The ethical foundations of health care reform - includes related article on faith groups and health care - Cover Story

Christian Century, June 1, 1994 by William F. May, William H. Foege

Our health care system contains much of which we should be proud and much that we should conserve. It has enlisted the devotion of millions of professionals, created splendid hospitals, clinics and research institutions, and dazzled the world with its technical achievements. And it has allowed for some choice in doctors. Any reform of the system must preserve its virtues.

Yet our health care system is seriously flawed. It fails to reach many of us: at any given time, it excludes over one-seventh of the population (about 40 million people) from health care insurance; it leaves another one-seventh under-insured. The consequences for individuals and families are devastating. When we exclude people from health care they suffer a triple deprivation - the misery of ilness, the desperation of little or no treatment, and the cruel proof that they do not really belong to the community. We make them strangers in their own land.

When individuals lack health care, the promise of our common life together is also diminished. In relieving private distress, the nation enables its people to contribute more fully to its public life. The nation thereby serves its own public flourishing.

Our system also does not offer enough primary, preventive, home and long-term care, and it woefully neglects mental health coverage. We tend to be acute-care gluttons and preventive-care anemics.

Reflecting this lopsided emphasis, the system oversupplies us with specialists (some 70 percent of our doctors are specialists, compared with only 30 to 50 percent in comparable industrial countries) and undersupplies us with generalists whom we need for effective preventive, rehabilitative and long-term care.

The system pays for procedures performed rather than good outcomes achieved, and it exposes those who cannot pay to dramatically lower success rates for a given procedure. It often overtreats; yet insurance sometimes disappears when most needed. It exposes to financial ruin the person who has lost his or her job. It locks others into jobs they do not want because of pre-existing medical conditions, and it often establishes lifetime limits on care.

The system burdens health care practitioners and institutions with too many regulations and forms. A financial officer at one hospital reports that her staff has to handle some 3,200 different types of accounts receivable. The head of the major city hospital in Dallas says he needs 300 people to handle what, at a comparable hospital under the Canadian system, can be dispatched by three people.

Our system also costs more to operate than any other health care system in the world; no other country exceeds 10 percent of its GNP in health care costs, yet we are above 14 percent and rising further out of control. The system now consumes one-seventh of everything that we not fully measure the cost. The "fringe benefit" of health care is anything but a fringe cost of producing cars, computers, refrigerators and, for that matter, education. In some of our industries, health care is the second-largest cost after wages and salaries. This fact reduces the competitiveness of American businesses: Why should companies build cars in Detroit if their health care costs per worker are $500 to $750 less across the bridge in Windsor, Canada? Some commentators have argued that we have recently slowed down the increasing costs of medical care. But under three presidents we have undergone temporary slowdowns in costs only to see them speed up again. For our own sake and the sake of our children, we must be better stewards of our nation's resources.

Further, our payment system is unfair. Businesses, insurance companies, hospitals, the government and patients engage furiosly in cost shifting as they fob off on others their expenses. Hospitals jack up their prices to the insured to cover their costs in caring for indigent patients. Some doctors try to skim off the well-insured patients, while avoiding others. Insurance companies pick healthy customers to avoid making payouts to the sick. Companies shift to part-time, temporary or younger employees to reduce fringe-benefit costs. The government's savings on Medicare and Medicaid patients sometimes comes at the expense of prices paid by insured patients. Some people are forced to stay on welfare because the low-paying jobs in the service industries do not provide the coverage they receive under Medicaid. All this artful dodging eventually dumps costs on workers and taxpayers, either through lower salary raises, higher taxes or higher insurance payments.

A major reform of our health care system will rank as the most comprehensive piece of social legislation since the establishment of the social security system. We cannot engage in so grand an undertaking without being clear about its moral foundations. In my judgment, those foundations are three: 1) health care is a fundamental good; 2) health care is not the only fundamental good; and 3) health care is a public good.

To say that health care is a fundamental good means that health care is one of the necessities of life. It is not an optional commodity, like a Walkman, a tie or a scarf. Mothers instinctively affirm this truth when they concentrate their hopes on just this: the birth of a healthy baby-ten fingers, ten toes, a good heart, robust lungs. Why this single, humble, anxious wish? The mother prizes her baby's health because of the promise it holds for the child's life and flourishing. Healthy children, and therefore health care, are part of a nation's covenant with its future.