By Donald W. Light, Ph.D.
Commonweal, February 22, 2002
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 or GE.
Despite these consequences, U.S. 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 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.[i]
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.[ii] Forty percent of all personal bankruptcies in the United States are attributed to medical bills people are unable to pay.[iii]
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.”[iv]
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 four 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. Nonfinancial 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 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.[v] But too many profit from the waste and inequities. Unfortunately, most of the “real remedies for the uninsured”[vi] lock in these wasted billions and lock out any efficient solution.
[i] Mossialos E, LeGrand J, eds. Health Care and Cost containment in the European Union. Aldershot, UK: Ashgate, 1999.
[ii] Shearer G. Hidden from View: The Growing Burden of Health Care Costs. Washington DC: Consumers Union, 2000.
[iii] Gottleib S. Medical bills account for 40% of bankruptcies. BMJ 2000;320:1295.
[iv] Menzel, Paul “Justice and the Basic Structure of Health Care Systems.” Pacific Lutheran University, January 2001, typed.
[v] Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of the U.S. health care system. N
ew England Journal of Medicine 1991; 324:1253-58. See letter 1994;331:336. This figure rose steadily through at least the mid-1990s. See Woolhandler S, Himmelstein DU. Costs of care and administration at for-profit and other hospitals in the United State. NEJM 1997:336:769-74. Correspondence 1997;337:1779-80.
[vi] Meyer JA, Wicks EK, Covering America: Real Remedies for the Uninsured. Wash. DC: ESRI, June 2001.
Donald W. Light, Ph.D., is professor of social and behavioral medicine at the University of Medicine and Dentistry of New Jersey and a founding fellow of the Center for Bioethics at the University of Pennsylvania, focusing on issues of distributive justice. He is a co-author of “Benchmarks of Fairness for Health Care Reform” (Oxford University Press, 1996). This article was adapted from Light, DW, “Health Care for All: A Conservative Case,” Commonweal, Feb. 22, 2002:14-16.