The Ethics of Universal Health Insurance 0190946830, 9780190946838

Table of contents :
Cover
The Ethics of  Universal Health Insurance
Copyright
Dedication
Contents
Acknowledgments
Note on Sources
Introduction
ONE Information about Health Care Systems
TWO The Ethical Issues Raised in Health Care Debates
THREE Personal Cost
FOUR Efficacy
FIVE Fiscal Issues
SIX The Case for Universal Health Insurance
SEVEN Beyond Health Care
References
Index

Citation preview

THE ETHICS OF UNIVERSAL HEALTH INSURANCE

THE ETHICS OF  UNIVERSAL HEALTH INSURANCE

ALEX RAJCZI

1

1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2019 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-​in-​Publication Data Names: Rajczi, Alex, author. Title: The ethics of universal health insurance / Alex Rajczi. Description: New York : Oxford University Press, 2019. | Includes bibliographical references and index. Identifiers: LCCN 2018052565 (print) | LCCN 2019005831 (ebook) | ISBN 9780190946845 (updf) | ISBN 9780190946852 (epub) | ISBN 9780190946869 (Online Content) | ISBN 9780190946838 (cloth : alk. paper) Subjects: LCSH: National health insurance. | Health insurance—Moral and ethical aspects. Classification: LCC RA412 (ebook) | LCC RA412 .R35 2019 (print) | DDC 368.4/2—dc23 LC record available at https://lccn.loc.gov/2018052565 9 8 7 6 5 4 3 2 1 Printed by Sheridan Books, Inc., United States of America

For my mother, my father, and my wife

It is only common sense to recognize that the great bulk of Americans, whether Republican or Democrat, face many common problems and agree on a number of basic objectives. —​D w i g h t D .   E i s e n h o w e r

CONTENTS

Acknowledgments Note on Sources Introduction ONE Information about Health Care Systems TWO The Ethical Issues Raised in Health Care Debates THREE Personal Cost FOUR Efficacy FIVE Fiscal Issues SIX The Case for Universal Health Insurance SEVEN Beyond Health Care References Index

ix xiii 1 6 54 81 166 210 233 248 297 323

ACKNOWLEDGMENTS

This book is not the work of one person, but of many. I am indebted to many colleagues and students at UCLA, Cal State Long Beach, Bowdoin College, the National Institutes of Health, and Claremont McKenna College, where I’ve taught for 15  years. I am grateful for the opportunity to serve on the ethics committees of three hospitals: Kaiser Fontana, Kaiser Ontario, and the University of California, Irvine. Many friends outside academia offered support without knowing it; they provided me with the life away from work that is so important to working well. And of course I am indebted to my family, both Rajczis and Sabeans, for providing that safe harbor without which a flourishing human life would simply be impossible. I owe special thanks to certain people. Some helped spark the ideas in this book or offered their insights on some or all of the manuscript: David Adams, Alex Aznar, Amy Berg, Michael Botta, Mike Diaz, Michael Green, Paul Hurley, Paul Menzel, Allison Scott, Bob Shapiro, Jon Shields, Paul Snell, Sara Stern, Laura Sucheski, Peter Thielke, and Jonathan Wolff. A few spent a truly heroic amount of time on the book, including Cory Davia, John Farrell, Frank Menetrez, and several anonymous

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reviewers. I owe a special debt to my research assistant, Jessica Williams, now a professor at the University of Kansas. Jessica had the thankless task of reading a 180-​page manuscript by a philosopher and rooting out all his factual errors about health economics, and her contribution was enormous. I  regret that I held onto the manuscript for years after Jessica and I worked together, and so I had to write about the most recent developments in health policy on my own. If there is a factual error in this book, you can be sure the fault is mine and not hers. What you don’t see are all the mistakes I would have made without her help. Once a manuscript is written it must be prepared and guided through publication. I thank my research assistant Amy Berg, now a professor of philosophy, for many hours of help readying the manuscript for submission to publishers. I offer my thanks as well to the many professionals at Oxford University Press, including my editor, Peter Ohlin. The publication of this book has made me think back on those philosophical heroes who inspired me to love philosophy in the first place. And so, at the risk of sounding grandiose, I want to acknowledge my debt to John Stuart Mill, Bertrand Russell, and Ludwig Wittgenstein. Later, after these figures inspired me to study philosophy, many people supported me as my career unfolded. I’m grateful to my mentors and colleagues at the Department of Bioethics at the National Institutes of Health, who started me on a research path that has led, after 15  years, to this book. I’m grateful as well to the people who gave their time and effort to support my professional career, including the late John Arras, Dan Brock, Zeke Emanuel, Nir Eyal, Aaron Kheriaty, Paul Menzel, Mathew Pauley, Dave Wendler, Dan Wikler, and Debby and Ken Novack. Jon Shields helped me stay the course. Helena de Bres has been a sympathetic soul within the world of philosophy. John Farrell has been an inspiration and good friend for 15 years.

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The philosopher Gilbert Ryle once said that appreciating the difference between right and wrong involves an inculcated caring, a learned habit of taking certain sorts of things seriously. I have tried my best to embody that kind of caring in this book, and to whatever extent I’ve been successful, it is because of the lessons in love, duty, and perseverance given to me, so generously, by my beloved parents. Finally, I thank my wife, Emma Sabean. She has been my greatest supporter and tireless editor, and I’ve benefited immeasurably from her unpublished works about John Stuart Mill, her unfailing conscience, and her philosophical insights about the ethics of health care. This book belongs to her as well. She is in part the author of all that is best within it.

NOTE ON SOURCES

This book builds upon my previous work, and I  thank several publishers for granting permission to reprint or rework substantial portions of the original publications. John Wiley and Sons permitted use of material from “A Critique of the Innovation Argument Against a National Health Program,” Bioethics, vol. 21, no.  6, July 2007, pp.  316–​323. Taylor and Francis Group LLC Books permitted use of material from “Fiscal Objections to Expanded Health Coverage: A Case Study of the ACA,” which was first printed in The Affordable Care Act Decision: Philosophical and Legal Implications, 2014, edited by Allhoff and Hall, pp. 195–​208. Material from “Wait Times and National Health Policy” was reproduced from the Journal of Medical Ethics, vol. 40, pp. 632–​635, 2014, with permission from BMJ Publishing Group Ltd. “Moral Transformation and Duties of Beneficence” was first published in Sophia, and material and ideas are reprinted by permission from RightsLink Permissions Springer Customer Service Centre GmbH:  Springer Nature, Sophia, 2017, advance online publication, June 23, 2017, (doi. org/​10.1007/​s11841-​017-​0596-​7). Material in the final chapter was first published in “What Is the Conservative Point of View about Distributive Justice?,” Public Affairs Quarterly, vol. 28, no. 4, October 2014, pp. 341–​373.

 INTRODUCTION

A UNIVERSAL HEALTH INSURANCE SYSTEM guarantees that

all citizens will have a reasonable way to obtain health insurance and therefore a certain social minimum of health care. The United States doesn’t have universal health insurance, and that has serious effects. Before the Patient Protection and Affordable Care Act (ACA) became law in 2010, millions of hard-​working Americans lacked health insurance, and as a result tens of thousands suffered and died every year. Even with the ACA in place, millions still lack insurance and thousands continue to die. These facts make a strong case for universal health insurance, but many people see reasons to be skeptical as well. Some Americans worry that universal health insurance will balloon the national debt and create excessive fiscal risk. Other people worry that a particular system asks too much of them, perhaps by increasing their taxes too far or by rendering health insurance unaffordable for them and their families. Still others worry that the ACA or some other system is simply poorly designed—​ inefficacious, unnecessary, or even counterproductive. This book examines these three objections to universal health insurance. I  find that the ethical principles underlying these concerns are legitimate, and that they might justify opposition to certain poorly designed universal health insurance systems. However, I argue that these principles don’t justify opposition to the many well-​designed systems that America might adopt. Addressing these objections is important for two reasons.

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One is that they are philosophically rich and interesting, and so exploring them leads to philosophical insights about the ethics of health care. In addition, these issues are some of the principal drivers of actual disagreement about health policy. By responding to these objections, we contribute to the real-​world case for universal access to health insurance. Though this book focuses on the health care debate in America, the points made here have larger import. Examining the American health care debate helps us understand the philosophies that motivate progressives and conservatives and lead them to disagree about social minimum policies. That in turn helps us pinpoint new ways to move forward any debate about the social minimum, including debates about goods other than health care and debates about social minimum policies in other countries.

OUTLINE Chapter one presents some key factual information on health systems. I  describe the American system before and after the ACA. I  also describe single-​payer systems and the regulated-​ market systems used in countries such as Switzerland and the Netherlands. Later chapters will discuss whether it is reasonable to reject universal health insurance on the grounds that it is inefficacious, fiscally risky, or excessively burdensome on those who fund the system. I  focus on these issues because I  think they are of serious philosophical interest, but chapter two argues that these same issues also drive many real-​world disagreements about health care in America. If that is right, then by refuting objections grounded in efficacy, fiscal risk, and personal cost, we not only engage with issues of pure philosophical interest but also help advance the real-​world case for expanded health insurance coverage in America.

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With that preparation behind us, chapter three explores the issue of personal cost. I argue that well-​designed universal health insurance systems do not impose excessive personal costs on those who support them. Furthermore, even if some systems did impose excessive personal costs, that would not justify opposition to universal health insurance, since we can instead support universal access systems that impose lower burdens on supporters. Chapter four takes up issues of efficacy, focusing on the objections that universal health insurance doesn’t promote overall health, stifles important innovation, and creates burdensome waiting lists. I argue that the first objection can be refuted with empirical data and that the second and third objections can be refuted using a combination of empirical data and philosophical analysis. Chapter five focuses on fiscal risk. I find that a few critics, with atypical views about health economics, might reasonably oppose systems like the ACA on the ground that, in the view of the critics, they create excessive fiscal risk. However, I  show that this is not a reasonable opinion for most people to hold and, more importantly, that well-​designed universal health insurance systems don’t create fiscal risk that is morally problematic. Chapter six pulls together the arguments of the previous chapters, explaining how they help advance the overall case for universal health insurance. Chapter seven then lifts off from the work on health care and develops a picture of the conservative point of view about distributive justice and a contrasting picture of the progressive point of view. Having those frameworks helps us understand why adherents of these views—​in America or elsewhere—​often disagree about social minimum policies. It also allows us to identify areas for future philosophical research that could help resolve the disagreements between conservatives and progressives.

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One thing of note is that, in this book, I do not take up the question of whether an ideally just society should have a social minimum in health care and instead simply presuppose that it should. For the most part I will also not take up the question of what exactly goes into that social minimum. I have made these methodological choices because the grounds for a social minimum in health care and other basic goods have already been thoroughly covered by others, including such egalitarian philosophers as Rawls, Dworkin, Nagel, and Waldron, as well as those exploring a more neutral or even “conservative” case for universal health case, such as Allan Buchanan and Paul Menzel.1 My goal is to show that even if we presume that an ideally just society should have a social minimum in health care, we still face philosophically interesting questions about whether people can reasonably oppose particular extensions of the health care social minimum on the ground that those extensions create problems of fiscal risk, inefficacy, or personal cost. These questions are underdiscussed in current philosophical writings, and since they also help drive the real-​world debate over health care, answering them allows philosophers to address philosophically rich issues while also advancing the public case for universal health insurance.

A N O T E O N   D ATA A N D   C I TAT I O N Once we begin probing issues of fiscal risk, efficacy, and personal cost, we’ll see that we cannot sensibly evaluate the merits of universal health insurance without incorporating data about health care systems. I’ll fully embrace that fact, and I ask readers’ understanding as I  lay out data about health care in the first two chapters, turning to philosophical analysis only after that 1. See, e.g., Buchanan’s “The Right to a Decent Minimum of Health Care” and Menzel’s “The Cultural Moral Right to a Basic Minimum of Accessible Health Care,” as well as his article with Donald W. Light titled “A Conservative Case for Universal Access to Health Care.”

