Why we cannot agree on the direction of health reform: an exploration of American values.

Most of the articles in this series examine historical forces that have shaped American health care policy. This article will ask the reader to step back from the swirl of events that have led to a health care system that provides excellent care to many and minimal services to a substantial minority. The purpose of this article is to place often contradictory health policies within their philosophical context. Such an analysis can lead to an understanding of the reasons for the simultaneous appearance of both competitive and regulatory features in the American health care system.

Underneath today's debate over health care reform is the fundamental question of whether or not there exists a right to health care. If such a right exists, are there limits? What are the relative responsibilities of the individual versus private or government entities in monetarily fulfilling this right? Four distinct philosophies (libertarianism, egalitarianism, utilitarianism, and Rawlsianism) have historically influenced America's response to these questions?

Major tensions exist between these four schools of thought. The most important policy tension exists between the libertarian foundations of America, characterized by "frontier spirit" and "self-reliance," and the egalitarian spirit exemplified by "equal opportunity for all." Tensions also exist within libertarianism and egalitarianism. Libertarians include not only groups espousing limited or no government involvement in the life of an individual, but also members of organizations, most notably the American Medical Association, that use the language of libertarianism to advocate policies serving their group interests. For example, physicians have supported the free enterprise right of physicians to set fees but not the free enterprise notion of unrestricted entry to medical school or, in the past, the right of health maintenance organizations (HMOs) te hire physicians on a salaried basis. Within egalitarianism, it is difficult to precisely define from both a policy and a philosophical perspective what is meant by "equal access" to health services. The vagueness inherent in the philosophy of egalitarianism does not provide an easy roadmap to determine what restrictions, if any, apply to health care benefits.

Libertarianism

The quintessential American belief in individualism and self-reliance reflects the influence of libertarianism. The emphasis of Louis Sullivan, MD, Secretary of Health and Human Services, on individual responsibility and self-reliance as an antidote to government control typifies a libertarian perspective. The libertarian influence on American values and legislation has limited government involvement in our health care system.

Robert Nozick best summarizes the philosophical underpinnings of the libertarian perspective. The state, according to Nozick, has only two functions: protection of individual rights and a "monopoly" over the use of force. Individual rights include the right to own property and freedom of expression. Other rights are granted to an individual as long as they do not impinge upon the freedom of action of other individuals. A critical difference between libertarians and egalitarians is the former's complete opposition to any form of distributive justice--the term philosophers apply to the distribution of services according to need. "...in a free society, diverse persons control different resources, and new holdings arise out of the voluntary exchanges and actions of persons. There is no more a distributing or distribution of shares than there is a distribution of mates in a society in which persons choose whom they shall marry," according to Nozick.[2]

Libertarians treat medical care as a simple commodity; it is a service the physician is empowered to dispose of as he wishes. In an article published in the New England Journal of Medicine 15 years ago, Slade argued, "Any doctor who is forced by law to join a group or a hospital he does not choose, or is prevented by law to make any decision he would not otherwise have made, is being forced to act against his own life. He is also being forced to violate his most fundamental professional commitment, that of using his own best judgment at all times for the greatest benefit for his patient."[3]

As a consequence, libertarians would argue that indigent patients should be able to obtain health services only if physicians are willing to provide them as an act of kindness. There is no place for the Medicaid program, for example, in the minds of pure libertarians.

The AMA has traditionally based its opposition to a fight to health care on Slade's libertarian argument, which emphasizes a physician's freedom of choice and the patient's freedom to choose his or her own physician. However,the AMA has historically disavowed other key libertarian principles: freedom of entry into the profession and a physician's right to join a managed care organization or to advertise for patients. On these issues, there have been basic philosophical differences between AMA policy and a pure libertarian perspective. Traditional libertarians would categorize the AMA as simply another interest group attempting to protect the interests of its members. It is the ability of the AMA to cloak the self-interests of its members in libertarian language consistent with many American values that has historically provided it with much of its political power.

