Justice: The missing talking point in the long-running healthcare debate
by Theodore Marmor
One of the most striking features of the American health care debate is how little attention was paid to the subject of justice. The idea of fundamental fairness, questions about solidarity and what it requires in the way of patient cost sharing, and the importance of equal access: all were central components of the public conversation about health care – in Canada and Britain and democracies elsewhere.
The specific tropes vary as do ideas about what, specifically, justice requires, but notions of justice were central to similiar public conversations about universal health care in Scandanavia and elswehere on the European continent.
What lessons might we have learned had the American debate been less provincial? And did ideas about justice solidify and stabilize the health reform efforts elsewhere?
Consider the the British National Health Service (NHS). From the outset, it celebrated the idea that medical care should be 'free at the point of service.' This is a core premise. The idea is that equally ill citizens should share equal access to care – regardless of their ability to pay, and that, were it otherwise, financial barriers at the point of service would disproportionately, effectively, allocate health resources to those who can afford to pay for them.
Interestingly, the English practice has never quite lived up to its egalitarian norm. For decades, the NHS allowed for 'pay beds' which accelerates access to care for those with private insurance for public hospitals. From the start, the British system permitted physicians to charge for 'private patients' even while they devoted the bulk of their time to NHS patients. So, the principled commitment to a more just distribution of medical care has, in practice, accomodated some limited privileges of English physicians and some patients. This form of a mixed market for medical care has been the subject of continuing controversy within the Labour Party. It has also provided a safety valve for discontented physicians or patients with means or private insurance. But the essential fact remains: in contemporary Britain, two seemingly conflicting ideas – guaranteed access according to medical need for most, and, some access according to ability and willingness to pay — coexist; and, this is so even though the NHS accounts for roughly 90% of expenditures and private insurance about 10%.
In practice, Canada is even more egalitarian. Consider Canada’s hospital and physicians' financial rules. The Hall Royal Commission report of 1964– the founding document in the Canadian medicare system – called for a universal, comprehensive, accessible, publicly administered, portable system of health insurance. This is designed to remove all financial barriers to hospital and physician care and thus ensures equal access for all citizens. Successful practice depends, however, on rules that require physicians – and hospitals – to participate fully or fully exempt themselves from the public insurance system. Doctors can’t charge patients who come to them under the Canadian Medicare Program. Indeed, except in very limited instances, the Program does not allow private health insurance for medical services that the Program covers. The obvious goal is to substitute medical need for financial clout as a criteran for access. Canada's system is remarkable in this regard. No other industrial democracy places such firm limits on private insurance purchase.
Similiarly, if one reviewed the health care programs in France, Japan, Holland, and Germany, a common pattern would emerge. Each country offers different, but limited, market options for those who want and can afford special treatment; each of these countries, as distinct from the U.S., created a universal health care program fundamentally based on the idea that medical care is a merit, not a market good. The equal access norm does not, of course, mean ideal practice, but care is more equally distributed. It is also true that more equal medical care does not necessarily mean that access to health care is equally distributed in these countries. Health care and health aren't the same thing, and making populations more equally healthy is much more difficult than making medical care more fairly distributed.
Enter the US debate -- and the relative omission of serious ethical justification for the health care overhaul, soon to be termed "Obamacare." During his long campaign for healthcare reform, Obama repeatedly and eloquently described the traumatic, destabilizing consequences under- and uninsured Americans face. Private health insurance, he said, presents for many Americans a nightmare of troubles -- recissions, denial of applications because of pre-existing conditions, misleading advertising, etc. Medical inflation and the problems it has caused were the focus of much public hand-wringing. Cost control, too, was the subject of great public interest. But, what makes the Obama reform package a 'just' one? Or a morally-compelling legislative effort towards what end? The expression "affordable health care for every American" was bandied about, but was not clearly defined. Instead, it was repeatedly invoked as a means to avoid the various personal horror stories told and re-told throughout the long debate. In fact, there was little talk about why affordable health care for all is a good, much less, important or democratic, idea.
The politics of reform, which produced legislative "victory," will continue. Indeed, in the last days before it passed, Obama campaigned for healthcare reform as if he had the elections of 2010 and 2012 in mind. The Obama reform rhetoric will provide the opportunity to reinforce why this overhaul made sense, why it should compel admiration rather than scorn, and why it might make a more just America. And, this campaign will be crucial to heading off weakening rather than strengthening Congressional adjustments while we wait for the bulk of the legislative reforms to be implemented between now and 2014.
Last summer T.R. Reid published a much lauded book about comparative health care reform experiences in leading democracies. In a review in Health Affairs, I contributed to critical acclaim surrounding The Healing of America and the compelling case it makes for unversal health care; in doing so, Reid invoked the moral arguments that animated reform efforts in France, Britain, Canada, Japan and Germany.
Yet, while rightly calling attention to the moral principles that undergirded reform efforts abroad, Reid conflates the idea that consensus is, on normative grounds, a necessary condition for reform and the notion that arguments for a more just distribution of care would help rally support. Reid’s treatment of Canadian development was, in fact, misleading. His coverage, for example, omitted mention of the long period between 1957 and 1971 when Quebec finally joined in the national medical insurance program. Reid implied that Canada arrived at a moral consensus, which resulted in the Medicare Program. In fact, the justice imperative underlying Canada's national insurance program was a more a product of the nation’s move to universal coverage, than it was the force that animated the move.
Impressed by the overall merit of Reid’s work, I did not want to detract from his argument, at least not last summer when it was far from certain Congress would pass any healthcare legislation. Now, however, it seems important to push those seeking to solidify and to improve reform legislation to consider, seriously and thoughtfully, the lessons of comparative experience abroad.
Theodore Marmor is the author of 13 books about health care and public policy, the most recent of which is The Politics of Medicare (Transaction Press); A professor Emeritus of Public Policy and Politics and Yale University, Marmor is editor of a recent collection of essays about healthcare policy, Fads, Fallacies and Foolishness in Medical Care Management and Policy (World Scientific Press, 2007).
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