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Is Health Insurance a Right?

Think Tank Transcripts:Is Health Insurance a Right?

MR. WATTENBERG: Hello. I'm Ben Wattenberg. President Clinton hasbet big on his health care reform, and Congress is madly rushing toput together some kind of health care plan. But what's really atstake?

Joining us to sort through the conflict and the consensus are:Paul Starr, professor of sociology at Princeton and author of thePulitzer-prize-winning book, 'The Social Transformation of AmericanMedicine'; John Goodman, president of the Dallas-based NationalCenter for Policy Analysis and co-author of 'Patient Power: SolvingAmerica's Health Care Crisis'; Theodore Marmor, professor of publicpolicy and management at Yale University and author of 'UnderstandingHealth Care Reform'; and Stuart Butler, director of domestic policystudies at the Heritage Foundation and co-author of 'A NationalHealth Care System for America.' Liberals and conservatives.

The topic before this house: Is health insurance a right? Thisweek on 'Think Tank.'

Are you confused about health care reform? Hard triggers, softtriggers? Medical IRAs, IPAs, PPOs, HMOs? MediCap, MediGap, Medicaid,Medicare A, Medicare B? Managed competition? Hillary's plan, Bill'splan, Clinton light, Clinton heavy? The Nickels-Stern plan, theCooper plan, the Graham plan, the Dole plan? Play or pay? Singlepayer, co-payments? Community rating, catastrophic coverage,universal access, universal coverage, global spending caps? Healthalliances? The Ways and Means Committee plan, the Finance Committeeplan? And of course, the resource-based relative value scale, orRBRVS?

You don't understand all that? Join the club. Today we are notgoing to talk about the paragraph A, subsection 5 aspects of healthcare reform. We are going to try to step back and talk about somebasic ideas and principles.

PRESIDENT CLINTON: (from 1994 State of the Union address) If yousend me legislation that does not guarantee every American privatehealth insurance that can never be taken away, you will force me totake this pen, veto the legislation, and we'll come right back hereand start all over again.

MR. WATTENBERG: In the next few months, Congress will decide howto respond health care ideas and his veto threat.

Today most experts agree that the United States offers the bestmedical care on earth, and America is the world's leader in medicalinnovation, developing wonder drugs to treat ulcers, heart and kidneydisease, new biotech vaccines, CAT scans, magnetic resonance imaging,organ transplants, and less invasive surgical techniques likelaparoscopy. We also have the best educated doctors.

But Americans spend nearly a trillion dollars a year to pay forhealth care, almost 1/7 of the U.S. economy, far more than any othercountry. And while insurance covers most people, it doesn't covereveryone.

First lady Hillary Rodham Clinton headed a 500-member task forcewhich produced a 1300-page plan designed to guarantee healthinsurance for all Americans. But behind the complexity, what's atissue? This plan and others being considered by Congress coulddramatically change the way Americans pay for health care, how it isdelivered and how they choose their doctors.

The fundamental question is whether the government should or canguarantee health insurance for everyone. Opponents ofgovernment-guaranteed health insurance have taken to the air waveswith the now-famous couple Harry and Louise.

'LOUISE': (from videotape) It's rationing, the way I read it. Youknow, long waits for health care and some services not evenavailable.

'HARRY': (from videotape): Government-controlled health care --Congress can do better than that.

MR. WATTENBERG: But defenders are trying to blunt these attacks.

'LIBERAL LOUISE': (from videotape) He said, 'What do we do whenthe government runs out of money?' Well, who's out of money, Harry?There's got to be a better way.

MR. WATTENBERG: John Goodman, why don't Harry and Louise have aright to guaranteed health insurance? What's so terrible about that?

