Debate on U.S. Health Care Reform Should Emphasize Ethical and Moral Obligations, Say Researchers

President Obama's health care reform efforts are struggling in part because the Administration has failed to make a strong argument for change on grounds of ethics and social justice, according to an article in a recent issue of Health Affairs.

Thus far the national debate has lacked a clear focus on the values and goals that should guide the comprehensive changes in health care financing and delivery sought by Obama and his allies, said Norman Daniels, Mary B. Saltonstall Professor of Population Ethics and Professor of Ethics and Population Health, and lead author of the article, "Access, Cost, and Financing: Achieving an Ethical Health Reform."

"Many people feel that President Obama's leadership role should have focused much more on building a base for the high ground on this issue," said Daniels, "so that people aren't asking ‘What's in it for me?' rather than ‘What should we be doing for the country?’ ”

Consequently, he said, Republicans have successfully spurred opposition to the Administration proposals by trumpeting "mythical scares" about government involvement and talking about "people who might lose" under health reform.

But even with the proposed health care legislation in political jeopardy, "it is not too late for him [Obama] to change this," commented Daniels, who undertook the Health Affairs article at the request of the journal's editor. Co-authors are Brendan Saloner and Adriana H. Gelpi, doctoral students in the Health Policy Program in the Harvard Graduate School of Arts and Sciences. Daniels is their advisor and is the author of a 2008 book, Just Health: Meeting Health Needs Fairly.

In the article, the authors outline the moral and ethical motivations for three major elements of health reform -- universal coverage, cost containment and fairness in financing.

Universal Coverage
Assuring equitable access to "a reasonable array" of health care services is necessary so that all individuals can make the most of their opportunities in life, which otherwise would be hampered by illness, disability, or premature death, the authors contend.

"We have obligations to keep people functioning normally," they said, not only by treating illness but also preventing it, and the current health care system fails to do this equitably. Among wealthy nations, the United States is alone in failing to provide universal coverage, Daniels observed.

The health care reform measure proposed by the House in June 2009 promises to cover 95 percent of Americans through a combination of individual and employer mandates and a public plan (the latter being a bitterly contentious point), but the article said that other arrangements might also succeed.

But a look at other countries reveals that even the fairest health systems alone haven't eliminated inequalities, which stem more broadly from disparities in education, wealth, power and social status, the authors argue.

On the controversial issue of health insurance for the 10 to 12 million illegal aliens, Daniels said he personally believes they should have coverage, noting that they pay taxes that support Social Security and Medicare. President Obama said insurance for illegal aliens has never been part of his reform proposal.

Cost Containment
Daniels and his co-authors put a moral spin on the need for controlling health care costs in a country that is spending an economy-draining 16 percent of its gross national product on medical bills. This is not simply an economic failing, but an ethical one, Daniels said, because "if you don't get good value for the money you invest in health care, you can't meet all the health care needs of the population, and there is also less to spend on other things that social justice says are important."

Making health care more efficient will require rationing of resources -- a concept that is "taboo" in the ongoing political debate, but which already exists in many "invisible" forms. "We do it all the time," said Daniels. "We have millions of uninsured people; and insurance companies spend 28 percent of their budget on profits, marketing, and making sure that people don't get certain benefits."

To ensure the most efficient use of resources, the United States should have an objective, independent body that would recommend treatments for Medicare and other public programs, say the authors. Such decision-making entities would make evaluations not just on safety and efficacy; they would "consider both cost-effectiveness and broader measures of the opportunity costs of disseminating one service rather than another."

Fairness in financing
The fair financing of health care requires a heavily regulated market and redistribution of resources from richer to poorer and healthier to sicker, according to the authors. One way in which the Administration-backed proposal seeks to achieve this is by adding a tax surcharge to high-income earners to support expanded coverage.

In a broader context, the authors say, the degree of resource redistribution in health care should depend "on what else society has done by way of redistributing other goods" from those better off to those worse off in opportunity. While countries like Norway have a good record of doing this, "the United States has thinned its social safety net and altered its tax system to redistribute less to those who are worse off," the article contends.

Saloner said that the current debate has "focused very narrowly on the implications of health system reforms." Yet it is important to "take a step back and look at what is happening in other areas of social spending and tax policy. Health care is a necessary but not sufficient condition," he said.

Daniels acknowledged that given the political brawling over health reform proposals, "this talk about ethics almost seems a bit academic."

"The real problem is that the debate has deteriorated so enormously over the summer," Daniels said. "We were trying in June, when we wrote this, to inject ethics into a debate that hadn't yet become so fouled with lies and distortions; now it seems that even dispelling those lies and distortions is a huge challenge."

-- Richard Saltus. Photo (c) iStockphoto.com/VisualField