Abstract
As I write this, in February of 1994, the United States seems poised on the verge of the largest reallocation of medical resources since the enactment of Medicare and Medicaid in the 1960s. The vehicle for this reallocation is a proposal drafted by Hillary Rodham Clinton’ s task force and submitted to Congress by President Clinton in November of 1993. Although this proposal will certainly be greatly modified by Congress, it is the starting point for all other proposals, so an evaluation of this proposal is in order. I was initially skeptical of managed competition systems, and I will point out several flaws in Clinton’s draft, but overall I think that it is an excellent proposal.
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Notes and References
Organization for Economic Co-operation and Development (OECD) (1993) OECD Health Systems: Vol. 1, Facts and Trends 19601991, OECD, Paris, p. 18.
OECD, p. 24.
Rie, M. A. (1981) The American and West German health care systems: a physician’s reflections, in Health Care Systems: Moral Conflicts in European and American Public Policy, Sass, H.-M. and Massey, R. U., eds. Kluwer Academic Publishers, Boston, pp. 75–83 at p. 76.
Statistics must be treated with care. In philosophy classes, one can do nothing while getting more data and refining one’s statistics. In the real world, however, not acting has costs so we must act on the best available evidence even if it is not perfect. Philosophy should lead us to act wisely—not to paralysis. To point out a possible problem with some statistic is not to show that we ought to ignore the statistic. If it is the best evidence we have, then we ought to act on the basis of that statistic.
This is the numerical average of female and male life expectancy. OECD, pp. 58,59.
This is the numerical average of female and male life expectancy. OECD, pp. 54,55.
OECD, p. 69.
OECD, p. 76.
Health Security: The President’s Report to the American People,US Government Printing Office, Washington, DC, 1993, pp. 2 and 11. This access problem adds weight to the claim that the United States does not get a good value for its health care dollar. Europeans are covering a much larger percentage of their population with care roughly as good as ours while spending less money. So the United States spends 0.16% of GNP for each percent of covered population, whereas Europeans spend only 0.078%.
See OECD, pp. 13–40 for details.
For a review of these arguments, see,e.g., Dougherty, C. (1988) American Health Care: Realities, Rights and Reforms,Oxford University Press, New York, and Buchanan, A. (1984) The right to a decent minimum of health care, Philosophy and Public Affairs,13,1 pp. 55–78.
The seminal work on the history of health care is Paul Stan’s Pulitzer prize winning The Social Transformation of American Medicine,Basic Books, New York, 1982. This book cannot be recommended too highly.
There are two other causes of the cost problem: an aging population and a longer-lived population. The average age of the population is rising as the baby boomers get older. Since older people use more health care, as the average age of the population rises, so will health care costs. Independent of the baby boomer effect, our population is living longer. As people live longer, they have more illnesses and accidents per lifetime. So total health care costs rise. I will not discuss these cost factors because we would not want to get rid of them. We do not want to keep the baby boomers from aging or stop making people live longer. In addition, these factors are not a cause of the cost difference between the United States and Europe. Europeans face the same conditions.
See Rosko, M. D. and Broyles, R. W. (1988) The Economics of Health Care,Greenwood Press, New York, esp. p. 13 and Enthoven, A. C. (1988) Theory and Practice of Managed Competition in Health Care Finance,Elsevier Science Publishers, New York, esp. pp. 32–42.
This effect, misleadingly called moral hazard, occurs in all insurance markets. People with car insurance have less reason to worry about theft and so are less likely to take antitheft precautions.
See Enthoven, esp. pp. 32–42.
See Stoline, A. M. and Weiner, J. P. (1993) The New Medical Marketplace,2nd ed. John Hopkins University Press, Baltimore, pp. 51–54.
Hillman, B. J. et al. (1990) Frequency and costs of diagnostic imaging in office practice: a comparison of self-referring and radiologist-referring physicians, N. Engl. J. Med., 323,23, 1604–1608.
Stoline, p. 111.
Eisenberg, J. M. (1986) Doctors’ Decisions and the Cost of Medical Care,Health Administration Press, Ann Arbor, MI, esp. pp. 15–17 and Chapter 2.
See Buchanan, A. “An ethical evaluation of health care in the United States,” in Sass, pp. 39–58, at p. 48.
See Sorkin, A. L. (1992) Health Economics,3rd ed., Lexington Books, New York, pp. 167–184.
A government program is regressive when it has the effect of transferring money from the poor to the rich. A program that transfers money from the rich to the poor is progressive.
Al1 the data in this paragraph are from Woolhandler, S. and Himmelstein, D. U. (1991) The deteriorating administrative efficiency of the U.S. health care system. N. Engl. J. Med. 324,18, 1253–1258.
