Some preliminary reactions to articles on medical payments systems (Gladwell-New Yorker & Goodman-Cato Institute)
Goodman's Cato Institute article takes the interesting positions that
(1) single payer systems are bad because they are not perfectly egalitarian.
I find this argument peculiar -- the author doesn't dispute the obvious fact that rationing by waiting is more egalitarian than rationing based on ability to pay, so if egalitarianism is a valid value, the single payer systems used in the rest of the capitalist world would seem to win on that ground, regardless of how imperfect they are.
and
(2) that mortality is not a good measure of the success of a health system, because mortality is correlated with, among other things, race and poverty, and is not strongly correlated to levels of medical spending (which is correct, with the US as the best example: we spend twice as much per capita on medical care as the next highest spender, but rank near the bottom of the developed countries in both infant mortality and life expectancy).
This also seems a strange argument to me. The reason we pay for doctors is to stay healthy, not to get operations. Insured Americans unquestionably get more operations than
citizens of other developed countries. But as the Goodman's Cato article acknowledges, the fact is that our
health is worse than our capitalist competitors. Indeed, even privileged Americans who receive more medical care faster than the state system provides in the other capitalist
systems, don't have better overall health. If your goal is to live a long, healthy life, you are better off being middle class in Greece (which is much poorer than we are)
let alone Sweden (which is richer) than upper middle in the US. And that doesn't even consider the third of our country that is uninsured.
The best predictor of over-all health and life expectancy, according to a series of studies summarized in Richard Wilkinson, Mind The Gap (Yale 2000), is egalitarianism, specifically a low social gradient (gap between rich, middle and poor). "Income inequality affects health independently of average living
standards, of the proportion of the population in absolute poverty, of expenditure on medical care, and of the prevalence of smoking" (p11)
If Wilkinson has his facts right, it is likely that one key reason why the US health statistics are so poor is that we are one of the most unequal of the capitalist countries. First party payor health care with employer insurance is, of course, a major component of that inequality. Presumably this is why Canada, with all its lines, less overall spending and fewer of the latest high tech gizmos, still manages to have better health than we do.
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Without getting into the merits of the argument over national health insurance, which seem to me to be beyond the scope of this course, one useful exercise might be to identify the factual and ethical points where the Gladwell-New Yorker and Goodman-Cato Institute articles differ and agree.
Factually, both agree, for example, that the US has relatively poor overall health statistics relative to its capitalist competitors, and that the US poor have worse health than the US wealthy. Although Gladwell doesn't specifically discuss the point, I assume he'd agree with Goodman's point that no single payer system is perfectly equal and that the rich in egalitarian countries often buy their way out of the nationalized system.
Neither clearly addresses the factual claim made by authors such as Richard Wilkinson, Mind the Gap (Yale, 2000), that the best predictor of overall health (i.e., infant mortality and overall longevity) is egalitarian social structure. Goodman's Cato article seems to acknowledge that advanced medical techniques don't do much to improve overall life expectancy; that is why it suggests we measure success by more limited measures such as the survival rate from individual cancers after detection (which will always make a high intervention system look better, even if all it does is catch cancers earlier with no cures at all). Gladwell, in contrast, seems to assume that more access to care will automatically improve the health of the uninsured -- that rotten teeth matter in the way that lack of sewers or vaccinations did a century ago.
As lawyers, we are more likely to be experts in identifying sound arguments and sorting out ethical premises than in studying whether life expectancy is improved more by expensive cancer operations or by increasing the minimum wage.
Here, the articles offer clear distinctions. Gladwell implicitly argues that the plight of the American poor is an American responsibility. He answers the basic question "Am I my brother's keeper" yes. Libertarians like the Cato Institute, of course, answer "no".
Second, the Cato article implicitly judges a health care system by how it reacts to extreme situations -- curing cancer -- suffered by the most privileged -- those who can pay for the most advanced care. Gladwell, in contrast, is interested in really primitive health care: the technology of filling cavities has not changed in many years. Should we judge the system based on its average performance (median or mean)? On its performance for the worst off? Its performance in the best of circumstances? Which question you ask is going to have an immense effect on which system you end up approving.
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Torts as we know it, is an expensive, fact dependent, individualized, fault based system. Even now, before you have studied it, you should be able to see that the more you value individualized treatment, the better it will look. The more that you think it important to assure that everyone get more or less the same results, the worse it is going to look. If you care deeply about making sure that people who've been injured get the care they need, it isn't going to be as attractive a system relative to social insurance schemes as if you care more deeply about ensuring that no one has to pay for something they weren't responsible for (in an individualized sense). These are one type of questions we need to struggle with.
Another set of questions come from the implicit background. These two articles both assume that the choice is between personal (non-distributive) insurance and social (single pool) insurance. In tort discussions, those two insurance alternatives will always be in the background, but there are other possibilities too. For example, leaving the injury where it lies is also always an alternative. Also, changing the circumstances so that future injuries are less likely.
Does it matter whether an injury just happened, or whether someone made it happen? Should people be held responsible for the inevitable, or predictable, consequences of
the actions they take? Only if the actions are in some (other) way anti-social? These are the questions we address next.
Goodman's Cato argument seems to be that making it easy for the wealthy to buy the latest technical advances in medical care is so important that we should ignore whether medicine
is actually making people healthy. Why would that be?
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Note that the New Yorker article made a somewhat different claim: Gladwell contends that the key justification of the US system is that it reduces use of medical care. Although Gladwell clearly does not think this is a valid goal, if the social hierarchy work is correct (that is, if it is true that equality matters more than the latest cancer drug in keeping people healthy) one might actually conclude that medical care isn't worth the money we spend on it, and that discouraging people from using the medical system might in fact be a reasonable goal. If Wilkinson is correct about how health works, we would get more bang for our buck by shifting advanced health industry funding into basic, non-hierarchal services: libraries, roads, sports stadiums, day care, primary care clinics, minimum wage, mortgage or rent subsidies, reducing concentrated pollution, and so on.
For purposes of this course, the most important point is to try to identify the values that Goodman-Cato and Gladwell are basing their arguments on, and then to try to think about how they are promoted, or not promoted, by the various payment schemes we will discuss, including our basic American system of torts combined with private (non-redistributive) medical insurance.
Goodman/Cato's libertarian position seems to be based on a fundamental moral premise that no one is her brother's keeper -- that if I am sick and you are healthy, there is no reason why you should pay for my health care. Gladwell takes the opposite ethical view, that we are all in this together, that the poor health of poor Americans is a national responsibility.
Wilkinson, in contrast, argues for a sort of enlightened self-interest: he claims, as a factual matter, that the libertarian is wrong. Even if you only care about yourself, the best way to improve your own health is to improve everyone's. This is obvious when we are talking about sewers and vaccinations, but Wilkinson extends it to the rest of life as well.