by Peter Lawson
This chapter is an exploration of some of the suggestions and debates that have surrounded the issue of national health care in the United States over the past few decades. In particular, this chapter will be an attempt to clarify some of the most common positions (both pro and con) surrounding the potential for a national health care system in the United States. Every effort will be made to present data from an objective point of view in order to allow readers to evaluate the strength of the arguments made. In the interest of concision and brevity this chapter will divide this complex issue into two distinct domains of discussion: moral, ethical and philosophical positions, and economic challenges. While this chapter will attempt to synthesize and summarize a variety of positions and opinions in regard to the issue of a national health care system, it should not be considered an exhaustive exploration of all the potential arguments regarding this issue. With this in mind, a number of interesting and potentially illuminating references will be provided at the end of this chapter, which could guide a reader in further research.
According to US Census data for 2001, the number of Americans without any form of health insurance was 41.2 million or 14.2% of the population. This number rose by 1.4 million from the previous year. Alarmingly, nearly 11.2% of children (8.5 million) under the age of 18 were without health coverage in the United States. While these data in their aggregate form seem to point to something of a crisis in health insurance coverage for millions of Americans, a closer look at some seemingly paradoxical demographics of the uninsured adds another layer to the picture. For example, consider the following excerpt from a US Census Bureau report on health insurance in 2001.
Among the entire population 18 to 64 years old, workers (both full- and part-time) were more likely to have health insurance (83.0 percent) than nonworkers (75.3 percent), but among the poor, workers were less likely to be covered (51.3 percent) than nonworkers (63.2 percent).1
As poor workers become ineligible for governmental insurance programs (such as medicaid) due to income limitations, they are still likely to be working in jobs that do not provide insurance benefits. This same document reports that, among the poor, the overall rate of those without health insurance was 30.7 percent, more than double the rate for the population as a whole.2 The uninsured face numerous threats to their health and are at increased risk for mortality and morbidity (for a more detailed examination of the issues surrounding the uninsured, see Eagan and Olds this volume).
Few would argue that these rates of persons without health insurance are acceptable. However, a sometimes acrimonious debate has surrounded this issue and its potential solutions. One such heavily debated suggestion to deal with the nations uninsured and underinsured has been some form of a national health care system. But before beginning a discussion of some of the various proposals that have been made and the arguments that surround them, it may be useful to examine a number of key ethical, moral and philosophical positions which underlie these arguments.
ETHICAL, MORAL AND PHILOSOPHICAL GROUNDS OF THE DISCUSSION
Though the discussion surrounding a national health care system in the United States can quickly turn into one that is dominated by political and economic considerations of feasibility and implementation, the issue itself is grounded in a set of ethical, moral and philosophical considerations. Various experts and pundits have weighed in on the debate surrounding calls for a national health care system precisely because this issue forces one to consider some of the most intrinsically difficult questions within the political and economic philosophy of the United States: the role of the state in private life, the appropriate position of the government vis a vis the market, and rights of individuals within a capitalist marketplace. Though the scope of these complex issues is certainly beyond the capacity of this chapter, some of the broad strokes of these issues may be useful for the development of the discussion at hand.
A recent meeting of the International Labour Organization (ILO) in Geneva, Switzerland produced a resolution in which health care was deemed a basic human right.3 This resolution represents a recent incarnation of decades of international recognition of the key role of health within a conception of basic human rights. Article 25 of the United Nations Universal Declaration on Human Rights, drafted in 1948, states:
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.4
One of the strongest statements of health as a basic human right was generated at the International Conference on Primary Health Care in Alma Ata, USSR in 1978. Article I of the Declaration states in part “The Conference strongly reaffirms that health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right…”5 Here the definition of health stretches into what some might consider utopian territory; however, the essential statement that health itself is basic human right echoes that of the UN’s Universal Declaration on Human Rights. Numerous national and international organizations have declared health and access to health care to be basic human rights. For example in 1998, “Dr Gro Harlem Brundtland, Director-General of the World Health Organization, called on the international community to enshrine health as a basic human right.”6 While the conception of health and access to health care as a basic human right may beg the question of the responsibility of the state to provide protections for such rights, suffice to say, that within these broad international agreements, it is assumed that the state functions, in part, to ensure and maintain the rights of its citizens.
Yet notions of health and health care as basic human rights are by no means monolithic or unchallenged within the discourse of health care provision. An alternative vision of health care as a commodity is also articulated and merits our attention. Various policy advocacy groups and think tanks have offered a view of health care as a service most efficiently and effectively provided through a free market. For example, Sally Pipes of the Pacific Research Institute (PRI) advocates for free market solutions to solving the dilemmas of health care in the United States. From a neoclassical, liberal economic position, governmental regulation or intervention in the market is something to be avoided. From the libertarian perspective advocated by organizations like PRI, governmental interventions “create dependency on the state, and allow the government to have excessive influence and control over people’s lives.”7 In a commentary published in The Washington Times, Michael Hurd succinctly argues
Health care is not a right -- no matter how often you hear otherwise. Health care is the consequence of heroic efforts on the part of individual doctors, who have every right to charge what the market permits. If we take away the right of medical professionals to set their own fees, we will undermine their independence and chase the best ones into early retirement.8
Here the rights to which Hurd refers are based on specific liberal conceptions of the free market and the rights of individuals to participate in that market. In Hurd’s argument, rights are intrinsically tied to the rationale of the economic exchange taking place, and not a notion of basic human rights (as described above).
