HEALTH CARE FOR ALL : A conservative case - the US is the only industrialized country in the world without universal medical services

Now that South Africa has legislated universal access to medical services, the United States remains the only industrialized or second-tier country in the world that fails to guarantee its citizens access to medical services. This is a curious omission for a country based on rights and liberty. It is equally strange from an economic and business point of view. For while foreign competitors get full medical benefits at one-third the cost, American employers are weighed down by ever-growing expense for health care. For Nokia, Volkswagen, and Siemens, this is an advantage over their American competitors worth millions.

Despite these consequences, U.S. conservatives continue to belittle universal access. They argue that health care should be private, with a public safety net only as a last resort. In so doing, they diminish some of their most cherished principles. For universal access to needed medical services enhances not only an individual's opportunity but also her or his productivity. In that sense, it is akin to universal schooling, which serves as a bedrock for maintaining and enhancing democratic institutions.

The first universal health insurance system was forged and passed in 1883 by an archconservative, Germany's Otto von Bismarck. He and other nineteenth-century conservative leaders in Europe were early advocates of universal access to medical services, for they saw such services as a practical means to secure a more vigorous work force and recruit healthier soldiers.

A conservative argument for universal access to health care, therefore, can be put quite simply: When people are ill, in pain, or disabled, they are less able to take care of themselves or others. In such circumstances, individual liberty and personal responsibility are quickly compromised. Even small disorders can turn liberty and responsibility into dependency. For example, mild depression and anxiety disorders--the most common mental-health problems in the United States, experienced by more than one in four every year--are especially relevant. They cripple the spirit as well as the body and can be more physically disabling than many physical disorders.

Economic opportunity is promoted by universal access to medical services in much the same way that public fire departments and policing promote the common good. A fire or robbery deprives an individual of material property. Fortunately, these are rare events. Illness or disability, on the other hand, can deprive an individual of the ability to stay on his or her feet, and they are much more common experiences. Furthermore, needed medical care can be a great financial burden on the seriously and chronically ill. Nearly three-quarters of all medical expenditures in this country are for the sickest 10 percent of patients. Losses in wages and earned income make matters even worse, particularly when able-bodied citizens can no longer care for themselves and their dependents.

In the United States, voluntary private health insurance has traditionally been seen as the answer for covering medical expenses. Not so abroad, where, like private fire departments, police, and schools, it was abandoned long ago as too limited to protect individual liberty, foster personal responsibility, and promote economic opportunity. Even in the United States, nearly half of all employers today choose not to offer health insurance to their employees. The result is that about 80 percent of the 40 million Americans who lack health insurance are workers or their dependents. These Americans have attempted to act responsibly and to better themselves. But when illness compromises their liberties and abilities, health care is often not there to get them back on their feet.

Furthermore, among the employers who continue to offer private voluntary insurance, most are thinning it out rapidly. When current policies include coverage and payment limits in the fine print, as well as co-payments and deductibles up front, these are forms of "disinsurance," of noncoverage in the name of coverage. These deeply compromised features of voluntary health insurance are why Americans who still have insurance increasingly pay much more out of their household budgets than do workers in any other comparable country.

Even in its heyday in this country, voluntary health insurance never covered the poor or the more elderly. That is why Medicare and Medicaid were developed, along with a wide range of public health-care programs. "Honor thy mother and thy father" and "Do unto others as you would have them do unto you" are central to religious ethics, and conservatives have taken them to mean we should look after people in their old age or infirmity. That is why a conservative like Norman Daniels, writing in Am I My Patient's Keeper? (Oxford University Press, 1998), has developed the philosophical implications for universal access to health care.

Despite the relief provided by such public programs as Medicare, Medicaid, and other coverage for the uninsured, private insurers in the United States claim that to remain competitive they have to minimize coverage for known disabilities and sicknesses. This winnowing is achieved through risk selection, coverage selection, and exclusion clauses. If insurers don't limit their liability, they lose out to those insurers who do.

This is the contradiction other countries have faced but we have not: The goal of private insurers is to minimize coverage for those most in need of it, while the goal of society is to treat those who need medical assistance most--to get them back on their feet, restore their liberties, and enable them to be productive. Universal access is achieved abroad by using a combination of insurance, other funds, and government programs. As a result, markets there are structured in such a way as to level the playing field among the sick, the vulnerable, and the healthy.

The growing practices of skewed risk selection, reduced coverage, and higher premiums are a violation of the conservative credo that people should not be allowed to free-ride. Today, however, thousands of employers and insurers are free riders. They dump their medical problems on the public system and force overloaded physicians and hospitals into deciding how hard they want to work without pay.

The philosopher Paul Menzel has written that the anti-free-riding principle "is itself fundamentally a pro-individualist principle with libertarian senses of justice. In holding people responsible, not just for the effects of their voluntary actions on others, but also for the costs of the collective enterprises from which they benefit, the anti-free-riding principle keeps collective solutions to human needs in tow, tying them tightly to people's ability and willingness to pay their costs." This principle is closely linked to another conservative tenet, the primacy of personal integrity: People ought to hold to the implications of their beliefs, values, and actions, for themselves and for others.

