we in a health care crisis?
have over 43 million people without any health insurance. We have
over 80 million people either without insurance entirely or with
inadequate insurance. It's nearly a third of the country. I'd say
that's a crisis.
primarily at risk in all of this?
to what many of us are likely to believe, the great majority of
people without health insurance are actually members of working
families. It's people who are hard-working, lower middle class families
who don't happen to have the good fortune to have an employer who
offers health benefits. When some of the hardest-working Americans
are the ones who don't have health insurance, I think we should
see this as a national problem and we should see it as an urgent
have a very complicated mix and public and private coverage of health
care right now. Unfortunately, it leaves too many people out. It
seems to me it wouldn't be such a difficult problem to bring into
the fold those many Americans who, for one reason or another, are
currently outside of our safety net. And we can bring them in in
a variety of ways. We can bring some of them into public programs,
some of them into private programs, perhaps some of them into publicly
subsidized private programs. But I think we can do it.
didn't the US embrace social insurance the way Europe did after
World War II?
all Americans who have private health insurance have it through
their employer. That's an historical accident. In the 1940s, during
the Second World War, wage and price controls were placed on American
employers, and in order to compete for employees, they could offer
health benefits. In those days, it was cheap. Americans have become
accustomed to having their health insurance through their employers.
Most of the world would regard that as an anomaly. They're accustomed
to having national programs of health insurance, however financed,
which guarantee all or virtually all citizens of the country, ah,
access to health care as they need it.
ethics play a role in health care policy?
I'm an ethicist, but I have to tell you I believe that ethics are
the foundation of American health care. Why do we think health care
ought to be provided to all Americans? Because we think health care
is a kind of basic need. It responds to something that all of us
experience. We experience either the threat of illness or the actuality
of illness, and we respond on a very intimate and personal level
to that when we see it in ourselves, but also in others. So it's
easy for us to understand how acute the need for health care coverage
can be for anybody who falls ill. Ill health can devastate a family.
It can devastate them physically, emotionally, and financially.
When illness comes, we should respond as best we can to minimize
the physical impact. There's no way to eliminate the emotional impact
on a family of ill health, but at least we can spare them the financial
devastation that so often comes along with a serious illness.
do we do to foster the ethical perspective more in the debate about
Americans are very good at denying the connection between our most
deeply held ethical values and our public policies. We need to connect
those in the realm of health care. We need to see how what we do
as a people, through a combination of public and private measures
that give access to health care to Americans who have it, we need
to see the connection between those policies and the things that
we value. We also need to see the connection between the lapse in
our policies, the holes in our policies that permit 80 million-plus
Americans to fall through entirely or in part.
is 'fairness' in this kind of debate?
if you ask the question, what sort of thing is health care, there
are a lot of different answers. Some forms of health care go right
to the core of what makes us vulnerable human beings, and to the
core of what we really value about health care. And that is to give
people a reasonable chance to lead a full and satisfying life, a
chance to work, to have a family, to have people that you care about,
and to have those relationships survive. All of us will be subjected
to threats of ill health from time to time, whether it be ourselves
or people that we love. To be able to respond as a community and
to provide people at least a decent chance of getting through those
moments by giving them the health care that could make a difference,
that's at the core of, I think, what we value about health care.
the insurance system unfair?
I'm an insurance company and you come to me and you want me to provide
fire insurance for your business and I find out that you keep a
pile of oily rags in the basement and you throw matches into that
rag after you light your cigarette, I'm not gonna want to insure
you. Or if I do, I'm going to charge you a very high premium. I'll
probably even tell you you'd better clean up your act. Well, that's
one way of thinking about insurance. The insurers call it actuarial
fairness. It's a moral concept. It's a concept that everybody ought
to pay according to their risks. Makes sense if I'm insuring a business
that voluntarily takes or avoids risks. Seems to me a perverse moral
logic if what you're talking about is health. I didn't choose my
genes. As my children occasionally remind me, they didn't choose
their parents. It was the luck of the genetic draw. If my genes
should predispose me to a disease like some form of cancer or heart
disease or diabetes or some other common disease like that, I don't
think I or anybody else should be punished because those it just
happened to be their genetic draw. Actuarial fairness would in fact
punish people because they had genetic predispositions to disease.
is fair then?
the heart of the current system of private health insurance is a
catch-22. Insurers least want to provide coverage for the diseases
you're most likely to have. People experience that every day in
the preexisting condition waivers, where an insurer will say, "We're
not going to cover you for disease that you bring in when you, when
you start your policy with us." How are we going to respond to that?
What's needed is a health care system that provides the care that
people really need when they need it. It may be limited to that
care which is most effective and not to some of the care at the
margins. We can have a public argument about what should be provided
and what ought not to be provided, but it seems to me when you've
got preventive measures and effective therapeutic measures that
really make a difference in people's lives, that ought to be something
that everybody should have access to.
about disparity of care geographically nationwide.
has been emerging that suggests that people may get different care
simply by living in a different part of the country, by being a
woman, rather than a man, or by having a different color of their
skin. If in fact that evidence is indicating prejudice, whether
conscious or unconscious, it is something we should work with every
ounce of our being to eliminate. If, instead, though, it's a marker
of just differences in care between rural and urban settings, between
inner city over-stressed hospitals and better-funded suburban hospitals,
then we should work on getting the system right. So, in part, it's
a question of whether these are systemic problems having to do with
the way we organize and finance health care or whether these are
biases, conscious or unconscious, having to do with individual health
have things changed?
a certain amount of sentimentality and myth in which we view the
past of medical care. It was never quite the Marcus Welby model.