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factual work is done. I hope that by the end of the book, it will be clear that this factual grounding pays off. Having it will allow us to conclude not merely that America should have universal health insurance if certain factual assumptions turn out to be true, but that we should have it period. When putting forward factual claims about health care, either in the text or in the footnotes, I’ve followed several rules. One is that at certain points I  extrapolate from existing data, and the extrapolations are often rough. To avoid looking inept, I was tempted to stop each time and say to the reader, This is a rough extrapolation, but that makes for cumbersome writing. I always try to make reasonable extrapolations, and I also trust my readers to notice and evaluate them. In addition, readers should note that numbers are frequently rounded when the rounding makes no difference to the points made in this book. To make the prose smoother, the rounded figures are often not qualified with hedge words like “about” or “approximately.” The citations contain precise figures. Some data is deliberately from past years—​e.g., data about the state of the American health system before the Affordable Care Act. Other facts were up to date when I wrote the manuscript, but since there is a constant flow of new health care data, some information will no doubt be out of date by the time readers engage with this book. I  encourage everyone to seek out the latest information, but it’s also important to note that, barring some major changes to the U.S. health system, the basic facts do not change much year to year, and those smaller changes do not impact the arguments I  offer for universal health insurance. For instance, I  doubt very much that the moral case for or against universal health insurance depends on the exact number of people suffering and dying from lack of health insurance each year. Instead, the key point is that the number is very large, and my goal is to explain why facts like that matter enough that every country should ensure that all citizens have a reasonable way to obtain health insurance.

Chapter One

INFORMATION ABOUT HEALTH CARE SYSTEMS

WE CANNOT DEBATE THE MERITS of different health sys-

tems without knowing how they work, so this chapter provides factual background. I begin by describing the American health care system before and after the 2010 Patient Protection and Affordable Care Act (ACA). After that I describe some of the health systems used around the world, focusing on two major options:  the single-​payer system used in Canada and the regulated-​market systems used in the Netherlands and Switzerland.1 This chapter also describes several proposals for enacting single-​ payer and regulated-​ market systems in the United States.

1. Probably the best introduction to worldwide health systems is T. R. Reid’s The Healing of America. (Reid also produced a Frontline documentary about worldwide health systems called “Sick around the World,” and at present it can be viewed for free on the internet.) Reid’s book is engaging in the way a popular book should be, and its only drawbacks are that it covers only select systems and that it largely narrates Reid’s particular observations rather than outlining how foreign health systems work in general. For more technical discussions, I recommend the chapter on international health systems in Bodenheimer and Grumbach, Understanding Health Policy; the chapter on health systems from Rice and Unruh, The Economics of Health Reconsidered; and the overviews of health systems available online from the Commonwealth Fund’s International Health Policy Center.

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A note on terminology: This book will focus on health systems which guarantee that all citizens have a reasonable way to obtain some robust level of health insurance, which is, of course, a means to health care. I’ll refer to such systems as universal health insurance systems, universal access systems, and universal health insurance. By ensuring reasonable access to health insurance, these plans are establishing what I’ll call a social minimum or safety net in health insurance and health care. I’ll refer to the ACA as a quasi-​universal system, since it aimed for something close to universal access, though it has fallen far short of achieving it.

T H E A M E R I C A N H E A LT H S Y S T E M BEFORE THE ACA Let’s start with the U.S. system as it existed before the ACA. Table 1.1 shows the sources of American health insurance in 2006.

Table 1.1

SOURCES OF INSURANCE IN 2006 Source

Number

Employment-​based insurance Uninsured Medicare Medicaid and SCHIP Individually purchased private insurance CHAMPUS, VA, military

51%, or 154 million people 15%, or 47 million people 14%, or 43 million people 13%, or 38 million people 5%, or 15 million people 1%, or 3 million people

Source: Data from Bodenheimer and Grumbach, Understanding Health Policy, p. 18.

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Medicare is the government program that covers almost everyone over age 65, although it covers some under 65 too.2 It does not cover all seniors because standard benefits are available only to those who pay into the Social Security system for 10 years, as well as their spouses, though those not covered by the standard benefits can buy in. To understand Medicare’s structure, think about how most health transactions work. Three parties are involved:  you pay your insurance company, your insurance company pays the doctor, and your doctor provides you with health services. Under Medicare, the government takes on the role of insurer, and the other two parties, you and your doctor, stay the same. (The government does not employ special “Medicare doctors.”) Medicare is essentially a government-​run insurance plan. Medicare beneficiaries sometimes believe that they get back only what they paid in, but that’s not so, for several reasons. First, like all insurance beneficiaries, Medicare recipients who use many services are subsidized by those who use fewer. Second, the benefits collected by Medicare recipients usually exceed their own past contributions.3 Third, Medicare has always been a “pay-​as-​you-​go” program—​or, if we want to be precise, a “you-​pay-​as-​I-​go” program. Younger workers fund the benefits received by older beneficiaries. When younger workers retire, their benefits will be paid by still-​younger workers, and so on. Medicare has several “parts.” Part A  covers hospitalization, temporary visits to nursing homes, and hospice care. Part B covers physician services. Part D covers prescription drugs. This coverage seems expansive, but a 2002 study showed that Medicare covers only 45% of the average beneficiary’s health 2.  For eligibility restrictions, see the Medicare, “Eligibility and Premium Calculator.” 3.  Steuerle and Rennane, “Social Security and Medicare Taxes and Benefits Over a Lifetime.”

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expenses.4 Medicare part C is an alternative form of insurance. Individuals can opt out of traditional Medicare and enroll in part C plans, known as Medicare Advantage Plans. Though still funded by the government, those plans are administered by private companies and provide benefits similar to those offered in parts A and B, and often D as well. Like Medicare, Medicaid is a government-​run insurance plan. Before the ACA, it was not aimed at all low-​income people; instead it primarily targeted low-​income children and pregnant women, though states could elect to cover more people if they chose.5 The federal guidelines before the ACA required states to cover: 1. Children younger than age 6 and pregnant women whose family income was at or below 133% of the federal poverty line (FPL). (In 2008, FPL was $21,200 for a family of four and $10,400 for a family of one.)6 2. Children 6 to 18 years old whose family income was at or below FPL. Medicaid also had to cover some low-​income parents: 3. Parents whose incomes were below states’ July 1996 welfare eligibility levels (often below 50% FPL).

4. Bodenheimer and Grumbach, Understanding Health Policy, p. 10. 5. Bodenheimer and Grumbach, Understanding Health Policy, p. 12. 6. United States, Department of Health and Human Services, “The 2008 HHS Poverty Guidelines.”

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And the program had to cover some other adults: 4. Most of the elderly, disabled, and blind people who were also covered by the federal Supplemental Security Income (SSI) program, a program intended to cover individuals with low income. Most of the low-​income individuals covered by Medicaid were in working families without access to employer-​based health insurance and who could not afford insurance on the private market.7 Absent a federal waiver, state Medicaid programs had to cover hospital services, physician services, laboratory work, X-​rays, prenatal care, preventive care, nursing home stays, and home health care. Coverage varied substantially between states. Drug coverage was optional but offered by all states to varying degrees. The State Children’s Health Insurance Program, or SCHIP, is similar to Medicaid.8 It covered uninsured children in families with incomes at or below 200% of the federal poverty level. Note three things about pre-​ACA Medicaid. First, states didn’t have to cover most adults without children. Since Medicare doesn’t cover most people under age 65 either, many uninsured people were not covered by any government program, even if they were very poor. Second, the income limits were low, even for adults with children. Thus many adults with children were not covered even if they were very poor. Third, Medicare didn’t (and still doesn’t) cover long-​term care, so Medicaid is the primary source of government-​sponsored long-​term care coverage

7. Kaiser Commission on Medicaid and the Uninsured, “Medicaid: A Primer, 2010,” p. 7. 8. Bodenheimer and Grumbach, Understanding Health Policy, p. 13.

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for the elderly. One of every six Medicare beneficiaries was eligible for Medicaid as well.9 The Veterans Administration system and CHAMPUS (a health insurance program for veterans) are a very small portion of U.S. health care, so I won’t discuss them in detail. Before leaving public programs, though, note how expansive they were even before the ACA. Americans sometimes think we have a private-​market health system, but the 84 million beneficiaries of Medicare, Medicaid, and veterans’ health programs—​28% of the population—​were clearly and directly getting their health insurance (though not their health care) from the government. This included almost everyone over age 65.10 Employment-​ based insurance covered 154  million Americans, or 51% of the population. Only about 60% of employers offered health coverage,11 and employees almost always paid part of the premiums. (That is, they paid part of the premiums directly, and for reasons I’ll discuss later on, most economists believe that the additional “employer contribution” is ultimately deducted from employee wages, so really employees are paying the whole cost of “employment-​based” insurance.) Employers frequently offered only one insurance plan. Estimates vary, showing that between 42% and 60% of employees had no choice in plan.12 A study by the Center for

9. Kaiser Commission on Medicaid and the Uninsured, “Medicaid: A Primer, 2010,” p. 10. 10.  And these figures are an undercount. The U.S.  government offers tax subsidies for the employment-​ based insurance received by 154  million Americans. It would take us too far afield to discuss these in detail. The point is that everyone who receives insurance through their employer has their health insurance partially subsidized. 11. Kaiser Family Foundation, “Employer Health Benefits: 2009 Summary of Findings.” 12. Trude, “Who Has a Choice of Health Plans?”

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Studying Health System Change (HSC) used the most generous methodology I  know of. Even if employees were offered only one choice by their own employer, the HSC counted them as having “choice” so long as their spouse was offered a different plan that the employee could sign up for. (Notably, the HSC did not try to determine whether signing up was affordable.) Even using this methodology, employees had no choice 36% of the time.13 The government offers tax subsidies for employment-​ based insurance, so people with employment-​based insurance are receiving subsidies, even though most don’t realize it. Fifteen million Americans purchased health insurance on their own, about 5% of the population. Notably, these people weren’t receiving the government tax subsidy, so if two people bought identical policies, the one who bought through the employer paid less than the person who bought on the private market. Finally, consider the uninsured. Political debates prior to the ACA often focused on the standard figure of 47 million uninsured. This number was and is controversial, so we should discuss it in detail.

The Uninsured One reason that estimates of uninsurance vary is that they use different definitions of “uninsured.” For people to count, must they lack insurance the whole year? For a month? A day? There are also questions about what counts as “insurance.” If people have bare-​bones plans that cover nothing but $50 per day for hospitalization, with no coverage for physician services, are they “insured”? 13. Trude, “Who Has a Choice of Health Plans?” For information on choice of plan type, see Kaiser Family Foundation, “Employer Health Benefits: 2009 Annual Survey.”

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The standard figure of 47  million uninsured used in pre-​ ACA debates came from the Census Bureau. Specifically, it came from the Annual Social and Economic Supplement (AESC) to the Current Population Survey (CPS). The CPS tried to measure the number that lack insurance for the entire year. However, after studying problems with the survey, the Congressional Budget Office (CBO) concluded that the CPS probably reflected the number that lacked insurance at any given point in the year.14 The CBO also estimated that in 1998 and 1999, 53% to 78% of the uninsured were uninsured for the whole year. Applied to the 2006 numbers above, this implies that between 25 million and 37 million Americans lacked health insurance for the entire year. The rest, between 10 million and 22 million, were uninsured for only some part of the year. (Estimates from the Centers for Disease Control [CDC] are similar. The CDC found 49.1 million uninsured in the U.S. at the time of their 2010 survey. Of those, 35.6 million, or 72%, had been uninsured for the entire year previous to the survey.)15 There are other controversies about the Census number. Some think it’s an undercount. If our goal is to provide citizens with reasonable access to health care, maybe we should look at how many were uninsured at any point in time during a single year. A  2003 CBO report found that using this criterion, the numbers of uninsured rose by between 42% and 48%. Applied to our 2006 figures above, this implies that the number who lacked insurance at some point during 2006 would be between 67 million and 70 million, or between 22% and 23% of the population.

14.  United States, Congressional Budget Office, “How Many People Lack Health Insurance and For How Long?” 15. Cohen, Ward, and Schiller, “Health Insurance Coverage.”