MR. GOODMAN: I think health insurance is a good thing for everyoneto have. But if you ask, is health insurance something everyone elseis obliged to give to us, is it a right in that sense? I would sayno, and I would say all the other developed countries that havedeclared that health care is a right don't really make it a right.You find, living in England today or Canada, I don't necessarily havea right to a CAT scan or heart surgery, and even if I need it, I maynot get it. MR. MARMOR: Well, but I think that's a good example ofwhere we ought to be clear what we're talking about. A right tohealth insurance is not the same thing as a right to health care.It's perfectly possible to be insured against the cost of care youget and have certain care unavailable.

So the first distinction I think we want to be clear about is thatthe concern about security is about the financial consequences ofgetting care. It's a separate question about whether we're talkingabout the right to health or health care itself. I think there's asharp distinction to be drawn, frankly, between our obligation to oneanother to cushion the financial consequences of illness and a morecontroversial view about how much we want to redistribute access tohealth status, which involves many things beyond medical care.

MR. BUTLER: And I think also, you know, the right issue is a rightto what, even if one were to accept the notion of a right. Is it aright, for example, to a free abortion, for everybody in America--everybody be compelled to have coverage for that? Is it a right tohave a particular procedure? You know, you've got to get into whatare we talking about in terms of specifics, even if you concede thenotion.

MR. WATTENBERG: Paul Starr, you were one of the fathers orgrandfathers of the Clinton plan. Why don't you hold forth?

MR. STARR: Well, I just want to say, Stuart is really now gettinginto the question of what's covered, what's in the benefit package. Ithink if you're going to say that there's no right to health care,then are you going to be the one who is prepared to tell someonewho's sick -- let's take a really heart-wrenching case, a child withleukemia -- are you prepared to be the one who says, I'm afraid youcan't have treatment because your family has no coverage?

MR. BUTLER: Yes, because

MR. STARR: Because, really -- no, consult your soul about thisbecause if you're not prepared to stand in a hospital admissions roomand kick people out of the hospital because they don't have coverage,then the issue is not whether people have a right to be taken care ofwhen they're sick. The issue is, do we have an obligation, all of us,to pay for it?

And that is really what a lot of this debate is about: willeverybody be obliged to pay for it, the way we have to pay for a firedepartment even if our house is not burning; whether we all have anobligation to pay for health insurance even if we never

MR. WATTENBERG: Does everybody have a right to a house with ayard?

MR. STARR: No, absolutely not. MR. BUTLER: But that's the issue.That's the issue, Paul. I mean, you know, you're not the only onewho's searched your soul on this issue, believe me. And I've livedunder a system in Britain, you know, which does, quote, 'guarantee' aright to health. People do not get particular procedures. There arepeople in the system who say, 'You won't get this.' Actually, theydon't say that. You just don't get it.

And the fact is that any system, any situation has to havesomebody making some decisions. The issue is, who makes thosedecisions? Do I get to make them? Does some commission in Washingtonget to make them? Does Hillary Clinton get to make them? Do you getto make them? That's the issue that we're talking about.

MR. WATTENBERG: Doesn't the situation now -- you were talkingabout a child with leukemia -- through charity wards and emergencywards, I mean there are -- most people in America, beyond the 85percent who are insured, when they have a health emergency orsomething very seriously wrong with them, don't they end up gettinghealth care, if not health insurance?

MR. GOODMAN: This is one of the great ironies about the wholehealth care debate. America is probably the only developed countriesthat has not formally stated that health care is a right, and yetAmerica goes further than any other country in saving the cocainebabies, in saving people from rare and expensive-to-treat diseases,even if they have no money.

MR. MARMOR: John, that is an irony, I agree with that. It's aninteresting irony. But I think you're getting away almostinstantaneously from the foundational question. What makes us thinkthere is a right to health insurance or health care at all? And then,separately, what is that a right to? They're separate questions.

MR. WATTENBERG: What is your answer? What guarantees us a right?

MR. STARR: I think the answer to this question that you've raisedabout whether people get care or not is that, yes, we do pay for themost expensive things, but the great irony in this, and we have a lotof evidence for it, is that people without coverage do get less care.

MR. MARMOR: There's no question about that.

