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Health care explained, though not beautifully.

Lately, some in bioethics have been asking, "Why don't bioethicists put more of their professional efforts into writing and speaking about the failure to enact universal health insurance? Why don't they identify it as a national moral failure and argue for change in the health care system on ethical grounds?" There have always been bioethicists interested in access to care, but on the whole, it is fair to say that the field has emphasized individual physician-patient issues over systems issues. One answer to the question is that Bioethics doesn't have that much to contribute. As a society, we know universal coverage is the right thing to do, but we can't decide how to do it. The people who can contribute are experts on political strategy and administrative and policy design.

I agree that the core of the problem is political, not ethical, and simple statements that universal coverage is morally required are of little help. Nevertheless, there is a significant contribution to be made by bioethicists--and by people who do not consider themselves bioethicists but who want universal coverage based on fundamental ethical principles. The contribution lies in identifying the values that universal health insurance serves, connecting those values to the details of system design, and explaining the connections to others to help advocate for the right kind of change.

Unfortunately, to do this well, a person must know a lot about how the current health care system works. The system is very complicated. It is not surprising that many bioethicists would rather focus on unplugging the comatose or creating clones rather than on a vast system that requires them to acquire arcane details about Medicaid eligibility requirements, the tax code, and an endless stream of acronyms--COBRA, ERISA, HMO, PPO, IPA, MSA, CMS ...

For those who are willing to take on that challenge, there is some good news. It is a lot easier than it used to be to get good information about the current health care system and its alternatives. The Institute of Medicine's new report Insuring America's Health: Principles and Recommendations is a case in point. It is the product of the Committee on the Consequences of Uninsurance, a group that has already produced five reports on various aspects of the uninsurance problem. The report concludes that "[t]he lack of health insurance for tens of millions of Americans has serious negative consequences and economic costs .... The situation is dire and expected to worsen." It backs up these conclusions (and many others) with a wealth of supporting argument and evidence drawn from the committee's five previous reports.

To address these problems the report recommends that "the President and Congress develop a strategy to achieve universal insurance coverage and to establish a firm and explicit schedule to reach this goal by 2010." The report also identifies five key principles that should guide the extension of coverage:

* Health care coverage should be universal.

* Health care coverage should be continuous.

* Health care coverage should be affordable to individuals and families.

* The health insurance strategy should be affordable and sustainable for society.

* Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.

The report does have limitations. It focuses on uninsurance and explicitly does not address the problem of underinsurance. The writing style is dry Washington "policyspeak." There is little analysis of ethical issues, and what there is lacks sophistication. Overall, however, the committee's work provides the kind of comprehensive and detailed background information needed by people who want to advocate for universal coverage on ethical grounds.

All signs indicate that we are gearing up for another round of political debate about what to do about health care. If you are concerned about the ethical foundations of health care reform, it's time to get ready. Read this book through, and keep it on hand to use as a source. Dip into the other five reports as well. Look also at other sources of basic information, such as the websites of the Henry J. Kaiser Family Foundation ( and the Robert Wood Johnson Foundation ( and This background should help people--including bioethicists--see the ethical implications of specific design features of proposed reforms and make useful contributions to the debate.

Insuring America's Health: Principles and Recommendations. By the Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine. Washington, D.C.: National Academies Press, 2004. 224 pages. $27.00 Paperback.
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Author:Baily, Mary Ann
Publication:The Hastings Center Report
Article Type:Book Review
Date:Mar 1, 2004
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