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(Again, CDC estimates from 2010 showed similar results. They found that 60 million people, about 20% of the population, lacked insurance at some point during the year prior to their survey.)16 These numbers might still undercount. If our goal is to ensure that citizens have access to health care throughout their lives, we should count all people who lacked insurance at some point during their lifetime. That number is surely much bigger, but I don’t know of any studies that try to estimate it. So the Census undercounts, but some people also believe it overcounts in several ways. First, some of the uninsured probably qualified for existing government programs but were not signed up. Estimates vary; one estimate on the high end is that before the ACA, 12 million of the standard 47 million uninsured qualified for existing programs.17 To be generous to opponents of health reform, we could grant this high estimate and assume there were only 35  million not covered by any program. (But note that if 12 million people qualified for existing programs and didn’t know or didn’t sign up, this was itself a problem with our policies. We can’t simply ignore it.)18 Moreover, some of the uninsured might have been able to afford insurance but didn’t buy it. Exact figures are difficult to find. A 2000 Kaiser Family Foundation study found that only 3% of the uninsured said they did not want or need insurance.19 16. Cohen, Ward, and Schiller, “Health Insurance Coverage.” 17.  National Institute for Health Care Management, “Understanding the Uninsured.” Cf. Dubay, Holahan, and Cook, “The Uninsured and the Affordability of Health Insurance Coverage.” 18. We should note, though, that people who are already eligible may sometimes, de facto, have coverage to some extent. That is true because when these people seek treatment, providers may sign them up for the relevant program. 19.  A  much higher estimate is given in Bundorf and Pauly, “Is Health Insurance Affordable for the Uninsured?,” which finds that health insurance

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Thus we could remove 1.5 million people from our last figure, for a running total of 33.5 million uninsured. A final complication is that about 10 million of the uninsured reported that they were not citizens. The Census Bureau doesn’t tabulate how many were in America legally or illegally; the best estimate for the time we are considering was that 6 million were in America illegally and 4 million legally.20 Some people might feel that a social minimum need not cover even legal immigrants, so they would deduct another 10 million from our running total. Again, I’ll grant this deduction for argument’s sake. Strikingly, even with the largest reasonable deductions from the 47 million figure, and even though we’re using the 47 million figure rather than the more relevant 67 million to 70 million figure (those lacking continuous health insurance throughout a year), there were still 23.5 million uninsured Americans before the ACA, or 8% of the population. On any reasonable definition, a large number of Americans lacked insurance. It’s worth covering one other factual issue: Why did people lack insurance? Were they largely able-​bodied people who refused to work—​maybe even undeserving of help? No. First, remember that in 2009, 8.1 million of the uninsured were children. Second, considering both adults and children, two-​thirds were from families with one or more full-​time workers.21 The number remains the same even if we focus only on uninsured adults with low income.22

was affordable for between 25% and 75% of the uninsured. For criticism of that estimate, see Bradley, “Comment.” 20.  Extrapolated from Passel and Cohn, “A Portrait of Unauthorized Immigrants in the United States.” Cf. National Institute for Health Care Management, “Understanding the Uninsured.” 21. Kaiser Family Foundation, “The Uninsured: A Primer, 2009,” p. 4. 22. Holahan and Brennan, “Who Are the Adult Uninsured?”

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Moreover, demographic breakdowns show that uninsurance correlated with factors that have little to do with whether a person is deserving.23 Unmarried people were more likely to be uninsured than married people, partly because a spouse provides an increased chance of getting medical benefits through the spouse’s employer. Nonwhites were more likely to be uninsured than whites. Men were more likely to be uninsured than women. Southerners were more likely to be uninsured than people in New England. And employees of small firms were more likely to be uninsured than employees of large firms. These facts suggest that uninsurance is not always a matter of deservingness but often is the result of extraneous factors. More generally, the structure of the U.S. system before the ACA allowed factors other than effort to affect insurance status. Only larger firms typically offered employer-​based coverage, and if people worked for a smaller firm or were self-​employed, they might not have had access to a group plan. They might also have been priced out of the private market. The median household income in America in 2010 was about $50,000, before taxes, and yet a 2010 survey found that the average cost of a family plan purchased privately was about $7,100, with an average of about $2,700 in additional out-​of-​pocket costs.24 Premiums would have been even higher for people with serious medical conditions, because prior to the ACA, insurers could charge more to insure sick people.

23.  All following from Committee on the Consequences of Uninsurance, Coverage Matters, pp. 67ff. On defining “deserving,” see p. 39 and surrounding of Cook and Barrett, Support for the American Welfare State. I discuss the notion in a later chapter as well. 24. Kaiser Family Foundation, “Survey of People Who Purchase Their Own Insurance,” p. 4.

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T H E A F F O R DA B L E C A R E   AC T Now let’s turn to the ACA. I’ll begin with an overview of the legislation, and after that we’ll discuss its current effects. Health reforms can aim at quality of care, cost of care, or extent of coverage. Parts of the ACA were intended to control costs and improve quality. The cost and quality improvements were important and probably received too little attention. However, since this book focuses on the ethics of coverage, I’ll concentrate on the ACA’s plan for reducing uninsurance.25 The bill placed an “individual mandate” on all Americans. The media slightly misrepresented this mandate and continues to do so. Reporters often say that Americans were required to buy health insurance, but that’s not right. If people didn’t want to buy insurance, they did not have to, but in that case they had to pay a financial penalty. The mandate was eliminated in 2017, but at the time of the ACA’s passage, it was hoped that the mandate might decrease uninsurance all by itself, because it might lead people who were voluntarily uninsured to purchase health coverage. However, most uninsured people couldn’t afford insurance, so the ACA tried to make coverage accessible in several ways. First, the ACA required employers with more than 50 employees to either offer health insurance or pay a financial penalty, and it offered tax credits to businesses with 25 employees or fewer. The hope was that both provisions would lead more businesses to begin offering insurance and therefore decrease uninsurance, though even at the time of passage, the CBO projected small effects, and some analysts projected that the ACA

25. One overview is found in Kaiser Family Foundation, “Summary of New Health Reform Law.”

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would actually lead to a net reduction in employer-​sponsored insurance.26 Second, the ACA proposed expanding Medicaid to cover all people who are not eligible for Medicare and live below 133% of the federal poverty line (FPL). This was a significant alteration: Medicaid would no longer target specific groups only; instead the plan was to make it a general program for people with very low income. Importantly, the Medicaid provision changed as a result of the Supreme Court decision in National Federation of Independent Business v. Sebelius.27 The ACA strongly encouraged states to expand Medicaid by denying them all Medicaid funds unless they complied with the requirements of the expansion. However, the Supreme Court ruled that this was unconstitutional, allowing states to opt in or out of the Medicaid expansion. In early 2018, 33 states and the District of Columbia had expanded Medicaid, while 17 states had not.28 Third, the bill established insurance exchanges. Exchanges are marketplaces where insurers sell their product to individual consumers. They are not physical marketplaces, of course; instead states disseminated the information via paper documents and websites. These marketplaces are regulated in order to make insurance more accessible and comprehensive. Companies selling in the exchanges must offer minimum levels of coverage, provide information on the quality of their plans, and offer insurance to anyone regardless of health status. Though companies may charge more for insurance offered to individuals 26. The Lewin Group’s estimates are among the most dire; see, e.g., “Patient Protection and Affordable Care Act (PPACA).” 27. The following details are from Kaiser Family Foundation, “Focus on Health Reform:  A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion.” 28.  Kaiser Family Foundation, “Status of State Action on the Medicaid Expansion Decision.”

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who present greater health (and thus cost) risks, there are limits. The exchanges are open only to individuals and to businesses with fewer than 100 employees. People living at between 133% and 400% of the federal poverty level may receive subsidies to offset some of their premiums. The hope was that these provisions would combine to make insurance more affordable and thus decrease the number of uninsured. Notably, initial analyses of the ACA didn’t predict universal coverage, even if the law had been enacted exactly as written. One good estimate was that 15  million citizens and legal residents would still lack health insurance, 5% of the population.29 Why would these people still lack insurance?30 Some would be eligible for existing programs but wouldn’t sign up. Some would be low-​ income individuals who would have to spend more than 8% of their income on even the cheapest insurance plans and who were therefore excluded from the mandate. Also excluded would be anyone who made too little to file a tax return. (Note that both of those groups might still make too much to qualify for Medicaid under the expansion.) Some would be people who preferred to pay the insurance penalty, including some younger people who didn’t want insurance. After its enactment, the ACA changed the sources and distribution of insurance in the U.S.  population, though not exactly as predicted. In 2018, about 11.8 million people purchased insurance via the exchanges, which is substantial but much

29.  Buettgens and Hall, “Who Will Be Uninsured After Health Insurance Reform?” 30. On this, see United States, Congressional Budget Office, “CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010”; and Buettgens and Hall, “Who Will be Uninsured After Health Insurance Reform?” See as well these popular discussions:  Beaulieu, “CBO Estimates 23 Million Will Remain Uninsured After Health Reform”; and Klein, “Who Is Left Uninsured by the Health-​Care Reform Bill?”

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lower than projected.31 As of 2016, 14 million people obtained insurance through Medicaid as a result of the ACA,32 and about 3 million signed up who were already eligible without the ACA expansion.33 Overall, the standard CPS uninsured rate fell from 14% in 2012 to 8.8% in 2016, though that still meant that about 28 million people were uninsured.34 Anyone uninsured after the ACA would of course continue to experience the problems of uninsurance, including financial and health problems. For instance, a 2002 Institute of Medicine study found that uninsurance led to 18,000 deaths annually when 44 million people were uninsured, or 409 deaths per million.35 Applied to the 28 million uninsured in 2016, one would therefore expect about 11,452 deaths annually. A later, updated study put the pre-​reform death rate at 35,000 deaths per year in 2005, or 745 deaths per million.36 Using that number, one would expect 20,860 deaths annually. Health policy experts

31.  United States, Centers for Medicare and Medicaid Services, “Health Insurance Exchanges 2018 Open Enrollment Period Final Report.” Cf. United States, Centers for Disease Control and Prevention, “Health Insurance Coverage.” The CBO revised its insurance predictions after the Supreme Court decision about the Medicaid provision, but even those were inaccurate: United States, Congressional Budget Office, “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision.” 32. Kaiser Family Foundation, “Medicaid Expansion Enrollment.” 33.  Kaiser Family Foundation, “Medicaid Expansion Enrollment.” This was higher than expected in the CBO projections: United States, Congressional Budget Office, “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision.” 34.  United States, Department of Commerce, Census Bureau, “Health Insurance Coverage in the United States: 2016,” table 1. 35. Committee on the Consequences of Uninsurance, Care Without Coverage, p. 165. 36. Wilper et al., “Health Insurance and Mortality in US Adults,” p. 4.

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still debate these estimates, but even skeptics agree that uninsurance causes extensive physical, mental, and financial suffering.37 The ACA did not eliminate the other problems with the American system.38 As we’ll discuss later, two common problems are inadequate insurance coverage, known as “underinsurance,” and medical bankruptcy. The ACA also does not guarantee that people with good insurance will be able to retain it rather than being forced into lower-​quality insurance plans through changes in employment or other circumstances.

THE LOGIC OF INSURANCE MARKETS The ACA is a complicated law, and some of its complexity is a response to the way insurance markets work. So, to understand the ACA or any other health system, it’s worth knowing about some of the forces at play in those markets.39 Suppose health insurance were sold to individuals the way we sell staplers or coffee mugs, with insurers setting prices as they choose and individuals paying for insurance on their own. In that market, private insurers would of course price their insurance so that they can make a profit, and this would lead them to price the insurance differently for different customers. If the 37. Thus see Kronick, “Health Insurance Coverage and Mortality Revisited.” Kronick is thoroughly skeptical of the IOM’s mortality numbers, but concludes that “there are both good theoretical reasons as well as reasonable evidence to suggest beneficial effects of health insurance” on “morbidity, financial security, mental health, and job lock” (p. 1228). Compare also Levy and Meltzer, “The Impact of Health Insurance on Health,” where the authors suggest that the evidence for a causal connection between uninsurance and mortality is weak, even though it might nonetheless exist. 38. Cf. Kaiser Family Foundation, “Key Facts about the Uninsured Population.” 39. The following description is slightly simplified, but not harmfully so.