MR. STARR: And what they get less of is the primary care, thepreventive care, the care that would keep them out of the emergencyroom.

MR. WATTENBERG: I read something, that the uninsured in Americaget 60 percent of the cost of what the insured get, and that's morethan people in England or Germany or Canada get. MR. MARMOR: That maybe true

MR. STARR: But, Ben, that's why we can do it. That's why we can douniversal coverage. A recent study indicated that covering theuninsured, if we just did that, covered the uninsured, it would raiseAmerican health expenditures by 2 percent.

MR. WATTENBERG: It's trivial. Most of the

MR. GOODMAN: I disagree with that.

MR. MARMOR: Do you? You think most of the uninsured are people whouse a lot of medical care? You know, it's not, John. MR. GOODMAN: No,but I think if you insure them -- I think if you expand coverage forany of us, we'll spend more on health care. All the studies showthat. All the studies show that if you can spend someone else's moneyin this marketplace, you'll spend more. We'll all spend more.

MR. STARR: But if we combine that with cost-containment measures,we're going to be able to come out ahead on that.

MR. BUTLER: If you're trying to get some fundamentals here, let'stalk about what we mean by a right. It seems to me, first of all,we're not talking about a constitutional right or anything like that.

MR. WATTENBERG: Or a statutory one at the moment.

MR. BUTLER: Right, except to some extent, people do have astatutory right to go into an emergency room and at least bestabilized. That is a legal right in this country.

But I'm trying to get at what do we mean by this concept of aright?

MR. WATTENBERG: But the Clinton plan establishes it as a right.That's what he said, that we'd never take it away from you; it's anentitlement.

MR. BUTLER: I understand that, I understand that. But when we talkabout a right, it seems to me, in this country, what we're reallytalking about is, Americans in general feel that we're a rich enoughcountry, we have enough expenditures in this area of health care, weare at a position where everybody in this country should be able toget access to some level of health care.

Now, that's not a right in any constitutional sense. It's afeeling that we're at a stage where we ought to be able to expectthat.

MR. MARMOR: I agree with that.

MR. BUTLER: And everything really flows from that. Then everybodystarts using other arguments, like rights and legal rights, butthat's really fundamentally what we're talking about.

MR. MARMOR: I think there is a consensus on this, that -- and weactually express it in the way we organize our medical carearrangements. We do not deny people care

MR. BUTLER: And the moral imperative that we have.

MR. MARMOR: The moral imperative, as Stuart says. I think there'sbeen a confusion in the public debate, as if this is a new issue.

MR. WATTENBERG: Let me try to get something clear. I mean here wehave two putative liberals and two putative conservatives, and youagree on the idea

MR. MARMOR: At a minimum

MR. WATTENBERG: -- of universal access.

MR. BUTLER: Except what I'm saying is that ordinary Americans aresaying, we want that. That's not the same as saying it is a legalright, a constitutional right or anything like that. What I'm sayingis merely an observation about how people in general think abouthealth care.

MR. WATTENBERG: Do you agree with that, John?

MR. GOODMAN: Yes, but I think that what Bill Clinton is saying issomething more than that.

MR. BUTLER: Absolutely it is.

MR. GOODMAN: What Bill Clinton is saying

MR. MARMOR: But let's just say what he said at the very least.Let's try to get clear

MR. GOODMAN: Just a moment.

MR. WATTENBERG: Just hold on a minute, Ted.

MR. GOODMAN: What is Bill Clinton saying to middle-class America?He's saying that I am going to force you to buy health insurance, youand your employer, whether you want to or not. Now, we can call thata right, but what it really is is a government-imposed obligation.It's we're not going to allow you the choice not to buy healthinsurance. That's what he's saying.

MR. WATTENBERG: Is late 1991, then Senator Lloyd Bentsenintroduced a health care bill. A little later on, in early 1992,President -- then President Bush added some things on. And it wassort of piecemeal reform. It involved affordability, it involvedmalpractice, it involved universal forms, all the little things --they're not so little

MR. MARMOR: All the insurance law reform.

