity.
The indebtedness of professionals vastly exceeds the school loans or fellowships they have received. No man or woman can go through medical school and think of himself or herself as self-made, and indeed thousands of professionals want to give back, even as they have received. The health care system must foster ways in which practitioners can make good on their profession as a calling, not just a career. The system must protect the integrity of professional judgment, weed out the incompetent or unethical practitioner, and encourage excellence.
The success of a health care system also depends upon an increased sense of responsibility on the part of the recipients of health care. We cannot solve our problems through a social mechanism alone. The success or failure of a system depends upon the "habits of the heart" of a citizenry. Patients must be active partners in their health care. Preventing a heart attack, recovering from a spinal injury, coping with a stroke—these often require changes in the patients’ habits. The system cannot gratify all wants or remove the mark of mortality from our frame. We need some self-control over our wants, some composure in the midst of illness, and courage in the face of dying. No system of itself can bring these virtues to us. We need to bring them to the system so that its benefits may sustain us more fully.
The ancient Romans tended to emphasize the benefits of citizenship; the Athenians emphasized its responsibilities. For its moral and economic success, our new system of health care will require both.
These three basic convictions about the good of health care and their derivative moral principles do not lie easily together. Tensions are sure to arise between paying for the fundamental good of health care and providing for other basic goods (and relatively trivial commodities). The goals of universal and comprehensive coverage, for example, will confront the hurdle of the start-up costs which major changes in either government or business invariably entail. Differences will also develop over the best mechanism and institutions by which to reach even agreed-upon goals. Inevitably, decisions about priorities will need to be made. Clinton signaled his judgment on one of them when in the course of his February speech on health care he declared that he would not sign a bill unless it offered universal coverage. But even on this issue differences exist as to how fast the country can or will move. (The administration hopes to offer universal access within four years of the passage of legislation.)
What are the political chances of forging a new health care system that addresses our needs? Are we willing to make significant changes? My tragic law of politics goes as follows: the perception of a problem and the willingness to solve it rarely join before the solution is beyond reach. We could have reformed the health care system much more easily when Harry Truman said we needed to do it in 1948 and when health care costs were 4.5 percent of GNP. The amount was large, but relatively marginal to our total GNP. Today, however, health care costs have risen to 14 percent of GNP, and 11 million people have jobs in the industry—some of them ready to attack changes that might affect their interests. The huge growth of the health care industry makes it relatively difficult to reform it. Gridlocks in government usually reflect gridlocks in society at large.
I am not unrelievedly pessimistic, however. The president has at least managed to put the problem on the national agenda. Politics, as Max Weber once put it, is at best slow boring through hard wood. I hope the Clintons have some success in sustaining the support of those 60 percent of the voters who have said they would consider some raise in taxes in order to provide universal coverage. Political solutions are possible but difficult—a good deal more difficult than my fellow Texan, just-lift-up-the-hood-and-fix-it Ross Perot, is willing to admit.
To achieve major reform we cannot treat health care simply as a partisan or an interest-group issue. We will need to return to our foundations as a people. Our founders assumed that if a nation could create a common good, it should make that good common. We can now deliver the good of health care to all our people, and this good will help secure and enhance the life, liberty and welfare that is our nation’s promise to its citizens. It is time to make that promise to each other.
Is such a covenant among us realistic, coming as it does so late in the day and with well-established interests already in the field? It will surely require a broad appeal to self-interest. But it will also need to appeal to what Lincoln called "the better angels of our nature," those angels that De Tocqueville must have discerned when he wrote that a "covenant exists...between all the citizens of a democracy when they all feel themselves subject to the same weakness and the same dangers; their interests as well as their compassion makes it a rule with them to lend one another assistance when required."
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