Several demographic and political trends have diminished the political position of the AMA in recent years. An increased supply of physicians has decreased the AMA's ability to influence its constituents. Many physicians are not old enough to remember that, as recently as the 1950s, a physician desiring hospital privileges had to be a member "in good standing" of the county medical society. Consumers' desire to be involved in health care decisions affecting their health has diminished physician control of medical. information. "Cultural authority" is the term Starr applied to physician control of medical information.[4]

A more plausible explanation for the decline in physician power than either growth in the physician supply or the decrease in physicians' cultural authority is the dramatic opportunity for profit in today's health care system. New business interests, including for-profit HMOs; biotechnology companies; and the federal government, the biggest payer of health services, have emerged in the past decade. Prior to 1950, physician care constituted the principal expense in the health care system. Automated laboratory machines were invented in the 1950s, the CT scanner in the 1970s. Today, the cost of technology towers over direct physician costs in monetary importance. Even if every physician were "virtuous," this would not pay for the technological support needed to help physicians make their clinical judgments.

While most physicians espouse the libertarian principles of freedom to choose one's own patients and to charge any fee, conflicting libertarian principles pertaining to the free market and the right of individuals to become involved in their own health have served to significantly diminish physician power. New business and consumer interests represent increasingly potent political counterweights to the AMA.

Libertarian theory does not directly respond to the challenge of the rising number of uninsured. Rather, libertarians emphasize the importance of the free market and individual responsibility for one's life-style and health status. A pure libertarian approach to health policy would mandate a nonintervention approach in all spheres of medical care. Within this framework there would be neither licensure of physicians nor a physician's obligation to provide medical care to the needy. A strict libertarian would not accept the concept of government responsibility for a "safety net." At best, a libertarian might compromise and allow tax credits for individuals to shop for the health insurance. The Heritage Foundation has recently detailed such an approach, and many elements of the Bush administration's health care platform adopt this perspective.

Utilitarianism

While most philosophical schools of thought consider justice from the point of view of the individual, a utilitarian looks at justice from the perspective of society as a whole. What maximizes the "good" for the majority of the population constitutes a "just" society. Thus, a utilitarian would advocate prenatal care if empirical research documented that costs to society of providing free prenatal care were outweighed by the benefits, both in decreased morbidity to patients and in long-term costs to society. Federal public health measures enacted in the 19th century derive their rationale from utilitarian considerations. The benefits to a majority of individuals outweighed the accusations of infringement on the rights of a patient with, for example, smallpox.[5]

When the President's Commission for the Study of Ethical Problems in Medicine emphasized five years ago the primacy of access to health care services, the overall argument in favor of this perspective was a utilitarian one. "The level of care that is available will be determined by the level of resources devoted to producing it. Such allocation should reflect the benefits and costs of the care provided. It should be emphasized that these benefits as well as their costs should be interpreted broadly and not restricted only to effects easily quantillable in monetary terms. Personal benefits include improvements in individuals' functioning and in their quality of life and the reassurance from worry and the provision of information that are a product of health care. Broader social benefits should be included as well, such as strengthening the sense of community and the belief that no one in serious need of health care will be left without it."[6]

While they are utilitarian in overall tone, there are also egalitarian themes in this passage. The integration of utilitarian, egalitarian, and often libertarian themes reflect historical tension in the development and implementation of changes in American health policy. This conflict, particularly between libertarianism and egalitarianism, is occasionally resolved on utilitarian grounds, especially when the conflict does not involve a fundamental aspect of the American health care delivery system. The implementation in 1983 of diagnosis related groups (DRGs) represents an example of a utilitarian solution to rapidly rising health care costs intended to maintain an "equitable" level of care for all Medicare patients. The federal government was able to implement the system because DRGs were not applied to all health care sectors. DRGs were enacted during the Reagan Administration, when the language of libertarianism was emphasized.