MR. WATTENBERG: -- the big things, but without the getting greatgovernment maw involved in it. Could you live with that kind of aplan? I mean the piecemeal reform idea.

MR. BUTLER: Well, I will -- I can, in a certain way, and let meexplain why. What we're talking about in health care reform, or whatwe've ended up talking about, I should say, in terms of the wayCongress is doing it is, Congress is trying to look at ways ofcompletely restructuring 1/7 of the entire economy. It is playingwith hundreds of billions of dollars.

Now, I genuinely feel that if government does that at one stroke,even if it's something that I may happen to approve of, it's likelyto get it absolutely wrong and it's likely to lead to disastrousconsequences.

MR. WATTENBERG: Just because you don't trust government?

MR. BUTLER: That is a major reason. It's not just that I don'ttrust government. I don't think that anybody who's been, you know,within 10 feet of government can really believe that in a three-daymarkup, you know, we can solve all these problems.

MR. WATTENBERG: Let me ask you a question. If you're Harry andLouise -- or four Harrys, or whatever, all right -- and you'resitting around watching that long list of things that we went throughin the beginning and you've got to make up your mind, is that thequestion, that you say, Harry, do I trust government? If I trustgovernment, I'm going to go with Clinton. And Louise, if I don'ttrust government, I'm not going to go with Clinton; I'm going to gowith Dole or I'm going to say no bill till we get some moreRepublicans in the Congress.

John, you try that. How should -- Harry and Louise have becomefolk heroes -- how should they decide this?

MR. GOODMAN: There is something to be said for that, that when yousee government about to do something that's going to affect somethingvery personal to you, your own health care, and you realize it's verycomplicated, and you realize that the complexity changes every weekand you'll never understand it all, it does kind of get down to whodo you trust. And if you don't trust the politicians who are about topass the bill, maybe you should be against it.

MR. STARR: And do you trust the insurance companies? Do you thinkAmericans trust the insurance companies more? My colleague WilburReinhard (ph) has put this very well: Medicare has never sent anotice to a beneficiary saying, `Sorry, we've discovered you havecancer. We're no longer willing to insure you.' But many people inthis country have had the experience of insurers turning their backson them.

As for trust, I would take Medicare any day over a privateprogram, over a private insurer.

MR. BUTLER: But, Paul, that's the kind of absurd tradeoff thatmakes the debate -- that makes it so difficult for Americans toreally understand what the basic issues are.

You're saying there's two choices. You either trust the insurancecompanies or you trust the government. You've got to get to thefundamentals of what is it that's causing people anxiety? Why areHarry and Louise concerned? Harry and Louise are primarily concernedthat they indeed may lose the coverage they now have.

Now, that does not mean that the government has to come in to tellthem what coverage to have. It doesn't mean you have to set up healthalliances. It doesn't mean you have to have a commission inWashington to tell them what benefits you've got to have.

You've got to deal with some ways of dealing with the insurancecompanies that are inclined to turn people off and to cut them outand say they're not going to have this benefit. You can deal withthat in a very surgical way. You know, you can have microsurgery todeal with that. You don't need to basically obliterate the patientand try and put them back together again, which is what the federalgovernment is trying to do.

MR. STARR: First of all, I don't think that's a correctdescription of what

MR. BUTLER: I'm sure you don't.

MR. STARR: -- health reform is about, because in fact thepresident's plan is trying to build on the foundation that we have,the foundation of employment-based financing, the foundation ofprivate health plans. It's trying to change the rules of that system

MR. GOODMAN: Could we agree on

MR. STARR: -- to create the incentives both to control costs andto insure everybody.

MR. GOODMAN: Could we agree on one thing?

MR. WATTENBERG: Give John Goodman a shot here now.

MR. GOODMAN: I think there's something we all agree on, that thepresident's plan is not even primarily about insurance reform. Mostmembers of Congress and most of the American public agree thereshould be some insurance reform.

