Title: What Price, America?
Author:
Section/SPIG: Community Health Planning and Policy Development
Issue Date:
“Why should we tolerate a system…?”
Critics of American health care often rhetorically phrase their criticism of it using this question, and if nothing else, it’s better than uncritical acceptance of our miserable status quo. But then they go on to present the usual set of common sense reflections about what we might have were we even as sensible about our health care as the Canadians and the Europeans. I see this from a more radical perspective, one from which it goes to the very roots of our being Americans.
Planning is the process that attempts to resolve such questions, but it has never been used to develop a national health care delivery system in this country! Resolving this is a question of values, and of bringing our incentives into line with our values. We need to reestablish the connection between our most deeply held ethical values and our public policies. So what are our values? If we don’t answer, “education, democracy, and community,” we’ll never have the right context in which to answer the one about health.
For Europeans, it’s the Principle of Solidarity. They will not permit profit making to endanger their communitarian values. Historically, our communitarian values were always implicit in our insurance plans. Health insurance first emerged during the 1930s with the creation of Blue
Cross plans to help individuals pay for the costs of hospitals and physician services. Hospitals began the earliest plans so that patients would be better able to use their services. These plans were “community rated,” meaning that all participants paid the same premium regardless of their age or health status. During World War II, private employers began to buy health insurance for their workers as a way to increase compensation without violating the federal government’s wage and price freeze —- and thus began the American pattern of employer-sponsored coverage.
Whether it’s an employer-provided benefit or an individually funded plan, today’s health insurance is, except in a few remaining states, casualty insurance, not social insurance. Insurance is now “experience rated,” where a person or group is charged a different rate depending on health history or demographic characteristics. And right there, we have given up a priceless communitarian principle against which today’s insurance instruments are immoral. Insurance terminology makes its intent explicit. Adverse selection occurs when people who know they are at high risk buy more insurance than those at lower risk. Moral hazard is the altering of one’s behavior because one is insured. Insurance companies do all they can to avoid these two consumer-friendly factors in the interest of minimizing their medical loss ratio. This is how managed care corporations define the money they spend caring for patients, and it epitomizes how the needs of sick patients are pitted against the profit maximization of these businesses.
Needless to say, these insurance instruments are one of the principal means of creating the disparities in access to health services and in health status that are endemic in our increasingly polarized society. Noting this, the Committee on the Consequences of Uninsurance of the Institute of Medicine, National Academy of Sciences, recently wrote:
"Imagine what the country would be like if everyone had coverage – people would be financially able to have health problems checked, to seek preventive and primary care promptly, and to receive necessary, appropriate and effective health services. Hospitals would be able to provide care without jeopardizing their operating budget and all families would have security in knowing that they had some protection against the prospect of medical bills undermining their financial stability or creditworthiness. The Committee believes that this picture could become reality and that it is an image worth pursuing because the costs of uninsurance to all of us – financial, societal, and in terms of health – are so great. The benefits of appropriate and timely health care are potentially even greater and can help motivate attaining this vision."*
* Insuring America's Health: Principles and Recommendations, National Academies Press (2004), page 7. <http://www.nap.edu/books/0309091055/html>.
My radical perspective is one that sees all this as an abrogation of our birthright as American citizens.
We the people of the United States, in order to form a more perfect union, establish justice, insure domestic tranquility, provide for the common defense, promote the general welfare, and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this Constitution for the United States of America.
Article I. Section 8. The Congress shall have power to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general welfare of the United States; but all duties, imposts and excises shall be uniform throughout the United States;
The preamble to the Constitution "provides" for the common defense but only "promotes" the general welfare. It is interesting that a right to education is not included specifically after these words, but no one would deny a child the right to education. Education is justified based on the general welfare duties. Health care is similar to education, and the argument can be made based on the same reasons.
Our forefathers understood human rights as derived from principles of natural law, based in the dignity and worth of the human being. The Declaration of Independence acknowledges the unalienable right of life, liberty and the pursuit of happiness. In order to pursue these rights, adequate health is a necessity; it is presupposed. Therefore, health care should be a right.
In 1943, President Franklin D. Roosevelt proposed a “Second Bill of Rights” for Americans, declaring “freedom from want” to be one of four essential liberties necessary for human security. Roosevelt’s definition of freedom included “the right to adequate medical care and the opportunity to achieve and enjoy good health.” The right to health was subsequently included in the UN’s Universal Declaration of Human Rights (1948), drafted with American guidance, and supported by our nation in the person of Eleanor Roosevelt:
Article 25
(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
(2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.
So, “Why should we tolerate a system…?”