8

The Elephant in the Room and the Ethical Vision Baked into Health Reform Proposals

As has been noted elsewhere in the book, it is an unwritten rule that in this country we prefer to debate proposed health reforms mainly in terms of technical parameters—actuarially fair versus community-rated premiums, deductibles, coinsurance, maximum risk exposure, high-risk pools, and so on.

In fact, however, our arguments always have been, are now, and will continue forever to be over the elephant in the room no one likes to mention, namely, the fundamental question, to what extent we should be our poor and sick brothers’ and sisters’ keepers in health care.

The wrestling match over U.S. health reform during the past decade—and especially the drama that played out within the Republican Party in 2017—is over this fundamental question.

Most countries have confronted this question head on long ago and settled it. In the United States, we have never been able to reach a politically dominant consensus on the distributive social ethic that should guide our health system, because we dare not confront that question at all (see figure 8.1). By contrast, we in the United States have debated these ethical issues only in camouflaged form for over a century now, but have never reached a politically acceptable consensus on the issue. The debate in 2017 on repealing and replacing Obamacare is merely a continuation of this camouflaged and confusing debate.

Figure 8.1 Americans Confronting the Ethical Dimension of U.S. Health Care.

Source: Alan Simpson/Alamy Stock Photo.

It is a question of social ethics, not of economics. Practically, the answers to this fundamental question express themselves in the particulars of the health reforms.

At one extreme, many Americans would like to see health care treated as a pure social good—like elementary and secondary education—to be available to all on roughly equal terms and financed by households on the basis of their ability to pay.

At the other extreme, many other Americans would like to see health care treated like any other basic, private consumption good—like food, clothing, and shelter—of which every American should be accorded a basic, bare-bones ration, but whose timeliness, quantity, and quality can be rationed by income class.

In between are millions of Americans who never give this issue any thought until they fall ill and face difficulties paying their medical bills; then they generally slouch toward the “social good” perspective on health care, unless they are very well insured or very rich.

Given the complexity of our health system, any health reform proposal contemplated by government is correspondingly complex, especially because those proposals involve ideological preferences. That complexity gave rise to a comment by President Trump that “Nobody knew that health care could be so complicated,”¹ although, after the stillbirth of the Clinton health reform plan in the 1990s and the breech birth of the Affordable Care Act of 2010 (Obamacare), he must have been the only one who did not know.

To health policy wonks, this author included, the details of health reform proposals are more titillating even than Lady Chatterley’s Lover. Although the details of the various ill-fated health reform proposals fiercely debated within the Republican ranks in the summer of 2017 are moot at this time, these details convey the general thrust of the debate and, in particular, the ethical vision baked into them. They are therefore summarized and assessed in the next two chapters, starting with chapter 9 on the Affordable Care Act as a backdrop for comparisons. The discussion in chapter 10 on the House and Senate bills omits the plan submitted by Senators Bill Cassidy (R-LA) and Lindsey Graham (R-SC) in late September 2017 because it was basically more of the same. The discussion in chapter 10 also includes a brief look at how the nonpartisan Congressional Budget Office has “scored” the proposals as to fiscal impact and the number of uninsured.