MR. WATTENBERG: Even you.

MR. GOODMAN: Even me. And I think once you buy into the system,you shouldn't lose coverage, you shouldn't have your premiumsincreased because you get sick.

MR. WATTENBERG: It should be portable.

MR. GOODMAN: Yeah, it should be portable. That's what I mean byinsurance reform. If that were all there was to this debate, we'dprobably get insurance reform tomorrow. The president is advocatingsomething far more than that. MR. MARMOR: But I think we should notbe discussing entirely whether the president's plan is the right one,but talk about options for dealing with the problems that lie beyondinsurance law reform.

One of the problems the president's plan and others try to dealwith is the escalation of the cost of medical care because we believethat over time consequences of that will be dire for the rest of theeconomy and for medical care later on. It doesn't -- the Clinton planhas the right objectives. It both wants to expand coverage and dothings that restrain this escalation of health care costs, but thereare many ways to do this. We're not talking foundationally here.

MR. WATTENBERG: Let me ask you a question. I am old enough andhave been around this town long enough to remember the 1960s, theearly 1970s, when the left was saying, we ought to reorderpriorities. Do you all remember that phrase, 'reorder priorities'?

And if you look at the national spending accounts, the differencebetween the late 1960s and the early 1990s is what we have done, byGeorge, is reorder priorities. The military budget has gone down andthe health care budget has gone way up.

Now, what on earth is wrong with health care costs going up? Isn'tthat what a humane society ought to do?

MR. MARMOR: In and of itself, Ben, nothing's wrong.

MR. WATTENBERG: Then why are you all saying you have to contain itwith

MR. MARMOR: If you'll let me answer, I'll give it to you. Insofaras we think we're getting value for money, it would be wonderful. Wedon't have a budget for the purchase of books, and if people thinkmore books is better, that's fine. It's that nobody believes thecombination of patchy coverage and health statistics that are not allthat impressive and a lot of insecurity is a good value for atrillion dollars' worth of expenditure. Moreover, the countries withwhich we do business, that is, our competitors, seem to be able toget somewhat better balance among cost, quality and access than we'vebeen able to. That's the negative consensus we've got.

Where we don't have consensus is either on the full range ofpurposes of health care reform, beyond what we've talked about, orwhat the insurance would do. There's lot of disagreement about, ifyou do A versus B, and we'll never get to them. And we cast thequestion

MR. GOODMAN: No, but the president has put down an approach --proposed an approach that's very radical. He has said -- he and hiswife Hillary have said, we want to push people into healthmaintenance organizations

MR. STARR: No, that's not true. MR. WATTENBERG: No, just hold on aminute. Let John finish.

MR. GOODMAN: -- and other managed care organizations.

MR. STARR: Fair enough.

MR. GOODMAN: And what the president is proposing is to pushAmericans into health maintenance organizations and other managedcare plans where the bureaucracy is going to increasingly dictate todoctors how they should practice medicine.

Then they're going to squeeze down on the income available tothese organizations and force them to ration health care. That isclearly the plan. Now, they may want to describe it in differentwords, but that is clearly what they have in mind.

MR. STARR: John, you are describing what's going to happen withoutreform. Employers now are moving people into managed care plansagainst their will. Under the president's plan, people would havetheir choice of an array of alternatives which would have to includea fee-for-service conventional insurance plan.

In fact, without reform, people will lose access tofee-for-service, the conventional kind of insurance that many of themare now losing access to under employer-controlled coverage.

MR. GOODMAN: Most of the people who advocate the very reforms thatyou advocate say that fee-for-service plans will never survive inthat market. They will be gone and people will not have, as apractical matter, that option.

MR. BUTLER: I think that's right. Let me put it another waybecause I think you may even agree with this. What you have today isa situation where most Americans work for an employer, that employerowns their health plan, determines exactly what benefits they'regoing to get, how much is going to be spent.

