By Allan S. Brett, M.D.
New England Journal of Medicine
Volume 361:440-441 July 30, 2009 Number 5
Amid all the rhetoric about health care reform, one claim has emerged as a trump card designed to preserve the current patchwork of private and public insurance and to stop discussion of a government-sponsored single-payer system in its tracks: the claim that single-payer health care — a Canadian-style Medicare-for-all system — is antithetical to “American values.” The idea that American values dictate a particular approach to health care reform is often stated explicitly, and it is implicit in the generalization that “Americans want” a particular system. The underlying premise is that an identifiable set of American values point incontrovertibly to a health care system anchored by the private insurance industry. Remarkably, this premise has received very little scrutiny.
Two related assumptions are buried in the language of “American values.” The first is that there are archetypical Americans — that if we know someone fits the category “American,” it should be possible to predict his or her general worldview accurately. However, we have good reason to doubt that assumption. In nearly all respects — ethnically, culturally, religiously, politically, and socioeconomically — Americans are increasingly diverse. The recent presidential campaign provides evidence that a monolithic conception of what it means to be “American” is problematic and outdated: those who championed the idea of “real” Americans (as distinct from Americans who are somehow less representative of American ideals) were precisely those whose candidate lost the election.
The second assumption is that Americans’ personal values predictably translate into certain orga nizational structures for the financing and provision of health care — and that a single-payer system is not among them. Exactly what might those values be? Are they self-regarding values directed toward maximizing individual well-being and potential? Or other-regarding values such as altruism or concern for community? Clear ly, most people — regardless of political, ethnic, or cultural identity — regard both sets of values as important in varying proportions; nothing precludes a single-payer system as one possible means of realizing a blend of these values.
The notion that American values militate against a single-payer system is advanced not only by advocates of preserving the status quo or making incremental changes but also by some who propose major reforms that nibble around the edges of a single-payer system. For example, Ezekiel Emanuel — now a special adviser on the Obama administration’s health care team — has proposed universal health insurance funded by a value-added tax on sold goods and services; all citizens would receive government-issued vouchers to purchase health insurance from private insurance companies. According to Emanuel, such a plan “coheres with core American values: individualism and equality of opportunity.” He argues that equality of opportunity dictates universal coverage and government funding, but individualism dictates preservation of the private insurance system: “Americans clamor . . . for the chance to choose. . . . We want to choose our insurance plans, our hospitals, our doctors.”1
The theme of “choice” also surfaces in the writing of Tom Daschle, President Barack Obama’s initial pick for secretary of health and human services. In his book Critical, Daschle proposes universal coverage delivered through a private-public hybrid plan. He all but admits that a single-payer system i s the best solution but abandons the idea because it is “politically problematic” and because “compared to residents of [European countries], Americans are more supportive of choice and suspicious of government.”2
Suppose that “freedom to choose” is indeed the paramount American value relevant to health care. For many people, it would surely imply choice of physician, hospital, or clinic. For such choice, a single-payer system beats the competition hands down. Incremental reforms preserving the private insurance industry and employer-based insurance would probably perpetuate the restricted choice of health care providers that many Americans already encounter: private plans typically limit access to certain physicians or hospitals, and physicians often refuse to accept certain plans. In contrast, single-payer proposals eliminate those restrictions.
Another possible meaning of “choice” is the freedom to choose from an array of private insurance companies. Here it is important to acknowledge that insurance is only a means for collecting and disbursing health care funds — not an end in itself. The key question is therefore whether private insurance is superior to single-payer insurance in ach ieving the desired end of efficient, cost-effective health care. Here, too, the single-payer system would probably prevail. Because administrative costs are consistently lower in single-payer systems than in private-based systems, more of the health care budget goes directly to patient care (and less to administration) in single-payer systems. Thus, American s have been misled by the rhetoric about choice. In contrast with the single-payer option, a system with multiple private insurers would continue to restrict one dimension of choice (selection of physicians) and perpetuate a choice most people would consider irrational (wasteful spending on administrative overhead).
A third dimension of choice is the freedom to choose whatever test or treatment a patient wants. This choice is system-neutral, pointing to neither single-payer nor alternative systems. Any reform initiative must control spending; unproven or unnecessary medical interventions should not be available in any system.
A closely related rhetorical device — the idea that Americans or American values are “unique” — also deserves attention. For example, Emanuel describes individualism and equality of opportunity as “uniquely American.”1 Senator Max Baucus (D-MT), chairman of the Senate Finance Committee, asserts that a public-private hybrid is essential because it is a “uniquely American solution.”3 Others describe rugged individualism as a “uniquely American” value that makes us “reluctant to provide our tax dollars to support someone else’s health care.”4 Such defiant-sounding assertions imply that “uniqueness” is a matter of pride and an end in itself. But these generalizations are impossible to prove, a distraction in the debate, and ultimately irrelevant. What is relevant is whether a solution works, not whether it is unique. Indeed, the aspect of the current U.S. system that is truly unique among developed countries is its failure to cover everyone — hardly something to brag about.
In their book Benchmarks of Fairness for Health Care Reform, Norman Daniels and colleagues reject these “ungenerous” views of our values, arguing that past failures to reform health care are better explained by the influence of interest groups whose wealth and power are threatened by reform.5 The authors propose that fair equality of opportunity is a more promising and relevant American value. Opinion polls support this proposal: in multiple surveys of randomly selected Americans during the past decade, more than 60% of respondents have favored government-guaranteed health care for all. Although these responses don’t necessarily specify a single-payer system as the only model for government-guaranteed insurance, they surely do not exclude it.
Policymakers debating health care reform should stop hiding behind the smoke screen of “American values.” Discussions dominated by references to uniquely American individualism, uniquely American solutions, or narrowly defined conceptions of choice tell us more about the political and economic interests of the discussants than about the interests of the Americans they claim to represent. In an increasingly diverse country that has a widening gap between rich and poor, a more promising approach is to start with the questions that matter to everyone: Will the system care for us when we’re sick and help prevent illness when we’re well? Will we have access to medical care throughout our lives without risking fi nancial ruin? Will we be able to navigate the system easily, without jumping through unnecessary hoops or encountering excessive red tape? Will health care spending be managed wisely? Health care reformers owe Americans a system that best addresses these questions — not one that merely pays lip service to ill-defined “American values.”
No potential conflict of interest relevant to this article was reported.
Source Information: From the University of South Carolina School of Medicine, Columbia.
References
1. Emanuel EJ. Healthcare, guaranteed: a simple, secure solution for America. New York: PublicAffairs, 2008:12-6.
2. Daschle T. Critical: what we can do about the health-care crisis. New York: Thomas Dunne Books, 2008:144, 204.
3. Medical News Today. Sen. Baucus hopes to introduce comprehensive health reform legislation this summer. March 5, 2009. (Accessed July 10, 2009, at http://www.medicalnewstoday.com/articles/141193.php.)
4. Garson A Jr, Engelhard CL. Health care half-truths: too many myths, not enough reality. Lanham, MD: Rowman & Littlefield, 2007:131-2.
5. Daniels N, Light DW, Caplan RL. Benchmarks of fairness for health care reform. New York: Oxford University Press, 1996:15-22.
http://content.nejm.org/cgi/content/full/361/5/440
