 |
|
Volume 4, Issue 11 - January 2002A Conservative Call for Universal Access to Health
Care
|
|
Guest
Writer Profile:
|
This
month we are very pleased to have as our Guest Writer, Donald
Light. The
United States remains the only industrialized or second-tier country
in the world that fails to guarantee its citizens access to medical
services. This is a curious omission for a country based on rights
and liberty. It is equally strange from an economic and business
point of view. For while foreign competitors get full medical benefits
at one-third less the cost, American employers are weighed down
by ever-growing expense for health care. For Nokia, Volkswagen,
and Siemens, this is an advantage worth billions over their American
competitors, Motorola, Ford, and GE.
Despite these consequences, U.S. fiscal conservatives continue to belittle
universal access. They argue that health care should be private, with a public
safety net only as a last resort. In so doing they diminish some of their most
cherished principles. For universal access to needed medical services enhances
individual freedoms, liberties, opportunities and the ability to be productive.
Illness and disability hobble them.
Conservatives in every other industrialize country support universal access
to health services in one form or another. Only American conservatives hold
the mistaken view that their values do not support it. Other countries provide
universal access in a variety of ways. Many countries use insurance, even private
insurance, coupled with firm rules that require everyone to contribute in equitable
ways. Many rely on tax-based systems, which studies show are the most efficient
means and holds down costs best. Often, medical services in these countries
are private.(1)
A conservative argument for universal access to health care can be put quite
simply:
When people are ill, in pain, or disabled, they are less able to take care
of themselves or others. In such circumstances, individual liberty and personal
responsibility are quickly compromised. Even small disorders can turn liberty
and responsibility into dependency. Needed medical care can be a great financial
burden on the seriously and chronically ill. Losses in wages and earned income
make matters even worse, particularly when able-bodied citizens can no longer
care for themselves and their dependents.
Medical bankruptcy is quite common in the United States but unknown in the
rest of the modern world where there is universal access. Costs totaling 10
percent of household income are not uncommon, and rise to 15 percent among
the working class.(2) Forty percent of all personal bankruptcies in the United
States are attributed to medical bills people are unable to pay.(3)
Voluntary Insurance Does Not Work
In the United States, voluntary private health insurance has traditionally
been seen as the answer for covering medical expenses. Elsewhere, it was abandoned
long ago as incapable of protecting individual liberty, fostering personal
responsibility, and promoting economic opportunity. One problem is that nearly
half of all employers choose not to offer health insurance to their employees.
As a result, most of the 40 million Americans who lack health insurance are
workers or their dependents. These Americans have attempted to act responsibly
and to better themselves. But when illness compromises their liberties and
abilities, health care is often not there to get them back on their feet.
Among the employers who continue to offer private voluntary insurance, most
are
thinning it out rapidly. Headlines appear weekly announcing forms of “disinsurance,” of
less coverage and high co-payments. Today we have what Uwe Reinhardt calls
unsurance, because we are unsure what it covers and unsure what it will cover
next month. The feature film John Q is about unsurance: Denzel Washington finds
that his policy has been switched without notice and his coverage in the fine
print greatly reduced. The goal of private insurers is to minimize coverage
for those most in need of it, while the goal of a free society is to treat
those who need medical assistance the most, to get them back on their feet,
restore their liberties, and enable them to be productive.
The philosopher Paul Menzel has written that the anti-free-riding
principle “is
itself fundamentally a pro-individualist principle with libertarian senses
of justice. In holding people responsible, not just for the effects of their
voluntary actions on others, but also for the costs of the collective enterprises
from which they benefit, the anti-free-riding principle keeps collective solutions
to human needs in tow, tying them tightly to people’s ability and willingness
to pay their costs.”(4) This principle is closely linked to another conservative
tenet, the primacy of personal integrity: People ought to hold to the implications
of their beliefs, values, and actions, for themselves and for others. Yet thousands
of employers and insurers are free riders. They dump their medical problems
on the public system and force overloaded physicians and hospitals into deciding
how hard they want to work without pay.
The nightmare conservative is the motorcycle gang rider: Live for the moment
with free abandon and let others pay for the consequences. But there are many
more nightmare conservative capitalists who do the same on a larger scale.
Why are these enterprises and individuals not held responsible by their fellow
conservatives?
Universal access to needed medical services is essential to achieve our traditional
conservative moral principles: the anti-free-riding principle, the principle
of personal integrity, the principle of equal opportunity, and the principle
of just sharing. The question then becomes: How can conservatives refuse universal
access to health care and remain consistent with their conservative values?
Here are some guidelines:
1. Everyone is covered, and everyone contributes in proportion to his or her
income.
2. Decisions about all matters are open and publicly debated. Accountability
for costs, quality, and value of providers, suppliers, and administrators is
public.
3. Contributions do not discriminate by type of illness or ability to pay.
4. Coverage does not discriminate by type of illness or ability to pay.
5. Coverage responds first to medical need and suffering.
6. Non-financial barriers by class, language, education, and geography are
to be minimized.
7. Providers are paid fairly and equitably, taking into account their local
circumstances.
8. Clinical waste is minimized through public health, self-care, prevention,
strong primary care, and identification of unnecessary procedures.
9. Financial waste is minimized through simplified administrative arrangements
and strong bargaining for good value.
10. Choice is maximized in a common playing field where 90-95 percent of payments
go toward necessary and efficient health services and only 5-10 percent to
administration.
The $350 billion, or 24 percent of healthcare expenditures paid
for managing, marketing and profiting from our fragmenting system
could be cut in half and
go to paying doctors and nurses for uncovered services.5 But too many profit
from the waste and inequities. Unfortunately, most of the “real remedies
for the uninsured” 6 lock in these wasted billions and lock out any efficient
solution.
References:
1. Mossialos E, LeGrand J, eds. Health Care and Cost containment
in the European Union.
ldershot, UK: Ashgate, 1999.
2. Shearer G. Hidden from View: The Growing Burden of Health Care Costs.
Washington DC:
Consumers Union, 2000.
3. Gottleib S. Medical bills account for 40% of bankruptcies. BMJ 2000; 320:1295.
4. Menzel P. Justice and the Basic Structure of Health Care Systems. Pacific
Lutheran
University, January 2001.
5. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency
of the U.S.
health care system. New Engl J Med 1991; 324:1253-58. See New Engl J Med
1994; 331:336.
This figure rose steadily through at least the mid-1990s. Woolhandler S,
Himmelstein DU.
Costs of care and administration at for-profit and other hospitals in the
United States. New
Engl J Med 1997; 336:769-74; and correspondence, New Engl J Med 1997; 337:1779-80.
6. Meyer JA, Wicks EK, Covering America: Real Remedies for the Uninsured.
Wash. DC:
ESRI, June 2001.
Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.