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Thomas H. Murray, PhD

Are we in a health care crisis?

Thomas H. Murray, PhD Thomas H. Murray, PhD
The Hastings Center

We 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.

Who's primarily at risk in all of this?

Contrary 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 problem.

We 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.

Why didn't the US embrace social insurance the way Europe did after World War II?

Almost 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.

Should ethics play a role in health care policy?

I know 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.

What do we do to foster the ethical perspective more in the debate about policy?

We 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.

What is 'fairness' in this kind of debate?

Well, 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.

Is the insurance system unfair?

If 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.

What is fair then?

At 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.

Talk about disparity of care geographically nationwide.

Evidence 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 care providers.

How have things changed?

There's 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.

In 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.

How do we deal with chronic care?

We've 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.

How do we solve this?

We 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.

Speak to how to pay for high cost prescription drugs
that are desperately needed.

Prescription 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.

Address private insurance reform.

If 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.

How might we solve the problems we have?

I think 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.

Anything you want to add?

In 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.

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