For the historical information in this paragraph and the argument that these restrictions were based on physicians’ economic interests and not on medical necessity, see Starr (e.g., pp. 220–225).
Besides being a cost problem, this affects the quality of care. I once had a series of over 100 tests done every three months for two years. My physician looked for trends in this data by flipping through about 100 pages of paper charts!
Health Security,p. 15.
Brennan, T., Leape, L. L., Localio, A. R., Weiler, P. C., Laird, N. M., Lawthers, A. G., Hiatt, H. H., Hebert, L., and Newhouse, J. P. (1990) Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N. Engl. J. Med. 324,6, 370–376.
Al1 the rest of the data in this paragraph are from Stoline, p. 205.
All the data in this paragraph are from OECD, pp. 114 and 115.
Callahan, D. (1987) Setting Limits: Medical Goals in an Aging Society. Simon and Schuster, New York.
If they wish, they may offer special perks (e.g., private rooms) in addition to the national benefit package.
It is not clear what these measures will be. The Clinton proposal leaves it to the National Health Board to make this decision. There is reason for worry here because it is important that these measures reflect real quality of care and not measures of cosmetic features of the plans. There is the potential for problems if the choice of measures is driven by lobbyists for the health insurance companies.
Manning, W. G., Leibowitz, A., Newhouse, J. P., Goldberg, G. A., and Rogers, W. H. (1984) A controlled trail of the effect of a prepaid group practice on use of services. N. Engl. J. Med. 310,23, 1505–1510.
Enthoven, p. 55.
Krakower, J. Y., Jolly, P., and Beran, R. (1993) U.S. medical school finances. JAMA, 270,9, pp. 1085–1091. Student tuition and fees represent only 4.1% of medical school revenues. So some argue that medical students pay only 4.1% of the cost of their education, but medical schools do research and provide medical services in addition to educating students. If one deducts all the revenue from research and medical services (implausibly assuming that students get no educational benefit from this research and service provision), tuition and fees are still only 7.4% of the remaining revenue. Another way to measure what percentage of their educational costs students are paying is to compare tuition and fees to the amount that schools report they spend on instruction (again assuming that students get no educational benefit from the other things medical schools do). Tuition and fees cover 15.1% of the money spent on instruction. So, on average, medical students pay between 4.1 and 15.1% of the cost of their education. Students actually pay a lower percentage of the cost of their education than these figures indicate because “tuition and fees” includes the tuition received from students, but that the students received as financial aid from the government. (All the data in this paragraph are from Krakower and are for the academic year 1991–1992.)
Egan, T. (1993) Hawaii: setting an example for the rest of the nation. The New York Times, Sunday, November 14, section 4A, p. 8.
Health Security, p. 24.
Jonas, S. (1992) An Introduction to the U.S. Health Care System, 3rd ed., Springer Publishing Company, New York, p. 129.
For this figure and a detailed discussion of this issue, see Menzel, P. (1990) Strong Medicine: The Ethical Rationing of Health Care,Oxford University Press, New York.
This being said, one could make a good case that the proposal ought to be modified to make some attempt to impose greater costs on those who voluntarily cause greater health care costs. For example, if it were shown that those who drink alcohol impose greater costs on the system than those who do not (even considering the lower costs caused by their early death), one might put a health care tax on alcohol.
For discussions of medical egalitarianism, see President’s Commission for the Study of Ethical Problem in Medicine and Biomedical and Behavioral Research, Securing Access to Health Care: Volume Two, Appendices ( Sociocultural and Philosophical Studies) US Government Printing Office, Washington, DC, 1983.
Of course the medical egalitarian may be an egalitarian tout court, but that view is not a part of medical ethics per se,and so I will leave it aside.
An in rem right is a right that holds against everyone, whereas an in personam right holds against a specific individual. A positive right is a right that someone perform an action. A negative right is a right that someone refrain from performing an action.
For a review of the literature on libertarianism, see Corlett, J. A., ed., (1991) Equality and Liberty: Analyzing Rawls and Nozick. St. Martin’s Press, New York.
If one must have a sin tax, a tax on alcohol would be preferable to a tobacco tax if, as seems likely, drinking has a higher social cost than tobacco.
Medicare, however, has been a leader in looking for innovative ways (e.g., DRGs) to reduce costs in FFS plans.
Health Security Act as originally presented to Congress, Title I, Subtitle B, Part 6, Section 1161.
For historical details, see Starr.
For historical details, see Starr.
For historical details, see Starr.
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Rainbolt, G.W. (1995). An Evaluation of Clinton’s Health Care Proposal. In: Humber, J.M., Almeder, R.F. (eds) Allocating Health Care Resources. Biomedical Ethics Reviews. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-447-4_4
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