But there have been some genuine changes in the way we insure health
care. It used to be that you would get an insurance policy that
would simply reimburse you for the bills you ran up with your doctor.
And so you could see the same doctor year after year. Two things
have happened to change that. One is doctors now tend to belong
to health care plans or panels. So if your doctor's not on the panel
of that particular HMO, you may not be able to see that doctor anymore.
You may have to pay a penalty or premium to do so. In addition,
your insurer may change their coverage every year or two. They get
a better deal from Oxford this year than they got from Aetna last
year, so they go with Oxford. And that may mean an entirely different
panel of physicians. So the doctor you've gotten comfortable with
over the past two years is no longer covered by your insurer, and
you may have to change doctors. If you believe that the continuity
of care and the relationship built up between a physician and a
patient makes a difference in health care, and I do believe it does,
then this is a distressing development.
these new health care plans the HMO type plans, not only do the
plans tell you which doctors you can see and which hospitals you
can use; they may also tell you which drugs you can take. And they
may change their mind about it. If they get a better deal from one
pharmaceutical company this month, but a better deal from a pharmaceutical
company for a similar, but not identical, medication next month.
And I think this can also be distressing to people.
do we deal with chronic care?
always tended to focus our concern about health care and health
care insurance on what goes on in the doctor's office and what goes
on in the hospital. In fact, there's always been a considerable
amount of care that goes on afterwards, goes on at home. What's
happened in the past decade has been an increasing off-loading of
care, sometimes very complicated and demanding care, from the hospital
to the home. We've tried to get people out sicker and quicker. That's
the saying. But where do they go? Well, in most cases they go back
home. And then the care falls largely on the family. If there's
a wife, it falls on the wife. If there's a daughter of an elderly
parent or even a daughter-in-law of the elderly parent, it tends
to fall on the daughter. Not that men don't also get a portion of
the care, the home care burden, but it's largely focuses on women,
and often on women in their middle years.
do we solve this?
need to listen to the voices of people who are doing home care.
I think we don't do that very much. For one thing, they don't have
the time or energy to speak up very much. They are often just consumed
and exhausted by what they have to do in the way of providing care
for a family member at home. We need to hear them. We need to talk
to them and find out what would be most helpful to them. When we've
done that, and we actually have a project at the Hastings Center
to try to do some of this, what we find are we need more responsiveness
from care givers, from physicians, from nurses, even from home care
health workers. We need to provide respite care. It can make an
enormous difference if I get away for an evening or two in a week
than if I'm locked up seven days and seven nights. To provide a
little respite care, a break, can be a real morale booster and in
some ways a life saver to people.
to how to pay for high cost prescription drugs
that are desperately needed.
drug costs seem to be rising rapidly and inexorably. And it's creating
a real hardship for many people. I was startled to find that my
own mother, at the end of 1999, chose not to fill a prescription
that she'd been given for a necessary drug because she had maxed
out her drug benefit for the year. She waited until the beginning
of 2000, when she could again get some coverage for it. I was very
stressed to hear that. She should have been taking her medication
even in December; illness doesn't know a calendar, the way insurance
companies may. One thing that seems certain is the number of drugs
and probably the cost of drugs is going to continue to rise. We
have a fruits of the Human Genome Project, and one of the fruits
of the Human Genome Project will be a vast, I think, increase in
the number and complexity of new drugs. I can't imagine that they're
going to be dirt cheap, at least for a long time. So we are going
to be faced with an ever-increasing pressure, I think, to spend
more and more money on drugs and, an ever-increased inability of
people to afford those drugs unless we find some way to fix that.
private insurance reform.
you, as an American, want to buy health care insurance, the worst
situation to be in is to be unemployed, self-employed, or to work
for a small employer. In those cases you're going to have to look
for the most expensive and difficult to find forms of health care
coverage -- if you can find it at all. Insurers cut a break to large
groups, and they can do this for a variety of reasons, economies
of scale, what's called the law of large numbers, but if you are
self-employed, if you want to start your own business, you are likely
to be in very tough shape if you need to also find health care insurance.
might we solve the problems we have?
there is a latest moral goodwill in the American people that needs
to be galvanized. I think if we can bring home to the American people,
in stories, not just in cold abstract numbers, the reality of the
inability to get health care that so many of our fellow Americans
experience, that will be a very good start. To ask what it is we
really value most about health care, how it can make a difference
in the lives of individuals and families, how it can make the difference
between a life with desperation and despair and a life with dignity.
I think we begin with that kind of moral quest.
you want to add?
an unintended way, it may be that the defeat of the Clinton Health
Care Reform plan of 1993-94, may have actually made people more
willing to accept a larger public role in health care coverage.
In 1993 and 1994, when the Clinton Administration was creating its
plan for health care reform, managed care was already a large train
hurtling down the track. Because the plan was defeated, many Americans,
I think, now attribute the things that they dislike, in some case
intensely about managed care, to the large companies, particularly
the for-profit companies, that own the plans. If the Clinton plan
had gone through, they'd probably be attributing all those features
to the government. So, ironically, now that people are saying the
problem is with the large, for-profit managed cares plans, rather
than with public plans, people might be more willing to contemplate
a larger public role in health care coverage.