Utilitarian arguments are used in the shaping of health programs directed at low-income individuals. The effort of Oregon to introduce explicit rationing into its Medicaid program represents a utilitarian effort to maximize benefits with available dollars. However, rationing would apply only to low-income individuals. Oregon continues to pursue the American libertarian tradition of free choice for the middle class but has adopted a utilitarian perspective for low-income citizens.

Utilitarian principles do affect the middle class with the advent of managed care. While not enthralled with restrictions on their right to choose their own physicians, the public has increasingly chosen managed care in an effort to obtain health services at a reduced price. In addition, Medicaid programs in several states have enacted policies that restrict health care access to specified providers. A utilitarian would dearly favor such a policy if it maximized access in the face of scarce resources.

Within American health policy, utilitarianism occupies the political center. In attempting to provide health services for the largest number of people, proponents of utilitarianism attempt to strike a balance between libertarianism and egalitarianism.

Egalitarianism

The right to health care may represent either a moral or a legal obligation. While egalitarianism specifies similar treatment for similar diagnoses, this position has never been, and very likely never will be, enshrined as a legal fight in the United States. The most active push for an egalitarian approach to health care for all Americans came during the 1960s and culminated in the push in 1971 for national health insurance. The high cost of medical care has forced most egalitarians to support a "decent minimum" of health care. This is the point of view one finds in the summary report of the President's Commission on Biomedical Ethics: "Society has a moral obligation to ensure that everyone has access to adequate care without being subject to excessive burdens."[7]

It is unlikely that a societal consensus will emerge on a specified set of services for the indigent population. Today's egalitarian stands on shaky philosophical ground, because the historical reality is that as American societal values have changed, so have egalitarian (but not utilitarian or libertarian) theories of justice. Thus, a 1990s egalitarian approach to health care would emphasize a basic package of health services for all Americans, while equal access for all services would likely have been insisted upon during the 1960s.

Egalitarianism represents a strong undercurrent in American popular political opinion. Despite this belief in equal opportunity, high medical costs have placed egalitarians in a weak position. Yet, many Americans are uncomfortable with purely utilitarian arguments applied to their health care system. To look for philosophical support for the popular political position of a "decent minimum," many have turned to John Rawls' path breaking study, Justice.[7]

Rawls

Justice, according to Rawls, is "the first virtue of a social institution."[7] At the same time, he states, in a libertarian vein, that "each person possesses an inviolability, rounded on justice, that even the welfare of society as a whole cannot override." [7] Rawls goes on to enumerate three principles that, if philosophically defensible, establish the primacy of justice without violating libertarian perspectives on individual fights. In descending order of importance, these principles are:

A. Principle of Greatest Equal Liberty: Each person has a right to the most extensive system of basic liberties compatible with a similar system of liberty for all.

B. Principle of Equality of Fair Opportunity: Offices and positions are to be open to all under conditions of equality of fair opportunity.

C. The Difference Principle: Social and economic institutions are arranged to benefit maximally the worst off.[7]

Under Rawls' theory of justice, health care may not be a 'basic liberty," as not all individuals have the same requirement for health care as they do, for example, for freedom of expression.

One of Rawls' underlying premises in Principles B and C is that an individual's natural talents should not be the only determinants of occupational achievement in society. This clearly differentiates the libertarian and Rawlsian points of view. Rawls is interested in maximizing an individual's "opportunity to pursue careers," but he strongly emphasizes that the initial distribution is strongly influenced by social and accidental events. According to Rawls, an individual's natural talents represent an accidental event. Rawls uses a philosophical device he calls the "original position," which would place everyone in an equal position from which a distribution of talent and a determination of the principles of justice would occur. Rawls believes that are several reasons why all members of society will agree to such a philosophical argument. First, everyone would have a "veil of ignorance." No individual would know who has talents or even the extent of his or her own abilities. If one accepts this postulate, the rational course would be for each individual to favor the least advantaged, because an individual would not know whether or not he is one of them. While health care is included in Rawls' Principle B, it is only one of many conditions that lead to fair opportunity. After distribution of"talents" and individual traits has occurred under the veil of ignorance, an individual may decide to trade social and economic advantages, or even a basic liberty such as freedom of choice, for greater access to health care.

