The present arrangement is failing us. We need to design a system that provides care for everyone.
|Timothy Engström||Wade L. Robison|
It was only a matter of time. An American corporation decided to outsource health care for an employee, flying him to India for an operation. The union objected, and so the employee did not go. But it is bound to happen. Health care costs are so high in the United States, and rising so rapidly, that just as it is cheaper for a company to outsource manufacturing, it is cheaper to outsource its contractual obligations to provide health care for its employees.
The same drive to cut costs explains why 100 of the top 1,000 companies in the United States now have on-site clinics and why that number is expected to grow to 250 by the end of the year. It is cheaper for companies to build a clinic and hire their own physicians than to send employees to existing health care providers.
These changes in our health care system are driven by economic, not moral, considerations. The cost of health care is expensive and rising significantly faster than inflation, and companies are locked into providing health care for their employees--if only because doing so retains employees. So as costs rise, companies are shifting more health care costs to employees and cutting benefits. Employees are paying more for less.
Worse, they are only a pink slip away from having no health care at all, a problem that faces over 75 million people for a significant length of time over any two-year period and is a constant reality for upward of 45 million Americans. The failure to provide universal coverage and portable health insurance is a problem that faces all of us. We are always at risk of a pink slip, and we are always at risk of infectious diseases from those without health insurance, who must be treated in emergency rooms, the most expensive way possible to prevent the spread of tuberculosis and other such infectious diseases.
An Unhappy Trajectory
We can, of course, continue to let the market drive changes in our health care system or let the government tinker within the structure created by market forces. But doing so will ensure that we end up with more of what we do not want: more people without health insurance because it is unaffordable; more bias in the coverage that does exist, with fewer and fewer children covered, fewer African-Americans and Hispanics, and fewer middle-aged single women with low-paying jobs; and even less choice than we now have of physicians.
By the standard markers for the health of a health care system, ours gets an “F.” The infant mortality rate is significantly higher than that of any other industrialized country, and higher even than some third-world countries. We provide the best care in the world--for those who can afford it. But we do much less than we could to prevent health care problems, to mitigate the natural infirmities of old age, or to distribute health care fairly and efficiently and cost-effectively--something other countries do successfully.
A System for Everyone
If we are to have a health care system we can be proud of, we need citizens to determine its future. As the Oregon reform effort has shown, citizen groups can reach agreement about how best to distribute health care resources and can become dominant in structuring a system that provides nearly universal coverage at reasonable costs. Through the deliberative process, citizens buy into the result and so support the system. Because the process is cooperative as well as deliberative, citizens keep in mind the common ethical values we share, or should share, with our fellow citizens.
Those ethical values ought to find their way into any new health care system. We ought to have a system that satisfies the minimally necessary health care goods for all our citizens--safe birth and healthy infancy, preventive care to preclude future illnesses and disabilities, care for us when diseased or subject to bodily faults, care in our old age.
We ought to have a system that is fair as well as efficient, with access for all. The insurance industry, however, sells a commodity and profits, as it must, by reducing its risks and liabilities--a recipe not for improving or expanding coverage but for higher costs and diminished coverage. The effect for health care practitioners is that they can make use of their hard-acquired skills at diagnosis and suggesting remedies only by fending off interference from third-party insurers. Their primary concern should be to provide for the health of patients, not ensure profits for the insurance industry.
If we are to achieve these moral values and help cure our diseased health care system, we need to arrange the system accordingly. With a third of every dollar spent on health care going to third-party insurers, it is obvious where the money for a healthy health care system can be found. But any decisions about how best to redesign our health care system ought to be the result of a nationally driven, but locally controlled, deliberative process of citizens.
“Health is wealth,” as Benjamin Franklin would say. We harm ourselves and our nation by having a health care system that does not provide the best possible health care for all of our citizens.
Timothy Engström and WadeL. Robison are professors of philosophy at the Rochester Institute of Technology in Rochester, N.Y.
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