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customer was healthy and had only the statistically average chances of becoming sick, then the insurance company could expect a relatively low payout in total benefits for that person. Knowing this, they would still price the insurance so that they can make a profit—​that is, at a level where the price of the plan exceeds their expected payout to the customer—​but even so, the price of the insurance might be low enough that many people could afford it. However, things would be different if an insurance company was considering selling a policy to someone with a costly preexisting condition like ongoing cancer, chronic obstructive pulmonary disease (COPD), or multiple sclerosis, or to someone who had a statistically high chance of becoming seriously ill. In that case, the insurance company could predict, with a high degree of certainty, that they would end up paying out large amounts of money for medical services, possibly hundreds of thousands a year for a certain number of years. They would only sell that insurance at a price greater than the cost of those services, since otherwise they would be losing money. This means that the insurance plan would cost more than most people could pay, and almost all sick or risky patients would be priced out of the market. Some healthy, low-​income people would go without insurance too, simply because they could not even afford the (lower) premiums for healthy individuals. Suppose we want to solve this problem and make sure that all people, including the sick and disabled, can afford to purchase health insurance. One thing we might do is adopt a set of laws mandating two things:  guaranteed issue, which requires that insurance companies sell to anyone who wants insurance, and community rating, which requires insurance companies to either charge everyone the same price for health insurance or at least limit premium variations to affordable levels. The combination of guaranteed issue and

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community rating would seem to make insurance more generally affordable, especially for the sick and disabled, who are normally denied insurance altogether or charged higher than the “community” price. However, the combination of guaranteed issue and community rating would create a new problem. Consider what would happen if we had guaranteed issue and community rating but continued to allow people to buy insurance or not, as they wish. In other words, imagine that we had community rating and guaranteed issue but no health insurance mandate of the sort we find in the ACA. Without a mandate, many healthy people would stop buying insurance, because they would know that when they got sick, they could then buy insurance (because of guaranteed issue) at a normal rate (because of community rating). Then, after the healthy patients dropped out of the insurance market, most people who purchased insurance would be the unhealthy who knew they would need it right away, and the insurance companies would be constantly paying out to those sick customers and taking in very little revenue from healthy ones. The only way the companies could remain solvent would be by increasing premiums for their largely sick customers to high levels. Insurance would become much less affordable again. Once prices begin going up, the few healthy people who still had insurance would have even more reason to stop buying insurance. When they dropped out, that would leave only the sickest patients in the insurance pool. Insurance companies would then have to raise premiums even further to avoid taking a loss. That would lead more people to drop out, and the process iterates. This is known in policy circles as a “death spiral.” The death spiral is not just a conjecture. States that have experimented with community rating and guaranteed issue without a mandate have experienced the problems

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just described.40 One empirical survey of eight such states found that: although results varied widely among the eight states, in general we found that, measured in terms of market size, level of premium, and availability of insurance options, individual health insurance markets deteriorated after the introduction of [guaranteed issue] and [community rating] reforms. Often, insurance companies chose to stop selling individual insurance in the market after reforms were enacted which resulted in a decrease in competition. Enrollment in individual insurance also tended to decrease, and premium rates tended to increase, sometimes dramatically. We also did not observe any significant decreases in the level of uninsured persons following the enactment of these original market reforms.41

The CBO predicts similar results in the U.S. market now that the ACA’s individual mandate has been repealed.42 The way to prevent the problem of the death spiral is by introducing an individual mandate to buy insurance or some other strong incentive to keep people in the insurance market.

40.  For one discussion of states which tried guaranteed issue and community rating without mandate, see Bobroff, “Brief of American Association of People With Disabilities.” On the problems that arise without mandates, see Monheit et  al., “Community Rating and Sustainable Individual Health Insurance Markets in New Jersey”; Cutler and Reber, “Paying for Health Insurance”; and Wachenheim and Leida, “The Impact of Guaranteed Issue and Community Rating on States’ Individual Insurance Markets.” Less scholarly though also interesting, including for their scholarly references, are Meier, “Destroying Insurance Markets”; and Millheiser, “What Happens if the Individual Mandate Is Struck Down?.” 41. Wachenheim and Leida, “The Impact of Guaranteed Issue and Community Rating on States’ Individual Insurance Markets,” p. 4. 42.  United States, Congressional Budget Office, “Repealing the Individual Health Insurance Mandate.”

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With a mandate in place, healthy people cannot drop out of the market and buy insurance only when they need it. That stops the series of events described above. This was one of the fundamental rationales for having a mandate in the ACA. Notice, though, that an individual mandate creates further complications in the insurance market. The reason an individual mandate prevents a death spiral is that, even though insurance companies will still pay out large amounts of benefits to the sick, they will take in premiums from healthy people who do not use health care that year or who use health care that costs less than the amount they paid in premiums. The profits from the healthy population are used to offset the losses on the unhealthy population. For this to work, though, premium levels must be set correctly, so that when everyone pays roughly the same premium (because of community rating), the company takes in enough from the healthy to both offset the losses to the sick and ensure an acceptable profit. The exact level of those premiums will be a function of market forces, but given the distribution of income in America and other industrialized countries, we can easily predict that some people will not be able to afford the insurance premiums, even if they are healthy, since some people simply make too little money to afford a standard insurance policy at any realistic rate.43 Since even a regulated market will not automatically make insurance affordable to low-​income people, it does not totally solve the problem of uninsurance. A  complete solution will 43. Note that in a system with guaranteed issue, community rating, and an individual mandate, the premiums for healthy people will be higher than they would have been in the pure market system we described at the outset. The reason is that in such a system, the insurance companies not only have to make sure that the premiums they take in for a particular healthy patient will offset their expected payout on that person, but also that they get enough extra profit from the healthy subscribers that the profits can help offset the payouts on other, very sick people.

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involve some sort of transfer of resources that makes insurance affordable to low-​income people. For instance, those people can be given subsidies, as in the ACA, or the money can be given directly to insurance companies in exchange for lower premiums. So far we’ve discussed the way in which unregulated markets create problems of uninsurance and the ways in which those problems can and cannot be solved. It’s worth noting a second problem that arises in any insurance system which does not require all people to be insured. In a system with an uninsured population, some of the uninsured will inevitably become sick or injured, and they will not be able to afford treatment on their own. Perhaps they get cancer, or perhaps they are hit by a bus when crossing the street, for instance, and now need an extensive stay in the emergency room, one that costs hundreds of thousands of dollars. The rest of us now face a dilemma. We can let the person go without treatment, which could lead to pain, suffering, and death. Alternatively, we can pay for the treatment. Our reactions to this dilemma might depend on the reasons why the sick and injured people were uninsured. However, some will be uninsured because they lacked the means to pay, and as a result, many of their fellow citizens (though not all) will feel that the sick-​but-​uninsured should not go without treatment, and so we might set in place a minimal safety net to make sure they receive some level of care. In the United States, we have the Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare-​ participating hospitals that offer emergency services to provide treatment for active labor and acute emergency medical conditions that could immediately result in serious impairment to bodily functions or internal organs. The care is not free, but it must be provided regardless of the patient’s ability to pay at the time of service. A minimal safety net such as EMTALA helps those who cannot afford insurance, but it also increases the incentives for people to remain voluntarily uninsured—​that is, uninsured

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even though they could reasonably afford to buy insurance. Why? Because if people know they will receive certain kinds of emergency care no matter what, that increases the temptation to not spend money on insurance. But now imagine that a voluntarily uninsured person ends up with a very expensive stay in the emergency department. Even though EMTALA allows the hospital to bill the patient, the patient might not be able or willing to pay, and so the costs are borne by the rest of us. The voluntarily uninsured patients are free-​riding on the minimal safety net rather than paying for the insurance that they could, by hypothesis, have afforded. The way around this problem is to require everyone to be insured through a mandate or similarly strong incentive. This was in fact the second major rationale for having a mandate in an insurance system like the ACA—​it prevents free-​riding.

A LT E R N AT I V E   S Y S T E M S Single-​Payer in Canada Let’s turn to alternative systems used throughout the world. The first is single-​payer. I’ll focus on Canada’s single-​payer system, which Americans hear so much about, but single-​payer is not exclusive to Canada. Some form of it is used in other countries as well, including Taiwan, South Korea, and the United Kingdom, among others. To understand single-​ payer, recall that most American health transactions involve three parties: you pay premiums to your insurer, your insurer pays your doctor, and your doctor provides you with services. A  single-​payer system still has three separate parties, but it changes one of them. Citizens in

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a single-​payer system do not pay premiums to a private insurance company. Instead they pay taxes or separate health care premiums to the government,44 which then runs an insurance program for all citizens. When you go to the doctor, the government (your insurer) pays the doctor’s bill. Though single-​payer can seem foreign to Americans, it is not very different from our Medicare program, at least if one focuses on traditional Medicare and not the additional options offered through Medicare Advantage plans. Americans pay taxes, and the government provides almost everyone over 65 with a Medicare insurance plan. Older Americans might be surprised to hear it, but most of them use something that is similar in many ways to a Canadian-​style single-​payer system. In some single-​payer systems, such as England’s, the government also employs most of the doctors, and hospitals are publicly owned. But that’s not the type of single-​payer system we’re discussing. Almost every Canadian doctor is in private practice and the vast majority of hospitals are privately run. The government only replaces the private insurance market. American Medicare is once again a helpful comparison. Americans using Medicare do not see “government doctors.” They see private-​practice doctors, and the government is only their insurer. Canada is divided into provinces, which are the rough equivalents of American states. In Canada’s single-​ payer system, the insurers are the provincial governments. Citizens pay taxes to the provinces in a variety of ways (sales taxes, payroll taxes, income taxes), and some additional funding comes from the national government. In return the provinces provide every citizen with health insurance. The coverage varies slightly from province to province, but all plans cover hospital,

44. In Canada, these are the provinces, with some funding coming from national government.

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physician, and ancillary services.45 Some provincial plans also pay for some prescription drugs (especially for people in financial need) and some long-​term care, though coverage varies by province.46 American insurance plans frequently restrict people to a select group of physicians. However, Canadians are eligible to see almost any doctor in the country. In recent years, six of the ten Canadian provinces prohibited private companies from selling insurance for services covered by the government. (Though a court decision in Chaoulli v.  Quebec introduced some complications into that arrangement, which I  will not discuss here.) A  single-​payer system doesn’t need to work that way, but there are two common rationales for forbidding private insurance for covered services. First, excluding private insurance prevents doctors and hospitals from offering preferential treatment to people with better insurance. Instead, since everyone has the same insurance, hospitals and doctors will (in theory) give out services in a fair and sensible way. Second, since all citizens have to use the system, it gives everyone a vested interest in making sure that the system runs well, whereas if all of the powerful citizens were on a separate insurance plan, then they might be tempted to let the public system fall into disrepair. Compare American Medicaid. Medicaid is largely directed at the poor, so middle-​ class voters have no vested interest in making sure the program works well, and we know that Medicaid covers fewer services and is accepted by fewer physicians than the Medicare program used by the middle class. Canadians can buy supplemental insurance for services not in the public plan. This insurance might cover gaps in the public plan or cover amenities such as private hospital rooms. About 45. Bodenheimer and Grumbach, Understanding Health Policy, p. 163. 46. Bodenheimer and Grumbach, Understanding Health Policy, p. 163.