Several aspects of the American health care delivery system are related to Rawls' three principles. An increasing number of health insurance plans restrict consumer choice of physician. In an effort to cut costs, most managed health care plans decrease access through some form of gatekeeper concept. The rising costs of health services and popular willingness to trade off some of freedom of movement in exchange for basic health services (Rawls' Principles A and C) account for this change in attitude.

The Rawlsian approach offers a possible resolution to the difficult to defend philosophical position of a "decent minimum" of health care advocated by egalitarians. At the same time, Rawls' approach preserves most aspects of libertarian concerns for individual freedom of choice.

Impact of American Values on the Debate

How can economists disagree? According to Thurow, economic forecasts and projections vary depending on the assumptions behind them, all of which are very much based on the political perspectives of the economists: "There is an ethical value judgment as to whose income ought to go up or down. This ethical value judgment has nothing to do with technical economics, but it is usually at the heart of differences between liberal and conservative economists...no one talks about liberal or conservative chemists. There are only chemists who in the rest of their lives happen to be liberals or conservatives."[8]

Libertarianism represents the dominant American value. A question in one of the many recent polls on American attitudes toward health care costs illustrates American support for an approach that emphasizes access to health services for those who can afford them: "Do you think that having two levels of health insurance--basic care for everyone and additional services for those who can afford it--would be an improvement over the system we have now, or not? 53%: Improvement; 39%: No Improvement 8%: Don't Know or No Answer. [9]

While bursts of "liberal" activism have resulted in major health care legislation, health care programs consisting of a liberal ideology woven into a libertarian framework frequently result in high cost and poor service to the intended population. The Medicaid program often exemplifies such a result.

The critical issue that the American libertarian perspective needs to address is not equality of health services but rather access to essential health services for the uninsured and the Medicare/Medicaid populations. As discussed above, health care costs until the 1960s were low enough that the "virtuous libertarian physician" could have taken care of most aspects of health services for low-income individuals (though this did not happen). Advances in medicine have changed this situation, and the possibility of significant profit not solely dependent on the labor of physicians and nurses has emerged. The entry of many corporations into the health care economy has introduced a strong competitive and for-profit motive into the health care system. The increasingly important role of, for example, insurance companies in the actual delivery of care makes it extremely unlikely that national health insurance along the Canadian model would become law in a country where even labor unions until recently were against such a program and where major government intervention in any sector of the economy has become unfashionable, particularly with the demise of the Soviet Union.

Currently, except for senior citizens and for the very poor, the insurance system is largely within the free market. In addition, consumers still have a choice of health care providers. American ideology favors the continued presence of a free market approach to health insurance, as long as it is affordable to the middle class. Similarly, American preference for libertarianism encourages consumer responsibility and choice for both their health care and insurance as long as it is available when it is most needed. Until the early 20th Century, the cost of health services could be easily met by the middle class. From the 1930s until very recently, voluntary health insurance largely provided by employers met middle class needs. This historical compact between the private health insurance industry, employers, and government to provide health care for the middle class and at least a portion of the poor has begun to fray at its edges. If this trend continues, American values, shaped by the philosophies discussed in this article, will determine new roles for government, private insurance industry, and consumers.