The nightmare conservative is the motorcycle gang rider: Live for the moment with free abandon and let others pay for the consequences. But there are many more nightmare conservative capitalists who do the same on a larger scale. Why are these enterprises and individuals not held responsible by their fellow conservatives?

Finally, medical bankruptcy is quite common in the United States but unknown in the rest of the modern world where there is universal access. Consumers Union has documented the high percentage of people forced to pay impoverishing proportions of their income in uncovered medical bills. Costs totaling 10 percent of household income are not uncommon, and rise to 15 percent among the working class. In fact, 40 percent of all personal bankruptcies in the United States are attributed to medical bills people are unable to pay. Many of these people are hit by illness unawares, as if struck by lightning; others live with chronic disorders and suffer deprivation over years.

But allowing such medical impoverishment offends the principle of equal opportunity, which holds that the opportunity for individuals to exercise their initiative and preferences should not be blocked. For this to happen, there must be just sharing of the prerequisites of equal opportunity, such as education and medical services. Both principles serve to restore those who are disadvantaged so that they can lead productive lives.

These conservative reasons for universal access to health care can be supplemented with practical ones. Private health insurance is much more costly and inefficient than universal health insurance. A detailed analysis by the New England Journal of Medicine in the 1990s indicated that 24.1 percent of what employers and citizens pay goes to the complex billing, marketing, and administrative structures of the voluntary American system rather than to clinical services. This is about three times the overhead in countries with private care but universal access, such as Germany, Japan, and the Netherlands, where Volkswagen, Toyota, and Siemens are based. If you subtract the difference (16.7 percent) from the $1.3 trillion we pay for health care, $237 billion would be freed for more medical services. Why waste so much money to get a health-care system that is more costly, inefficient, and less just?

As now constituted, the voluntary private insurance market in the United States is so fragmented by customization and market niches that it does not resemble a viable market leading to efficiency and good value. A recent study of 2,277 people in the Seattle health-insurance market found that they were covered by 755 different health-insurance policies and 189 different health-care plans. Seattle employers probably think they are getting a good deal; but overall, few of them are, because such a fragmented market is inherently wasteful, as well as discriminatory.

In general, American employers and employees pay much more and get much less than their competitors in Germany, France, Japan, the Netherlands, and Finland. That is why conservatives elsewhere have concluded that universal access is both the right and most efficient thing to do. They have achieved it in a variety of ways. Many countries use insurance, even private insurance, coupled with firm rules that require everyone to contribute in equitable ways. Other countries rely on tax-based systems. In fact, studies consistently show that tax-based financing is the most efficient means and holds down costs best. But many countries use insurance, even private insurance, coupled with firm rules that require everyone to contribute in equitable ways.

Often, medical services in these countries are private. That is why I have avoided the terms "universal health insurance" and "universal health care," because each refers to only one of several alternatives. There are three or four ways to provide adequate and affordable health care, to do right by our parents and neighbors, and to foster individual freedom.

To facilitate such goals, I propose ten guidelines for responsible health care:

1. Everyone is covered, and everyone contributes in proportion to his or her income.

2. Decisions about all matters are open and publicly debated. Accountability for costs, quality, and value of providers, suppliers, and administrators is public.

3. Contributions do not discriminate by type of illness or ability to pay.

4. Coverage does not discriminate by type of illness or ability to pay.

5. Coverage responds first to medical need and suffering.

6. Nonfinancial barriers by class, language, education, and geography are to be minimized.

7. Providers are paid fairly and equitably, taking into account their local circumstances.

8. Clinical waste is minimized through public health, self-care, prevention, strong primary care, and identification of unnecessary procedures.

9. Financial waste is minimized through simplified administrative arrangements and strong bargaining for good value.

10. Choice is maximized in a common playing field where 90-95 percent of payments go toward necessary and efficient health services.

Universal access to needed medical services is essential to achieve the four traditional conservative moral principles: the anti-free-riding principle, the principle of personal integrity, the principle of equal opportunity, and the principle of just sharing. The question then becomes: How can conservatives refuse universal access to health care and remain consistent with their conservative values? The moral case for universal access is more compelling than the case for public libraries, parks, schools, or even most public roads.

For too long, we have ignored or opposed efforts to simplify the American health-care system, at a cost of ill-spent billions. Today's system not only fails hospitals, physicians, patients, and families, but is collapsing under the burden of its own complexity and inefficiency. It is possible to design a low-cost universal plan that maximizes choice. The time to do it is now.

Donald W. Light is co-author of Benchmarks of Fairness for Health Care Reform (Oxford University Press, 1996). He serves on the board of the Universal Health Care Access Network and is a Fellow at the Center for Bioethics at the University of Pennsylvania.

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