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two-​thirds of Canadians have some form of supplemental insurance. Individuals either purchase it themselves or their employer provides it as a fringe benefit.47

The Regulated-​Market Systems of the Netherlands and Switzerland As an alternative to single-​payer, this book focuses on the Dutch and Swiss universal health insurance systems. They deserve study for several reasons. First, conservatives and Republicans have often advocated “consumer-​driven health care,” and some of its biggest advocates think that the Dutch and Swiss systems are good examples of consumer-​driven care.48 Second, later I will discuss Ezekiel Emanuel and Victor Fuchs’s proposal for American universal health insurance. That system isn’t identical to the Dutch and Swiss systems, but the systems are related and can shed light on each other. Third, Switzerland bears interesting similarities to the United States. The Swiss cantons—​the equivalent of American states—​are quite independent, and the Swiss are generally skeptical of large national programs. The Swiss are also strongly capitalistic, like Americans. Before 1995 Switzerland, like the U.S., had no universal health insurance system, but since then it has made the transition. It’s an interesting model for study. The Dutch and Swiss systems have an individual mandate that requires individuals to either buy insurance or pay a penalty.49 Insurers are private companies, either non-​profit 47. Rice and Unruh, The Economics of Heath Reconsidered, p. 280. 48. Herzlinger and Parsa-​Parsi, “Consumer-​Driven Health Care.” 49.  For a general overview of the Dutch system, see Klazinga, “The Dutch Health Care System.”

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or for-​profit,50 and individuals buy their insurance from those companies rather than receiving insurance from the government. This is an important point; it shows that in some respects, the Swiss and Dutch systems are more market-​based than the U.S. system. Even pre-​ACA, 28% of Americans got their health insurance from the government, but in Switzerland and the Netherlands, there are almost no public programs at all. The Dutch and Swiss rely on private insurers in the hope of fostering competition and thereby improving performance and patient satisfaction. Insurance companies in these countries are regulated. For instance, insurers must accept all applicants and cannot charge more just because a person is sick or likely to become sick.51 Insurers may charge different premiums, and policies may vary in other ways as well. For instance, in Switzerland, insurers may sell policies with a higher deductible and lower premiums, plans with bonuses for no claims, and managed care plans. In the Netherlands, about 50% of total premium payments come from general tax revenues, and the rest come directly from individual payments. In Switzerland, hospital funding comes partly from premiums and partly from governments, with all other funding coming exclusively from individual premium payments. Both countries subsidize premiums for households demonstrating need, and about 40% of households receive the subsidies. Private insurance may also involve cost-​sharing 50. On profit restrictions on the basic package, see Rovner, “In Switzerland, a Health Care Model for America?” 51. The Swiss and Dutch governments undertake risk adjustment to equalize risk across companies. The process is different in the two countries. For a description of how the Dutch undertake risk equalization, see Lynch and Altenburg-​ van den Broek, “The Drawbacks of Dutch-​ Style Health Care Rules,” p. 6.

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through deductibles and coinsurance. Swiss deductibles and coinsurance are notably high—​high enough that they might make it difficult for low-​income individuals to easily access care.52 In the Netherlands deductibles are lower.53 The governments set minimum standards for insurance plans, and the basic plans would seem generous even to Americans with high-​quality American insurance. In the Netherlands, for example, the basic plan must cover all “essential health care,” including GP appointments, hospital care, prescribed specialist care, hospital stays, ambulance services, postnatal care, some prescription drugs, and rehabilitation care such as physical therapy, occupational therapy, and dietary advice.54 Generally speaking, individuals may see almost any doctor in the country, although 22% of the Swiss population voluntarily enrolls in health maintenance organizations (HMOs) that contract only with select physicians and, theoretically, have lower premiums as a result.55 In both countries, many citizens buy supplemental insurance for such things as adult dental care, private hospital rooms, or to ensure choice of physician while hospitalized.56 Swiss coverage for long-​term care is weak, covering 50% of services, although this is still more coverage than most Americans have. 52. Sturny, “The Swiss Health Care System.” 53. See Klazinga, “The Dutch Health Care System,” which points out that out-​ of-​pocket expenditures in the Netherlands totaled only 6% of national health expenditures. 54. Civitas, “The Swiss Healthcare System (2002),” pp. 2–​3. See also Klazinga, “The Dutch Health Care System.” 55.  Radio Télévision Suisse, “Fortes disparités dans le choix des modèles d’assurance maladie.” 56.  Lynch and Altenburg-​van den Broek say 92% of the Dutch purchased supplemental insurance (“The Drawbacks of Dutch-​Style Health Care Rules,” p. 4). See also Klazinga, “The Dutch Health Care System.” Tanner reports that 40% of Swiss purchase supplemental insurance (“The Grass Is Not Always Greener,” p. 27).

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Both countries have low rates of uninsurance; only about 1.5% of the Dutch population and below 1% of the Swiss population are uninsured.57 These numbers include people residing in the countries illegally. Uninsurance rarely results from inability to pay, although some people do fall behind on premium payments, and this may indicate that for some, the subsidies are inadequate.58 In Switzerland, many of the uninsured are not legal residents.59

Single-​Payer in America Let’s turn to proposals for single-​payer in America. Advocates of universal health insurance never want to adopt another country’s health system wholesale. The goal is always to emulate the best in other countries while avoiding their flaws. So when we talk about single-​payer in America, we should not imagine a direct imitation of Canada’s system but rather a single-​payer system designed with American needs in mind. The most straightforward proposal for single-​ payer in America may be the “Medicare for All” (MFA) proposal, which is pending in the U.S. Congress as H.R. 676. Its official title is the United States National Health Insurance Act or Expanded and Improved Medicare for All Act. The MFA proposal would make everyone residing in the United States eligible to enroll in our existing Medicare program. It would cover all “medically necessary services”:60 primary care and prevention, inpatient care, outpatient care, emergency care, prescription drugs, 57.  Leu et  al., “The Swiss and Dutch Health Insurance Systems,” p.  vii. For Dutch: Westert et al., “Dutch Health Care Performance Report 2008.” 58. Insure the Uninsured Project, “Netherlands.” 59. Medecins Sans Frontieres, “Switzerland.” 60. United States, House of Representatives, H.R. 676, p. 4.

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durable medical equipment, long-​ term care, mental health services, noncosmetic dental services, substance abuse treatment, chiropractic services, and basic vision services. No cost-​ sharing would be allowed. For instance, individuals could not be charged a copayment for each medical service they receive, as is common in current American insurance plans. To receive payment from MFA, medical institutions would have to be public or non-​profit. Investor-​owned institutions that wanted to participate could convert to non-​profit and their investors would be compensated for the costs. The bill would allow private companies to sell insurance for services not covered by MFA, but no company could cover the same services. This would encourage almost all physicians and medical institutions to accept MFA, so Americans could seek treatment from almost anyone. The program would be financed from a trust fund, and that fund would receive money from several sources. First, the bill’s authors propose that the program’s expenses can be partly covered by reducing bureaucratic expenses in the existing U.S.  health care system, by purchasing drugs in bulk as they do in Canada, and by making use of the money the government already spends on health care. New revenue comes from increasing personal income taxes on the top 5% of earners (in 2016, those making $225,000 and over),61 by instituting what the authors call a “modest” payroll tax of the sort that funds Social Security, and by placing a “small” tax on stock and bond transactions. This money would be paid to participating physicians and medical institutions. Larger institutions would be paid monthly sums established during annual negotiations between the providers and the regional directors of the MFA program. These 61.  United States, Department of Commerce, Census Bureau, “Historical Income Tables,” table H-​1, “All Races.”

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sums must be based on past expenditures, projected changes in levels of service, wages and input, costs, and proposed new and innovative programs. Physicians and other medical professionals could be paid either through fee for service or by salary, and they cannot bill extra for any covered services. The reimbursement rates are set by negotiation between the practitioners and the officials of the MFA program. The director of the program would be appointed by the secretary of the Department of Health and Human Services (DHHS). There would also be an Office of Quality Control with its own director, and the director’s job would be to “provide annual recommendations to Congress, the President, the Secretary [of DHHS] and other Program officials on how to ensure the highest quality health care service delivery.” Since these officials are named by a political appointee, one might worry that they would be subject to political pressure. It is probably impossible to avoid politicizing health care decisions altogether, but to at least help guard against this, there is a National Board of Universal Quality and Access, which is a bit like the Federal Reserve, but for health care. Members are appointed by the president with the advice and consent of the Senate. The Board must include at least one health care professional, one representative of institutional providers of health care, one representative of health care advocacy groups, one representative of labor unions, and a citizen patient advocate. They would offer advice about quality, access, and affordability to the secretary of DHHS and the director of the national insurance program. Another proposal for single-​payer comes from Physicians for a National Health Program (PNHP), and it differs from MFA in several ways. For instance, it is funded through our progressive income tax system,62 and it emphasizes that boards 62. Woolhandler et al., “Proposal of the Physicians’ Working Group for Single-​ Payer National Health Insurance,” p. 802.

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of experts and community representatives should make decisions about the extent of coverage.63 Yet another single-​payer proposal was made by Arnold Relman, former editor of the New England Journal of Medicine. Relman’s proposal differs from the MFA and PNHP plans in various ways. For instance, while the MFA and PNHP plans eliminate cost-​sharing, Relman allows cost-​sharing to prevent overuse of services. In addition, one of Relman’s most innovative suggestions is that we fund the system using a separate, earmarked health care tax.64 It would be based either on income or assets and have graduated rates. Relman argues that a dedicated tax would partly insulate health care from the heavily political congressional budgeting process, and I’ll note that it might also force the American public to think more directly about health care expenditures. Whenever they wanted a larger benefit package, they would have to lobby Congress to raise the health care tax. The cost of additional services couldn’t just be paid out of the national debt. Relman’s proposal places the most stress on independent administration. The national health insurance program would be run by a national medical care agency. The agency would oversee the insurance plan, which then pays out to private-​ practice doctors and hospitals. One of the agency’s most important jobs would be to define the national benefit package. Relman wants an agency that is “accountable to Congress, but  .  .  .  [which has] independent and stable authority, which would protect it from variable political winds in the legislative and executive branches of government.”65 The agency’s

63. Woolhandler et al., “Proposal of the Physicians’ Working Group for Single-​ Payer National Health Insurance,” p. 799. 64. Relman, A Second Opinion, p. 116. 65. Relman, A Second Opinion, p. 126.

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members would be nominated by “the important organizations and constituencies in health care” and appointed for long terms by the president.66 Relman makes explicit comparisons with the Securities and Exchange Commission, the Federal Trade Commission, and the Federal Reserve.

Regulated-​Market Systems in the United States: The Voucher System of Emanuel and Fuchs I don’t know of any detailed proposals for an American version of the Swiss and Dutch regulated-​market systems,67 but a somewhat similar system was proposed by Ezekiel Emanuel and Victor Fuchs in the New England Journal of Medicine, and later expanded by Emanuel in his book Healthcare, Guaranteed. Emanuel and Fuchs propose a health care voucher system. All Americans would receive a voucher from the government for private health insurance. They could submit the voucher to any qualifying private-​market insurance provider, and in exchange the insurer would provide a medical plan that covers basic health services. Providers could not reject applicants or refuse to renew them. In effect, Americans would be entitled to insurance from any private-​market insurance company servicing their area. Emanuel speculates that “in most regions, consumers will have a choice among five to eight qualified health plans or insurance companies. In larger cities, as many as fifteen or twenty competing plans might exist; in rural areas there might be only one or two plans.”68 These plans might have different physician 66. Relman, A Second Opinion, p. 126. 67.  See, though, Pauly et  al., “A Plan for ‘Responsible National Health Insurance.’ ” 68. Emanuel, Healthcare, Guaranteed, pp. 86–​87.