Conclusion

Since the Colonial period, Americans have viewed economic success as a sign of virtue and poverty as the result of a misspent life. In complaining about Americans' unwillingness to help the poor, Horace Mann, a 19th century observer of American culture! complained: "In this country, we seem to learn our rights quicker than our duties."[10] The rights Mann refers to are the libertarian principles enshrined in our constitution. The Bush approach to health care reform emphasizes the twin libertarian principles of the free market and individual responsibility. However, as Thomas Edsall recently observed, "The central political error of the Bush administration may well turn out to be that it used the 1988 campaign to manipulate voters on a variety of emotional issues and then failed to do anything concrete about the issues once it took over the White House. Health reform has recently become one of these issues."[11]

Lest liberals take heart in the increased visibility of health reform, it is not at all clear that the American voter is supportive of drastic changes in the health care system, let alone of new taxes to support such changes. Exit polls after the 1992 New Hampshire primary revealed that, while voters desired health reform, they were not willing to pay higher taxes for these reforms. Furthermore, while liberals enthusiastically looked to Harris Worford's thumping of Bush's protege, Richard Thornburgh, as indicative of Pennsylvanians' support for national health insurance, a closer look at Worford's campaign advertisements reveals that he never challenged the dominant role of the insurance industry in today's health care system.

There is an important difference between government as a purchaser of health services and a governmentrun national health service. American preference for the former reflects underlying values that represent aspects of egalitarianism intermixed with a dominant ethos of libertarianism. Over the next 10 years, American values will determine the direction government health policy will take on the "purchaser-national health service" continuum. Underlying American values will also determine what, if my, role the insurance industry will continue to have. Finally, American belief in individual responsibility will have a significant impact on what financial obligations and choices consumers will have as they seek to obtain increasingly expensive yet effective health services.

References

1. Further background material on the four schools of thought that are discussed in this article can be divided into primary and secondary sources. With respect to libertarianism, readers are referred to Noznick, R. Anarchy, State, and Utopia. New York, N.Y.: Basic Books, 1974, and Noznick, R. Philosophical Explanations. Cambridge. Mass.: Belknap Press of Harvard University, 1981. On the utilitarian school of thought, one naturally turns to John Stuart Mill, Utilitarianism. With respect to egalitarianism, individuals interested in primary source material should turn to Rousseau, J.J., Discourse on the Origin of Inequality. The writing of John Rawls that is most frequently quoted in this article is Rawls, J. A Theory of Justice. Cambridge, Mass. :Belknap Press of Harvard University, 1971. There is a great deal of secondary material on philosophical aspects of justice and health care. A special issue on the right to health care issue was published in the Journal of Medicine and Philosophy 4(2), 1979. Earl E. Shelp edited a volume entitled Justice and Health Care. Holland: D. Reidel and Publishing Co., 1981. One of the few efforts at integrating aspects of philosophy with health policy can be found in the recently completed work of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. See, particularly, the two volumes entitled Securing Access to Health Care. Washington, D.C.: U.S. Government Printing Office, 1983. For an important sociological study on current attitudes on individualism in the United States, see Bellah et al., Habits of the Heart. Berkeley, Calif.: University of California Press, 1985.

2. Nozick, R. Anarchy. State and Utopia. New York, N.Y.: Basic Books, 1974, p. 150.

3. Slade, R. "Medical Care as a Right: A Refutation." New England Journal of Medicine 285(23):1288-92, Dec. 2, 1971.

4. Starr, P. The Social Transformation of American Medicine. New York, N.Y.: Basic Books, 1982.

5. Chapman, B., and Talmadge, J. "The Evolution of the Right to Health Care Concept in the United States." Pharos 22(1):30-51, Jan. 1971.

6, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Washington, D.C.: U,S, Government Printing Office, 1983, p. 36.

7. Rawls, J. A Theory of Justice. Cambridge, Mass.: Belknap Press of Harvard University Press, 1971.

8. Thurow, L. "Why Do Economists Disagree?" Dissent 29(2):176, Spring 1982.

9. Poll conducted by researchers at the Harvard School of Public Health, Department of Health Policy and Management, the day after the 1992 New Hampshire presidential primary.

10. Filler, L. "Horace Mann and the Crisis in Education." In Cochran, T. Challenges to American Values. New York, N.Y.: Oxford University Press, 1975, p. 92.

Norbert Goldfield, MD, is Medical Director, 3M/hEALTH iNFORMATION sYSTEMS, wallingford, CONN.