The Ethical Issues Raised in Health Care Debates

This book will ask whether universal health insurance systems are objectionable on the ground that they are inefficacious, fiscally risky, or require that individuals bear excessive personal costs. These issues are of serious philosophical interest, but there is also substantial evidence that opinions about fiscal risk, efficacy, and personal cost drive many Americans’ actual views on health care. This chapter surveys the polling data about these issues. The end of the chapter discusses the limitations of this evidence as well as alternative hypotheses about the drivers of the health care debate.

Introduction

Most Americans see the need for a national health policy that guarantees reasonable access to health insurance for all citizens, but some worry that a universal health insurance system would be inefficient, create excessive fiscal risk, or demand too much of them, either by increasing their taxes or by rendering their own health insurance unaffordable. After describing these three objections and the role they play in health care debates, the introduction outlines the contents of each chapter. It concludes with some remarks about how data will be handled in the book’s later chapters.

Information about Health Care Systems

One cannot discuss the ethics of health policy without understanding how health systems work, so this chapter provides background on the American health system before and after the Affordable Care Act. It also describes two universal health insurance systems the U.S. could adopt. In Canada’s single-payer system, the government serves as the basic insurer for the entire population. In the regulated-market systems of Switzerland and the Netherlands, citizens must purchase health insurance through private companies, and the government’s main jobs are providing subsidies to less wealthy individuals and ensuring that insurance companies deal fairly with citizens. The chapter concludes by examining the core ideas behind consumer-driven health care, a set of specific policies that conservatives often add to their health care proposals.

Beyond Health Care

This chapter argues that this book’s examination of the American health care debate has revealed larger lessons. Latent in our discussion is a whole new approach to debates about the social minimum—one that can prove useful during inquiries into any part of the social safety net, not just health care, and that can be applied to debates in any country, not just the U.S. Specifically, the discussion in the previous chapters has hinted at a way of understanding a conservative point of view about distributive justice, one that is usually overlooked. This chapter describes it more thoroughly and explains why it is philosophically significant. The chapter then identifies the parts of the conservative view that progressives might challenge, thereby building up a picture of the progressive view itself. The chapter closes by explaining why it is valuable to frame debates over the social safety net in this new way.

The Case for Universal Health Insurance

The previous chapters have examined three significant objections to universal health insurance—objections focused on fiscal risk, efficacy, and personal cost. This chapter synthesizes the responses to those concerns, revealing that they fit together into a single, coherent outlook on the ethics of health care. It is argued that in light of the considerations offered in previous chapters, the Affordable Care Act is problematic—deserving of support only in the face of inferior alternatives. In contrast, there are no similar problems with well-designed single-payer or regulated-market systems. The chapter concludes with some reflections on the next steps in a complete case for universal health insurance.

Fiscal Issues

Some people cite fiscal concerns as a reason to oppose expansions of the health safety net. This chapter develops and examines those fiscal concerns. The opening sections lay out some information on government debt and the fiscal risks it can create. After that the chapter analyzes how considerations about fiscal risk could most plausibly figure into assessments of universal health insurance. It is argued that in some instances, there are legitimate fiscal objections to expansions of the health safety net but that fiscal objections cannot ground opposition to well-designed universal health insurance systems.

Efficacy

Some people express concern that social minimum programs might be ineffective, inefficient, counterproductive, or unnecessary. This chapter focuses on three specific worries about efficacy that are often expressed in real-world debates about universal health insurance: the worries that universal health insurance systems would not improve aggregate national health, that they would reduce medical innovation, and that they would produce waiting lists. The first is best addressed using purely factual information, but concerns about innovation and wait lists require philosophical analysis. The chapter argues that concerns about innovation and wait lists are philosophically misguided.

Personal Cost

Some people object to social minimum programs, including certain health care programs, because they believe the programs impose excessive taxes and other personal costs on those who fund them. This chapter argues that the most plausible philosophical reconstruction of this objection would rely on a personal cost principle which says that, in general, the proper level of the social minimum is at least partly a function of whether the benefits provided by the social minimum programs outweigh the costs, when judged on a scale that assigns disproportionate weight to those who bear the costs. It is argued that the personal cost principle can find a place within several plausible theories of justice, and that, in addition, the benefits of a well-designed universal health insurance system outweigh its costs.