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and hospital networks, different drug formularies, and so on, just as insurance plans have now. Insurers could not charge additional premiums for the basic package. The basic health benefits would be modeled on the benefits members of Congress receive. Congressional plans are broad, covering office visits, hospitalization, preventive care, prescription drugs, some dental care, mental health care, and physical and occupational therapy. According to Emanuel, this coverage “is more generous than Medicare and better than that which 85% of Americans currently receive through their employers.”69 Fuchs and Emanuel countenance modest copayments so long as they don’t prevent those with low income from getting care. Americans could use their own money to buy benefits not offered in the standard plan. These might include access to a greater variety of drugs, more mental health benefits, coverage for complementary and alternative medicines, and “concierge medicine” that eliminates waiting times for doctor’s visits and covers house calls. The entire system would be managed by a national health board and 12 regional sub-​boards. The national board is modeled on the Federal Reserve. Members would be nominated by the president and confirmed by the Senate. They would serve fixed, long terms and can be re-​nominated only once. The board’s principal tasks would include defining the basic benefits package, contracting with health plans, informing Americans about their health care options, and reimbursing health plans for the vouchers they take in. It would also collect data about patient satisfaction, quality of care, and any risk adjustments or geographic adjustments that accompany payments. The board would establish an independent institute for technology and outcomes assessment. The institute would

69. Emanuel, Healthcare, Guaranteed, p. 86.

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research the effectiveness and value of medical procedures. Those results would be made publicly available and would inform the decisions of the board. The voucher system would be funded by an earmarked value-​added tax, or VAT. VATs are complex; here it is enough to know that they are similar to sales taxes, and thus the voucher system would be funded by taxing purchases. Emanuel and Fuchs note two advantages of an earmarked tax. First, the tax can fund the federal health board itself, which would partially insulate it from political pressure and special-​interest lobbying. Second, Americans could more easily see the connection between the taxes they pay and the health care they receive. If they want a greater basic benefits package, they will have to support a tax increase—​no more financing of entitlements through the national debt. Emanuel also suggests extensive malpractice reform. Each regional health board would have a center for patient safety and dispute resolution. The center would hear patient complaints and compensate patients for medical errors. If patients were not satisfied with a center’s offer, they could still sue, but the hope is that this form of arbitration would reduce malpractice costs. It is important to be clear on the government’s role in a voucher system. In a single-​payer system, the government is not providing medical care but rather medical insurance. In the voucher system, the government is even farther removed. It is not in the insurance business but is instead a regulator of insurance companies and distributor of funds. Americans would still be enrolled in private insurance plans, and they would still get their health care from private doctors and hospitals. The voucher system is in many ways similar to the regulated-​ market systems of other countries, but the United States might also more directly emulate Switzerland and the Netherlands. The cornerstones of those systems are (1) an individual mandate to buy insurance, (2) regulations requiring insurers to accept all

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applicants and not base prices on an individual’s level of sickness, and (3) subsidies for those who still could not afford insurance. The ACA already moves America in these directions, but to move fully to the Swiss and Dutch models, America would have to enact several changes, largely at the same time. First, we would need to phase out public programs such as Medicaid and Medicare. Eliminating Medicaid might have political support; the program has many detractors. Medicare would be more problematic, and the program could either be eliminated outright or (borrowing a suggestion from Emanuel’s book) phased out by allowing everyone in Medicare to remain on it for as long as they want, but ending new enrollment. Second, we would have to adjust premium subsidies to ensure that health insurance is affordable to all. Third, we would need to tackle tax breaks for employer-​ based insurance. Almost everyone who studies these tax breaks thinks they are grossly unfair;70 they amount to a subsidy for people with employer-​sponsored insurance and an implicit penalty for those who buy insurance privately. That subsidy also pays out more to people who are wealthier. Given the obvious unfairness, the subsidy should probably be eliminated. Fewer employers would provide insurance, although (as in the Netherlands) some might continue to offer premium assistance to employees.71 Eliminating employer-​ sponsored insurance would also free employees to shop among multiple plans, as the Swiss and Dutch do. That would increase choice and encourage greater competition among insurers.

70. See Owcharenko, “A Principled Path to Rational Health Care Reform,” p. 2. 71.  Lynch and Altenburg-​van den Broek, “The Drawbacks of Dutch-​Style Health Care Rules,” p. 5.

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Budgetary Issues Chapter five will discuss the fiscal effects of universal health insurance, but here we should review some basic budgetary facts. One topic is the cost of different systems. Comparing total dollars is pointless, since different countries have different population sizes. Therefore a common way of measuring costs is as a percentage of gross domestic product (GDP). Using statistics from the Organization for Economic Cooperation and Development (OECD), table 1.2 shows total public and private health expenditures in 2016. Table 1.2

PERCENTAGE OF GDP SPENT ON HEALTH CARE IN 2016 (PUBLIC AND PRIVATE SPENDING COMBINED) Country

%

United States Switzerland Canada Netherlands

17.2 12.4 10.6 10.5

Source: Data from Organization for Economic Cooperation and Development, “Health at a Glance 2017,” p. 133.

We can also measure spending per person. Table 1.3 contains OECD data from 2016. These figures will surprise many people. Do other countries really spend far less and yet cover everyone? Simply, yes. There’s a large debate about why the U.S.  system costs so much more than other systems, but here are some commonly cited factors. First, the U.S. is wealthier than some other countries, and when you have more money, you tend to choose to spend more on health care. Second, we pay higher prices than

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Table 1.3

PER CAPITA SPENDING ($PPP) ON HEALTH CARE IN 2016 (PUBLIC AND PRIVATE SPENDING COMBINED) Country

$PPP

United States Switzerland Canada Netherlands

$9,892 $7,919 $4,752 $5,385

Source: Data from Organization for Economic Cooperation and Development, “Health at a Glance 2017,” p. 135.

people in other countries for the same health care goods and services.72 Third, we have much higher administrative overhead than other countries with simpler systems. Remember that the U.S. system has literally thousands of different players, all employing large bureaucracies to keep track of who qualifies for what, for how long, to what extent, and so on. Buyers incur administrative costs too. For instance, companies must focus on health care benefits rather than their core mission, and they have to employ large numbers of additional staff to manage health benefits.73 Fourth, cost is affected by usage of health services, though we must be careful to identify the exact nature of the problem. Many Americans probably believe that for our greater spending, we get a greater quantity of medical care. That is not so.74 In reality, people in other countries frequently 72. Cf. Anderson et al., “It’s the Prices, Stupid.” 73.  Woolhandler, Campbell, and Himmelstein, “Costs of Health Care Administration in the United States and Canada.” 74. Though it’s still true that our costs may be higher than necessary because of excessive volume. On this, see Kaplan, Disease, Diagnoses, and Dollars; as

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receive more medical services than Americans.75 Americans don’t always have access to more high-​cost, high-​tech services either; for instance, the Swiss have more MRIs and CT scanners per capita than we do.76 What is true is that Americans use more high-​cost, high-​tech services than other countries. Sometimes we use them well and improve people’s health, but sometimes we use expensive medicine for no good reason—​driving up total costs.77 Finally, America has higher costs because of malpractice lawsuits. These don’t directly add much to health spending, but many people speculate that they lead doctors to practice defensive medicine and thus overprescribe services and medicines.78 Some policy experts would cite additional factors too, including nonnegotiated drug prices, high specialist physician incomes, dominance of fee-​for-​service payment, overreliance on emergency room care (particularly among the uninsured, who may have no alternative), and the current tax subsidy for insurance premiums.79

well as some of the research and reports from the Dartmouth Institute for Health Policy and Clinical Practice, The Dartmouth Atlas of Health Care. 75. Oberlander and White, “Public Attitudes Toward Health Care Spending Aren’t the Problem.” See also Emanuel and Fuchs, “The Perfect Storm of Overutilization.” 76. Anderson et al., “It’s the Prices, Stupid,” p. 99. 77. Sirovich et al., “Discretionary Decision Making by Primary Care Physicians and the Cost of U.S. Health Care.” See also the Dartmouth Institute for Health Policy and Clinical Practice, The Dartmouth Atlas. 78.  United States, Congressional Budget Office, “Key Issues in Analyzing Major Health Insurance Proposals, December 2008.” 79. Note also that Fuchs, “Cost Shifting Does Not Reduce the Cost of Health Care,” cites the following additional factors:  higher ratio of specialists to general practitioners, excess and unused capacity, open-​ended funding, and less social support for the poor, who then develop more severe and expensive problems.

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For our purposes in this book, we don’t have to debate the causes of high spending. We only need to know that the systems used in other countries cost less than ours. That said, we can’t assume that if we emulated the systems used in Canada, Switzerland, or the Netherlands, our spending would drop to 10 to 11% of GDP. Advocates of American universal health insurance recognize that Americans want a system that avoids wait-​lists and makes use of innovative, high-​technology care. That costs money, so the advocates generally propose maintaining spending at approximately current levels. For instance, the PNHP single-​payer proposal suggests spending at our current levels rather than trying to cut back to Canada’s.80 Likewise, Emanuel bases his spending proposal on the current cost of health care offered to federal employees, including members of Congress. One might think that if we offer high-​quality health insurance to everyone, including the 45 million who were uninsured before the ACA, total spending must go up. Not necessarily. Universal health insurance systems are more efficient, so one can theoretically increase the number of people covered, and cover them at high levels, without affecting total spending very much. Return to Emanuel’s proposal from 2008 that we offer people congressional-​quality health care. The average annual premium for that insurance in 2006 was $5,180 for individuals and $11,216 for families.81 Multiplying by the size of our population (and introducing some other complexities), Emanuel concluded that the total cost of the voucher system for the non-​ Medicare population would be $995 billion annually, about $7 80. Woolhandler et al., “Proposal of the Physicians’ Working Group for Single-​ Payer National Health Insurance,” p. 802. See also Rasell, “An Equitable Way to Pay for Universal Coverage,” p. 181; and Grumbach et al., “Liberal Benefits, Conservative Spending.” 81. Emanuel, Healthcare, Guaranteed, p. 95.

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billion less than we were spending at the time of Emanuel’s calculations. His calculations are not beyond dispute; premiums for the congressional plan might change if everyone took part in it. But Emanuel does provide a plausible proposal for maintaining total health spending at something like current levels. Similar conclusions have been reached about single-​payer. The best studies are out of date; they were completed in the 1990s, when single-​payer was more in the forefront. In 1991 the Government Accounting Office (now the Government Accountability Office) was asked to estimate the costs of a single-​payer system. Their conclusion was that “if the universal coverage and single-​payer features of the Canadian system were applied in the United States, the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured.”82 A 1993 CBO analysis concluded that a single-​payer system like Medicare for All would save money overall if it retained copayment requirements, and that we could institute a system with no copayments at all by raising total national health expenditures by 5%.83 Updated analyses after the 1990s find the same thing.84 Though universal health insurance need not cost more than we currently spend, my assumption throughout this book will be that it will also not cost significantly less. Naturally the case

82.  United States, General Accounting Office, “Canadian Health Insurance,” p. 3. 83.  United States, Congressional Budget Office, “Preliminary Estimate of the Effects of S. 491, American Health Security Act of 1993, on Government Outlays and National Health Expenditures,” p. 14. 84.  Grumbach et  al., “Liberal Benefits, Conservative Spending.” See also Thorpe, “Impacts of Health Care Reform.” This was written for the National Coalition on Health Care.

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for universal health insurance would only grow stronger if a universal health insurance system could reduce total spending.