Hurd’s economic argument leads us to a series of economic questions that are better addressed through the lens of a specific proposal for a national health: How much would such a specific national health initiative cost? In what sectors of the economy would potential burdens be born? What other economic impacts (both positive and negative) might arise from the implementation of a national health care system? In order to address these issues, we will now turn our attention to one suggested form of national health care (the so-called single payer system) while bearing in mind that a number of other national health plans have been suggested with widely different mechanisms and potential economic effects.
DEBATING THE ECONOMICS: THE CASE OF THE SINGLE-PAYER SYSTEM
Cost is inarguably one of the central features in any discussion of the existing health care delivery system in the United States or any potential replacement or reform of the existing system. The United States spent $1.4 trillion on health care in 2001, or 14.1 percent of its Gross Domestic Product (GDP). According to one recently published study, this figure is expected to grow to $3.1 trillion by 2012, an amount which would constitute 17.7 percent of the GDP.9 Critics of the current health care delivery system note that many other industrialized nations spend considerably less on health as a percentage of GDP while maintaining health care services for all citizens; none spends more as a percentage of its GDP. In 2000 for example, Canada spent only 9.1 percent of its GDP on a national health care delivery system which provides health care for all Canadians.10 Let’s consider some of the discussion surrounding the economics of a national health care system for the United States, focusing on the proposal for a single-payer system.
While numerous ideas have been suggested to reform the US health care delivery system, one of the most cogently argued cases for a single-payer health care system in the United States was published in 1989 by David Himmelstein and Steffe Woolhandler in the New England Journal of Medicine.11 As presented by the authors, a single-payer system would provide health care coverage for all Americans by setting federally mandated fees for services and paying these through a single source (i.e. the federal government). Because many of the current health care dilemmas faced by patients and providers alike are focused around economic issues, it is not surprising that Himmelstein and Woolhandler make economic considerations central to their argument. Himmelstein and Woolhandler argue that “the public administration of insurance funds [through a single-payer system] would save tens of billions of dollars each year. The more than 1500 private health insurers in the United States now consume about 8 percent of revenues for overhead.”12 Under the single payer system proposed by Himmelstein and Woolhandler, federal regulation would control costs by eliminating redundant administrative bureaucracy and profit from the system. The authors argue that despite the need to levy taxes in order to support the system, the long-term benefits would balance initial costs, since the current high cost of health care is already borne by citizens, employers, and the government (through programs like Medicaid and Medicare).
Critics of a single-payer system argue that “the evidence demonstrates without doubt that socialized medicine is inefficient and more expensive than the free-market alternative.”13 Citing the tax burden of the National Health Service in the UK, Conrad Meier argues
England’s single-payer health care plan has turned into a tax burden far worse than what we’ve experienced to date in this country. The burgeoning costs—in the form of high income taxes, insurance taxes, premiums, lower wages, reduced productivity and job opportunities, plus extra fees and hidden taxation—have become a stranglehold on middle- and low-income consumers.14
While it should be noted that the UK system is not, in fact, a single-payer system (in the UK the government controls and regulates all aspects of health care, under a single-payer system the government would provide remuneration and set fees), the sort of argument Meier mobilizes forms the bulk of economic arguments against the implementation of a single payer system in the United States.
There is nothing approaching consensus concerning the economics of a single-payer systems. Proponents argue that additional cost incurred in the provision of health care for all citizens would recouped through increased efficiency and the elimination of for-profit insurance coverage. Opponents of a single-payer system argue that such a system would increase inefficiency and costs by placing the burden of a massive centralized bureaucracy in the hands of the federal government. Interestingly, economic arguments opposing a single-payer system often blend economics with ethics and morality. As Meier suggests
The propaganda produced in support of single-payer health care ignores the truth and is designed to motivate people through the use of scare tactics; distorted and often fabricated information; and undocumented facts and figures on how much such a plan would cost in premiums, income taxes, lost state revenue, job dislocation, individual freedom, and human suffering.15
Certainly this criticism could be levied against Meier’s own analysis which notably contains no citations or references to empirical data. These data are strikingly absent, as is independent, non-partisan research and analysis on the subject, and more efforts toward this end will likely be necessary before a reasonable conclusion can be reached about the future of a national health care system in the United States.
3. International Labour Organization. Resolution Concerning Health Care as a Basic Human Right. Joint Meeting on Social Dialogue in the Health Services: Institutions, Capacity and Effectiveness. October 2002. Geneva. http://www.ilo.org/public/english/dialogue/sector/techmeet/jmhs02/jmhs-res.pdf
4. United Nations Universal Declaration on Human Rights. 1948. http://www.un.org/Overview/rights.html
5. World Health Organization. Declaration of the Alma Ata Conference. http://www.who.int/hpr/archive/docs/almaata.html
8. Hurd, M. Rhetoric Notwithstanding, Health Care Is Not A Right. The Washington Times. April 6, 1993. http://www.drhurd.com/medialink/health-care-not-a-right.html
11. Himmelstein, D., and Steffe Woolhandler. A National Health Program for the United States: A Physicians’ Proposal. The New England Journal of Medicine. January 12, 1989.
Additional Reference Sources
Heritage Foundation. www.heritage.org
The Heartland Institute www.heartland.org
The Pacific Research Institute www.pacificresearch.org
Physicians for a National Health Plan. www.pnhp.org
The Universal Health Care Action Network www.uhcan.org