The Healing Game

Health care reform offers the possibility for advances in social justice of a magnitude not seen since the civil rights era. But health "reform" could just as easily institutionalize many of the worst features of the present system, perpetuating for generations the race, class, and gender discrimination that now taint American health care.

With the moral stakes so high, one might expect a grassroots ferment for reform among people of conscience. However, most Americans, trained as "good patients" to defer to health professionals, remain passive. For many people, the technical jargon of health reform either obscures the moral issues or makes them feel inadequate to address those issues actively. As a result, the policy debate is left by default to "experts," many of whom have a vested interest in the present system.

It need not be so. Ordinary citizens can grasp the health policy choices facing our democracy. To advocate for a more just health system requires no special credentials. All that is required is a basic appreciation of the flaws of the current system, an understanding of the politics of reform, and clarity about the moral choices that face us.

Most Americans are dissatisfied with their current health care system. They recognize that in many ways it is inefficient, inequitable, and inhumane. And the problem is getting worse. Health costs continue their decades-long spiral at inflationary rates twice that of national economic growth. More and more of the country's most vulnerable citizens are pushed to the margin of the health care system, even as the incomes of health care entrepreneurs continue to rise.

The politics of health reform are simple and harsh. The struggle for health care reform is a zero-sum game between those with a vested interest in the status quo and everyone else. Because of the national deficit, there will be no large new infusion of federal funds into the health care system. Private business, which now foots much of the nation's insurance bill, is determined to curb, not increase, its outlays for employee health benefits.

These realities mean that any gains in affordability and accessibility of health care will be won only by reducing the income of the health and insurance industries and by lessening their present control over the health care system. Conversely, those who profit so handsomely from the status quo can hang on to their advantages only by the continued exclusion or marginalization of millions of Americans. We already spend half again as much as other countries that insure all of their people, so there is enough money already in the health care system to provide decent care to all Americans--but only if we impose major changes on that system. This truth is not lost on the health and insurance industries, whose political spending during the last election outstripped that of any other lobby.

In other words, this battle for social justice is like all others: Those who benefit from inequities in the current system will not willingly accede to change. Hence the urgent need for strong public insistence upon real reform.

IF THE POLITICS of health reform are straightforward enough, so too are the moral choices we now confront. The central question we must answer is whether to treat health care as other industrialized nations do, as a human right. Or will our national policy continue to regard health care, first and foremost, as a lucrative business?

To most people, the answer is not difficult. But for elected officials, buffeted by the demands of health industry lobbyists, it is painfully hard. To a great extent, the seeming complexity of the current debate is a function of politicians' need to obscure their dilemma by blurring the basic moral choices.

Although there are scores of different health reform proposals in circulation, almost all are variants of one of the two major approaches around which the reform debate now centers: "single payer" vs. "managed competition." The easiest way to understand them is to recognize that they proceed from very different assumptions about the nature of the health care crisis.

Single payer assumes that health care does not respond to the discipline of markets, because sick consumers lack the power to bargain for the care upon which their health, and even lives, may depend. Therefore government intervention is necessary to prevent profiteering and to protect the public, in the same way that utilities which provide other necessities of life have long been publicly regulated. As in Canada, private insurers are all but eliminated. Government becomes the single purchaser of all health services, offering the same health benefits to all citizens and controlling costs through the imposition of overall health spending limits or "global budgets."

Managed competition, on the other hand, preserves the philosophical cornerstone of the current system by treating health care, first and foremost, as a business. Managed competition's underlying assumption is that much of the blame for the current crisis belongs to the public. The rhetoric of managed competition smacks of victim-blaming: The sick are seen as wasteful in their consumption of health services because they do not shop for lower-cost care.

Proceeding from this premise, managed competition calls for the establishment of large brokers, called Health Insurance Purchasing Cooperatives (HIPCs). HIPCs would make purchasing decisions on consumers' behalf and use financial incentives and sanctions to manage the consumer's use of health services. Health care providers would band together in competing managed care networks, which would become more efficient as a result of having to bargain with more sophisticated purchasing agents.

For all its support from doctrinaire free-market advocates, managed competition has several serious deficiencies. It is an untested theory whose ability actually to contain costs is questioned by the Congressional Budget Office and others. What's worse, there is no guarantee of universal insurance coverage. To work properly, the original theory of managed competition depends upon universal insurance coverage, but congressional conservatives have dropped that feature from their proposal.

It is doubtful that the theory can work at all in rural states, which lack enough providers to establish competitive networks. Managed competition would continue the link between insurance status and employment--to the disadvantage of minorities, women, and others who face discrimination in the labor market. Finally, managed competition is enormously complex and perpetuates the costly administrative overhead of the private insurance system.

Despite all these technical drawbacks, managed competition has some commanding political advantages. President Clinton has endorsed the concept, as have the major business, health care, and insurance industry lobbies. It is nearly a given that whatever reforms are finally enacted, they will be described by the amorphous title "managed competition."

FACED WITH THESE political realities, there is a division among health advocates. Some insist that the clear superiority of the single payer approach compels us to argue for its adoption and to accept no substitutes. Others argue that single payer is politically impossible. We must relinquish it, they say, and concentrate instead on trying to influence the shape of whatever proposal is ultimately enacted. To historians of American social policy, who recall that previous efforts at health reform foundered on just such disputes among would-be reformers, the present conflict is troubling.

A path out of this quandary seems to be taking shape. Many advocacy organizations are avoiding the jargon of health policy altogether in recognition of the fact that most Americans have little understanding of, and less interest in, the nuances of single payer vs. managed competition, HIPCs vs. global budgeting. These advocates recognize that managed competition can, with sufficient grassroots support, be modified to achieve the fundamental goals of reform. They have formulated generic principals that any true reform must embody, whatever it may be called. Those principals are simple, and they focus on the major moral choices that our nation must make:

• Health care is a human right. Therefore, universal coverage is a must. Such coverage must be phased in promptly, lest there be an erosion of political support for reform and so that costs can be more effectively managed.
• Cost controls must be assured. Without them, any expansion of coverage is unsustainable.
• Everyone must share the same health benefits. The disadvantaged must not be segregated, as they are in the current Medicaid program, in a public plan vulnerable to political attack and provider discrimination. If there are to be competing health plans, all Americans must have the ability to choose from among them.
• Coverage must be comprehensive. It must include essential services now missing from most insurance plans. Most notably, this would include long-term care, with an emphasis on home and community services.

Administration must be open and accountable to the public.

Announcement of the Clinton administration's proposals begins a debate that now moves to Congress. The campaign for health reform must also be carried to each state, since state governments will make critical choices about how any federally mandated reforms are to be implemented. Achievement of health justice will require the sustained support of all Americans who yearn for a more just society.

Gordon Bonnyman worked with uninsured and underinsured people through the legal aid office in Nashville, Tennessee and was the author of "Moral Malpractice: Behind America's Health Care Crisis" when this article appeared.