C O N S U M E R -​D R I V E N H E A LT H   C A R E We’ve discussed the American system and several universal health insurance systems. But health policy debates often discuss “consumer-​driven health care,” or CDHC. CDHC is not a complete health system like a single-​payer or regulated-​market system. To understand CDHC, it’s best to start with the motivation behind it. Regina Herzlinger is one of the inventors of CDHC. She says that “when consumers apply pressure on an industry, whether it’s retailing or banking, cars or computers, it invariably produces a surge of innovation that increases productivity, reduces prices, improves quality, and expands choices.”85 Edmund Haislmaier of the Heritage Foundation makes the same point. He says that “if responding to consumer needs and preferences is made the organizing principle of the [health care] system, then insurers and providers will have the right incentives to develop innovative ways to deliver better value to consumers and patients in the form of lower costs and improved outcomes.”86 But Herzlinger, Haislmaier, and others worry that flaws in the health insurance market prevent consumers from influencing industry. They want to improve health care markets in the hope that market forces will bring down costs and improve quality. CDHC advocates develop this core idea in different ways. Below I’ll list a few of the most common proposals. I’ll describe

85. Herzlinger, “Let’s Put Consumers in Charge of Health Care,” p. 45. 86. Haislmaier, “Health Care Reform,” p. 3.

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these the way CDHC advocates would—​e.g., as measures aimed at “lowering costs”—​but keep in mind that before enacting any CDHC proposal, we would want to ask whether CDHC reforms will truly have the effects that their proponents say they would. The data is at least unclear.87 Herzlinger describes several problems with employer-​ provided insurance. First, employers offer employees a restricted range of plans to choose from, and the plans are often

87.  In particular, note two things:  (1) One central idea in CDHC is to increase competition and rely on market efficiency, but actual markets aren’t always as efficient as theory predicts. For instance, private-​market Medicare “Advantage” plans were supposed to increase efficiency, and yet they ended up costing, on average, more than traditional Medicare (Bodenheimer, “High and Rising Health Care Costs. Part 1,” p. 852). Such things might happen if consumers don’t comparison shop in the way models predict (cf. Fung et al., “Systematic Review”; Sillence et al., “How Do Patients Evaluate and Make Use of Online Health Information?”; Salisbury, “How Do People Choose Their Doctor?”). For instance, in Switzerland, the entire population can choose from a vast number of plans, and yet Swiss citizens don’t comparison shop the way economic theory predicts (see Herzlinger and Parsa-​Parsi, “Consumer-​ Driven Health Care”; Reinhardt, “The Swiss Health System”; Rosenau and Lako, “An Experiment with Regulated Competition and Individual Mandates for Universal Health Care”; and Cheng, “Understanding the ‘Swiss Watch’ Function of Switzerland’s Health System,” pp.  1446–​1447). Other research shows that seniors are often in suboptimal part D Medicare plans (see Heiss, McFadden, and Winter, “Mind the Gap!”; Hanoch et al., “How Much Choice Is Too Much?”; Domino et  al., “Why Using Current Medications to Select a Medicare Part D Plan May Lead to Higher Out-​of-​Pocket Payments”). Even highly educated medical professionals have a hard time choosing the best plan (Hanoch et  al., “Choice, Numeracy and Physicians-​in-​Training Performance”). (2) Using HDPs, a central pillar of CDHC, might produce at best marginal cost savings. This may happen because, among other things, most health spending is on complicated problems which quickly exceed the deductible, with the sickest 10% of the population accounting for 70% of all medical costs (Bodenheimer, “High and Rising Health Care Costs. Part  4,” p.  26; cf. United States, Agency for Healthcare Research and Quality, “The High Concentration of U.S. Health Expenditures”). Some researchers have even speculated that HDPs increase costs when compared with the best alternatives, such as HMO plans (United States, Congressional Budget Office, “Consumer-​Directed Health Plans”).

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very similar. As a result, employees may buy more or less insurance than they want or need. Herzlinger proposes that employers give employees a fixed sum to spend on health care and many plans to choose from. Some might choose a standard plan, but others might choose a plan that covers only catastrophic events and opt to save the rest of the money to use on pharmaceuticals, new glasses, or a long-​term care plan. Second, Herzlinger points out that when employees choose insurance plans, they usually have little information about the advantages and disadvantages of each. As a result markets cannot function efficiently. A  company offering shoddy service would normally lose customers. But if consumers don’t know the service is shoddy, the problem is never corrected. Herzlinger wants to give employees two kinds of data: customer ratings of the plans and objective information on the plans’ health outcomes. Third, we know employees are sometimes offered a choice between plans. Sometimes the plans may cost the employer the same amount, but even if the plans cost different amounts, the employer may offer them to employees at the same price.88 From the employees’ point of view, the two plans cost the same, and this eliminates the incentive to enroll in the cheaper plan, even though the employees might do so if they were spending their own money. Herzlinger proposes that each employee should pay the plan’s true cost out of the fixed sum mentioned earlier. Fourth, employers currently pay insurance companies the same amount for every employee, regardless of whether the employee is sick or well. This means that insurance companies spend their time trying to cherry-​pick the healthiest employees and have no incentive to create specialized programs to improve the health of the sickest patients. Herzlinger’s solution is to pay insurers based on the level of illness of the enrollee.

88. Herzlinger, Consumer-​Driven Health Care, p. 76.

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The issues just listed concern the interaction between purchasers and insurance companies. But CDHC advocates also worry about the relationship between insurance companies and medical care providers such as hospitals and doctors. Herzlinger argues that when doctors and hospitals establish integrated units focused on problems like congestive heart failure or kidney disease, they reduce costs and improve outcomes. The problem, though, is that doctors and hospitals have no current incentive to establish those integrated units. Doctors and hospitals are usually allowed to bill only for specific services or episodes of illness; they cannot bill for an extended course of treatment in an intensive, multispecialty center. The result is fragmented care. The CDHC solution is to allow providers to bill for whole courses of treatment that take place over a long period of time and may involve a variety of doctors working together. CDHC advocates also focus on problems during patient-​ doctor interactions. To understand this problem, consider a nonmedical market transaction. If a shirt costs $30, each of us would decide how much we value shirts and how many we want to buy at that price. But now imagine that shirts were subsidized so that the cost was only $5 per shirt. In that case we might buy more shirts. Maybe we’d even buy more than we need, just for the fun of having extra shirts in different colors. Subsidies may produce overuse. CDHC advocates worry that the same thing happens with medical care. The real cost of a doctor’s visit may be $100, but insured patients may pay nothing or a minimal copayment that is less than the market cost. As a result patients may overuse services. For instance, suppose I think I have a cold, and I know doctors can’t do anything for colds. If a doctor’s visit costs $100, I’m unlikely to go. But if a doctor’s visit is free under my plan, I might go just to make sure that I don’t have strep throat. I end up using more services than I otherwise would.

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One could debate whether this is really “overuse.” Maybe we want people seeing doctors regularly rather than guessing about whether they need care. But if, like CDHC advocates, we conclude this is a problem, one possible solution is to give people high-​deductible insurance plans, or HDPs. High-​deductible plans require the patient to pay for an initial amount of medical care before insurance kicks in. For instance, on a $5,000 HDP, I would have to pay the first $5,000 of my medical expenses before the insurance begins paying at all. The hope is that because I’m paying the expenses, I’ll reduce my use. And yet if I  face serious illness and need more than $5,000 of care, the expenses over $5,000 are covered. HDPs could be disastrous if people couldn’t pay their deductibles—​they wouldn’t get care at all. For that reason, CDHC advocates often pair HDPs with health savings accounts, or HSAs. HSAs are savings accounts from which people can pay their deductible. Importantly, deposits into HSAs are tax free, giving people an incentive to set aside the money. (It might seem that consumers would pay lower up-​front premiums for CDHC plans, but more in total costs if they became sick. That may or may not be the case. If the HDP covered more catastrophic costs than a standard plan, it’s possible that the HDP would cost the consumer more overall. Overall health care costs could also be lower in an HDP than in a traditional plan, depending on what is covered and what problem the patient faces.) In sum, CDHC’s goal is to lower costs and improve quality by correcting (alleged) problems in health care markets. With the basic idea in front of us, we can grasp a very important point that is almost always overlooked in debates about universal health insurance. Single-​payer and regulated-​market systems are overall plans for providing health insurance in the United States. By contrast, CDHC is not an overall plan for health

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insurance in the United States. Instead it is a collection of particular ideas that can be attached to other, larger systems. For instance, one CDHC proposal is to provide consumers with information about the quality of health plans. This is not an alternative to other systems but rather an idea that can be incorporated into the other systems. In fact, Emanuel’s voucher system does incorporate the idea by establishing a national health board that collects and disseminates information about the quality of health plans. Or consider high-​ deductible plans. In the single-​ payer systems described above, deductibles were either low or nonexistent. But if one is convinced by the arguments of CDHC advocates, deductibles can simply be set higher. That would still be a single-​payer plan. It would just be a single-​payer plan in which the government provides health insurance with a high deductible. I’m emphasizing that CDHC is not an alternative to the other systems because, in America, universal health insurance is usually portrayed as a Democratic idea and CDHC as a Republican idea. This gives the impression that the two systems are “rivals” which can be compared. However, that impression is incorrect and leads to severe confusion. CDHC proposals may have merit or not. Whichever it is, though, they are a collection of specific ideas that must be attached to some larger plan for health insurance in the United States. We can attach them to the current system, to a regulated-​market system, or to a single-​ payer system. But we cannot simply advocate “consumer-​driven care” in a void. Unfortunately, CDHC advocates haven’t been very explicit about the larger system in which they’d situate their ideas. Some politicians want to add CDHC reforms to our current system. That proposal would not establish universal coverage. CDHC may or may not lower costs, but even if it does, it will not lower

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costs so much that health insurance is affordable to, say, a diabetic earning minimum wage. A comparison may help. Right now the highest-​resolution televisions are very expensive, and some Americans can’t afford them. That happens even in a well-​ functioning free market because even though markets help make production efficient and bring down costs, they don’t suddenly make a $4,000 item cost $20. This problem with CDHC is well known. It does not bother some people, because they are focused on reducing cost growth and improving quality, and they do not have the goal of achieving universal access.89 However, other proponents of CDHC advocate additional reforms designed to eliminate uninsurance. For instance, Herzlinger proposes government subsidies that would ensure that everyone can afford health insurance on consumer-​driven markets.90 Herzlinger notes that that system would be similar to the Swiss system. She writes approvingly of that system while recommending additional changes to make it even more consumer-​driven.91 Some CDHC proponents want to eliminate the current tax subsidy for employer-​sponsored health insurance and replace it with an alternative, such as a same-​dollar tax credit for all citizens, which might or might not take us toward universal coverage, depending on the amount.

89. Many recent Republican proposals do not aim at universal access. For a summary of Republican proposals offered during the 2010 debate, see Kaiser Family Foundation, “Focus on Health Reform: Side-​by-​Side Comparison of Major Health Care Reform Proposals.” For discussion of the effects of one such proposal, see Jacobson, “GOP Health Care Reform.” 90. Herzlinger, Consumer-​Driven Health Care, p. 79. 91. Herzlinger and Parsa-​Parsi, “Consumer-​Driven Health Care.”

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S U M M A RY We cannot engage meaningfully with real-​world health care debates without a proper factual grounding, so this chapter has described the U.S. health care system as well as alterative universal health insurance programs. But which system should we adopt? That question raises a host of ethical issues, and even in a book-​length treatment, we cannot address all of them. In the next chapter I identify some issues that are both philosophically interesting and which seem to play a prominent role in actual health care debates.

Chapter Two

THE ETHICAL ISSUES RAISED IN HEALTH CARE DEBATES

THERE ARE MANY PHILOSOPHICAL QUESTIONS we can ask

about national health policy. The most prominent philosophical writings focus on whether an ideally just society would have a social minimum at all, in health or anything else. For instance, the important writings of John Rawls, Ronald Dworkin, and Robert Nozick all concentrate on that issue. I will have something to say about the case for a social minimum in chapters three and six, but in most parts of this book, I’ll leave aside the question of whether society should have a social minimum in health care, simply presuming that it should. One reason to do so is theoretical: I believe others have adequately made the case for a social minimum in health care, and I see little reason to re-​hash what they’ve said. Another reason is pragmatic. Below I  will present social science data which suggests that the vast majority of Americans, of any ideology, already agree that an ideally just society should have a social minimum in health care. Their believing it doesn’t prove that it’s true, of course—​ that’s why we need the theoretical work just mentioned—​but the fact that both theoretical work and public opinion already support a social minimum in health care does suggest that it would be useful to explore some additional philosophical issues in the health care debate.