Employers today want to spend less. So they're doing things to meas an employee, telling me I'm going to have to have care in acertain way, and so forth.

There are various ways of dealing with this. One way is to say,well, let the government make these decisions. Let me write mycongressman and let my congressman decide what I'm going to have,what care, how much is going to spent.

Another way, of course, is to look at steps to give me greatercontrol over how much is going to be spent. Maybe I want to go intomanaged care, maybe I think that a cheaper plan that restricts mychoice of doctors may be good for me. Maybe I like that. Maybe Iprefer to spend more on it.

So in other words, we're really talking about a fundamentaldecision point here. Do we correct a flawed system where somebodyother than me and my doctor decides what I'm going to get, which isthe employer? And how do we change that? Do we go towards me havinggreater control or do we go towards some other institution havinggreater control?

MR. WATTENBERG: I want to ask a sort of philosophical question.All this sort of restructuring, this sort of Darwinian capitalismwe've been going through in the '80s, has driven a polity to look forgovernmental nets.

MR. STARR: It is upheaval in the economy that is producing a lotof insecurity. It's not just that the number of people with healthinsurance has gone down. Employer-provided health insurance has gonedown. People with employer-provided pensions have gone down, too.Employers have been shifting people to part-time.

So there is an erosion in what some people have called theoccupational welfare state. And it is partly a response to that whichwe're seeing now. People want something else to provide the securitythat they can't get.

MR. WATTENBERG: That more free enterprise has driven a demand formore government.

Can you briefly -- let's go around, starting with Paul Starr --briefly -- tell Harry and Louise what you all agree on, what you alldisagree on, and what they ought to think -- briefly.

MR. STARR: What most of us agree on, maybe not everybody, is thatthe insecurity that millions of Americans feel about their healthcoverage is very deeply rooted. It may be getting worse. There islots of evidence that it's getting worse.

The situation is not stable. We need to do something about that.We don't agree exactly on what that something should be, but it's notas though we're on a stable ship. We're on a ship that's reallytilting, and it's going to hurt a lot more people in the rest of thisdecade unless we take some very significant action today.

MR. MARMOR: I think we agree that the costs are unsustainable overthe longer run. I think we agree that there is insecurity. And Ithink we agree that insurance against the cost of medical care shouldbe made more secure.

I think where we disagree is in the diagnosis of what it wouldmean if the government were to play a larger role in addressing thoseproblems. And we disagree, for example, about the capacity of theprivate sector to right these wrongs with minimal change.

I don't know beyond that what we disagree and agree on, but it'smuch more agreement than would meet the eye.

MR. GOODMAN: Harry and Louise should be concerned that evenwithout a reform bill, that the desire to control costs can affectthe quality adversely of the health care that they receive.

And I think all of us agree, to a certain extent that the qualityis important and quality is threatened, although on this side we maycare more about that issue. But that's it. In the desire to controlcosts, do we threaten quality, do we destroy quality? That's what thepublic should be focused on.

MR. BUTLER: We certainly agree that Harry and Louise, likemillions of Americans, really fear insecurity. Insecurity is the rootof this pressure for change. We agree on that.

I also agree here that whatever you do, there are fundamentaltradeoffs that have not been made clear to the American people. Wemay disagree a little bit on what some of those tradeoffs are, butyou can't be presented with there's a perfect solution and no cost.And that's what's been happening.

And where we disagree, I think, is broadly which direction to goin. Do we solve the insecurity problem by giving greater control togovernmental institutions on our behalf, or do we solve this problemby giving greater control to individuals to make decisions and tocontrol the dollars? That seems to me to be the fundamental divideabout which way you think is the best one to solve the problem.

MR. WATTENBERG: Okay. Thank you, Stuart Butler, Ted Marmor, JohnGoodman, Paul Starr. And thank you.

We have appreciated hearing from you. Please continue to send yourcomments and your questions to us at the address on the screen.

For 'Think Tank,' I'm Ben Wattenberg.

END

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