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This book will examine three such issues, asking whether universal health insurance systems are objectionable on the ground that they are inefficacious, fiscally risky, or create excessive personal costs. I hope my examination of these questions will show that they are of serious philosophical interest. In my own case, though, I am not led to examine these issues merely because they are theoretically interesting. Instead, these particular issues also stand out to me because there is substantial evidence that opinions about fiscal risk, efficacy, and personal cost drive many Americans’ opinions on health care. Therefore, by examining these issues philosophically, we also engage with some of the debates that shape public opinion on health care policy. The aim of this chapter is to put readers in a position to decide for themselves whether issues of fiscal risk, efficacy, and personal cost are of interest principally because of the philosophical questions they raise or whether, in addition, they are of interest because they also help drive the health care debate. I begin with a snapshot of the evidence that many Americans’ views on health care policy are partly shaped by issues of fiscal risk, efficacy, and personal cost. At the end of the chapter, I discuss the limitations of this evidence as well as alternative hypotheses about the drivers of the health care debate. A few technical notes before beginning: This chapter can’t review anything close to all the social science research on public opinion about the social minimum. Instead I will be able to give only a few selected examples that are representative of the larger body of data,1 and I’ll cite additional research in the footnotes for those who want to read about the larger patterns. Readers checking the footnotes will see many citations from the same 1. Naturally poll results vary over time, but I do not list any that are outside the normal trends or variations. For some surveys of changing opinions over time, see Shapiro, “From Depression to Depression?”; and Panagopoulos and Shapiro, “Big Government and American Opinion.”

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works, such as Blendon et  al.’s American Public Opinion and Health Care and Gilens’s Why Americans Hate Welfare. I refer to those works frequently because they are convenient collections of many different polling results, but, with the exception of a few quotes, I do not rely on the authors’ analysis. The research ranges from the 1980s until the present so as to give a broad picture of recent history, but I avoid any data that is older, since that might reflect attitudes that are out of date.

D ATA A B O U T S U P P O R T F O R   A S O C IA L M I N I M UM Pundits make it sound as if Americans are hopelessly divided about whether society should have a social minimum in health care. That’s incorrect. Although some people reject a social minimum in health care, including some political leaders, the vast majority of Americans agree that an ideally just society should ensure reasonable access to health care and other basic goods for all hard-​ working citizens and other deserving individuals, such as children, those unable to work, and the elderly. For convenience sake, I’ll refer to this as a commitment or belief in a social minimum. Some evidence for the widespread commitment to a social minimum comes from polling about our existing social minimum programs:  Social Security, Medicare, Medicaid, unemployment, and so on.2 Contra stereotypes, which say that Democrats support these programs and Republicans oppose

2. In addition to the sources cited below, see Page and Shapiro, The Rational Public, ch. 4. In The Welfare State Nobody Knows, Howard presents evidence that, when properly calculated, the American social minimum is actually quite large and does not lag as far behind other developed countries’ as some people say. This might be taken as some evidence that Americans agree that there should be a social minimum, even if its implementation is atypical for developed countries. See also c­ hapter 6 of Howard for polling information on

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them, we find support that crosses ideological lines. The most obvious and plausible reason for such support is, of course, the belief that society should provide a social minimum in certain goods. Consider the results of a 2011 Harris Poll shown in table 2.1. The question was “For each of the following government services, please indicate how strongly you support the policy or service.” The percentages indicate the number who answered either “a great deal” or “a fair amount.”3 The table includes many government services, and for easy identification, I  have boldfaced the ones which help ensure a social minimum.4 With the exception of Food Stamps (which I’ll discuss later), all the major social minimum programs are supported by robust majorities across party lines.5 Notably, this Harris Poll has

social minimum policies, as well as ­chapter 17 and following of Ladd’s The American Polity. The idea that Americans agree on certain principles of economic justice fits with the larger thesis that there is not an extensive “culture war” or cultural divide in America on most issues. On this, see Culture War? by Fiorina, Abrams, and Pope; Wolfe’s One Nation, After All; Page and Jacobs’s Class War?; and Hunter and Wolfe’s Is There a Culture War? 3.  Harris Poll, “New Harris Poll Underlines Political Difficulty of Cutting Government Services.” With the following data and all similar data, one might worry that individuals endorse social minimum policies because of a desire to appear morally good. However, this does not appear to be a major factor. See Gilens, Why Americans Hate Welfare, pp. 196ff. 4.  Including Social Security and Medicare in the class of social minimum policies might seem controversial. Almost all Americans expect to use these programs, so support for them could be a manifestation of self-​interest rather than a belief in a guaranteed social minimum. But as pointed out in the previous chapter, Medicare and Social Security are in fact redistributive. Here I  make the assumption that support for these programs would not change significantly were those facts more widely known than they presently are, although this is admittedly speculative. 5. See Page and Jacobs, Class War?, p. 72 for data showing that Republicans are more supportive of Food Stamps than is indicated here. Rather than relying

Table 2.1

SUPPORT FOR SELECT GOVERNMENT SERVICES AS A PERCENTAGE Party ID Total Republican Democrat Independent Crime Fighting and Prevention Medicare, the health insurance program for the elderly and seriously disabled Social Security National Park Service Defense Federal Aid to Public Schools Unemployment Benefits Environmental Protection Medicaid, the health insurance program for people with very low incomes Intelligence Services Food Stamps Immigration and Naturalization Process Foreign Aid

%

%

%

%

88

89

89

89

88

86

92

90

85 82

81 79

93 85

85 84

80 79

88 70

77 90

81 77

76

67

86

77

76

64

88

75

74

60

86

74

73 61 56

78 46 49

74 75 65

74 61 55

34

26

44

32

Source: Data from Harris Poll, “New Harris Poll Underlines Political Difficulty of Cutting Government Services.”

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been done for many years,6 and since 2005, support for all social minimum programs has been increasing overall.7 The fact that the numbers have not changed much is striking, and recent polls confirm these results. For instance, a 2017 poll restricted to health care showed that all but a very small percentage of self-​identified Republicans and conservatives favor continuing Medicare and Medicaid.8 A University of Maryland survey laid out the details of SNAP benefits and then asked respondents their opinions about the program, and the vast majority of self-​ identified Republicans wanted benefits maintained or increased.9 Though it is less common, some studies sort people based on expressed ideology rather than party. In the National Election Study in 2000,10 individuals were asked which of two statements more accurately captured their ideology: “the less government, the better” or “there are more things the government should be doing.” Restricting ourselves to the former is one way of identifying people who are “conservative” about social minimum policies. These conservatives were then asked whether on that data, though, I have used the data which indicates a greater partisan divide, since this only helps my critics and makes my job harder. 6. And if we move beyond this Harris Poll, we see that these same results seem to hold over longer periods of time. See, e.g., Cook and Barrett, Support for the American Welfare State, p. 174. 7.  Harris Poll, “New Harris Poll Underlines Political Difficulty of Cutting Government Services.” Self-​identified Republicans show little change over time, with single-​digit reductions in support for unemployment benefits and Medicaid, but single-​digit increases for Medicare, Social Security, and Food Stamps. Many of these changes are within the margin of error. 8. Bialik, “More Americans Say Government Should Ensure Health Care Coverage.” 9. Program for Public Consultation, “Americans on SNAP Benefits,” p. 5. 10.  The data below is cited in Shaw, “Changes in Public Opinion and the American Welfare State.” The same studies also support my previous claim that self-​identified conservatives are far more skeptical about programs like Food Stamps, “aid to blacks,” and “welfare” programs.

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Table 2.2

OPINIONS ABOUT FUNDING FOR SAFETY NET PROGRAMS Program

Social Security Child Care Aid to Poor People

% saying increase funding

% saying % saying maintain decrease funding funding or eliminate

47 47 33

46 38 52

6 15 15

Source: Data cited in Shaw, “Changes in Public Opinion and the American Welfare State,” p. 631.

funding for certain safety net programs should be increased, kept the same, or decreased/​eliminated. The results are shown in table 2.2. Even self-​described conservatives overwhelmingly support these social minimum policies. Other ways of picking out conservatives yield similar results.11 As noted at the outset, these are only a few examples of the social science data, and the larger patterns are identified in the many scholarly works on this subject. One exhaustive survey of the empirical research is Martin Gilens’s book Why Americans Hate Welfare.12 Gilens pores over many surveys and finds that “Americans express a stable, coherent, and complex set of preferences toward antipoverty policy.”13 The book’s title is in one 11. For instance, in the same survey, people were asked which of two statements more accurately captured their ideological outlook: “We need a strong government to handle today’s complex economic problems” or “The free market can handle these problems without government being involved.” The latter group still supports the safety net policies identified in the text. 12. Less detailed, but very readable, is Page and Jacobs’s Class War? 13. Gilens, Why Americans Hate Welfare, p. 8.

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way misleading, because the analysis reveals that Americans are generally supportive of social minimum programs. They “hate welfare” by opposing programs which (in their view) allow lazy people to sponge off the government. Thus Gilens summarizes: Despite their individualistic inclinations, Americans do not oppose the welfare state; in fact, they strongly support it. The American public consistently expresses a desire for more government effort, and higher levels of spending, for almost every aspect of the welfare state. Year after year, surveys show that most Americans think the government is not doing enough (or not spending enough) for education, health care, child care, the elderly, the homeless, and the poor.14

Similar conclusions have been drawn by other experts who survey the polling data.15

Underestimation by Polls The surveys above may actually underestimate the extent of social agreement about the importance and justifiability of social minimum programs. Here’s why. What I have called “belief in the social minimum” is a belief that an ideally just society should have a social minimum. If someone doesn’t believe that an ideal society should have a social minimum, let’s call their opposition ethical. But when people accept that society should have a social minimum, but believe that some specific social 14. Gilens, Why Americans Hate Welfare, p. 2. 15.  For instance, Page and Jacobs write that “[Americans] expect individuals to take care of themselves, but they accept that government help may be needed to address concrete barriers to pursuing opportunity. Americans favor programs that equip individuals to pursue employment opportunities through education and training, and programs that protect them from threats to economic security such as illness, old age, or disability” (Class War?, p. 3).

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minimum program somehow isn’t furthering that goal, or isn’t furthering it as well as some alternative, let’s call this opposition to the particular program practical. Polls may underestimate ethical agreement because they can make it look as if Americans are ethically opposed to social minimum programs even when their opposition is merely practical. Take the Harris Poll cited above. 40% of Republicans didn’t favor Medicaid, and 15% of Americans didn’t support social security. Perhaps such people are ethically opposed to those programs, but instead, many might believe that the current programs merely have significant practical problems and should be replaced by better alternatives. For instance, Americans who think they should be allowed to privately invest some of their Social Security could show up as “opposed” to the program even though they support the principle behind it. This problem stands out when we ponder the results for items like “crime-​fighting and prevention.” 11% of Republicans said they don’t support “crime-​fighting and prevention.” Obviously, 11% of Republicans aren’t against having a police force. The negative answer merely indicates that they don’t like something about our current system, such as the level of policing or current drug laws. We might hope that different polls could separate ethical and practical opposition. For instance, some polls ask whether people “favor the government helping people who are unable to support themselves,” and one might think negative answers would always indicate ethical objections to social minimum programs. But that’s not so. Polls suggest that some people believe that social minimum programs almost always don’t work and thus universally oppose them on those grounds.16 Likewise, some respondents may oppose helping people who are “unable 16. Cf. the worry cited by Gilens, Why Americans Hate Welfare, p. 38, where many Americans say that the government doesn’t know how to eliminate

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to support themselves” because they interpret that to mean “people who don’t, for whatever reason, have enough money.” And then respondents may oppose government help because they believe that most poor people are simply lazy and unwilling to take available jobs.17 Ideally, we want polls that tease apart these subtle differences. Such polls are rare, though, and the best I  know of is rather old: a 1972–​1973 survey from the Research Institute in Social Welfare which suggests that most opposition is practical.18 There are less precise though suggestive polls from more recent years. For instance, a Quinnipiac Poll from 2017 showed that even among self-​identified republicans, 97% said it was important to them that health insurance be affordable to all Americans, with 69% saying it’s very important.19 So there are reasons to think that many polls underestimate ethical support for a social minimum. The next few sections offer evidence that most opposition to social minimum programs does not arise from opposition to a social minimum in principle but rather from worries about several specific practical problems.

poverty; as well as the discussion of a belief in (alleged) government incompetence in Fiorina, Abrams, and Pope, Culture War? See also Pew Research Center for the People & the Press, “Partisan Polarization Surges in Bush, Obama Years,” Section 4: Values About Government and the Social Safety Net.” 17. Gilens, Why Americans Hate Welfare, p. 56. Cf. p. 48. 18. Gilens, Why Americans Hate Welfare, p. 39. 19. Quinnipiac University Poll, “March 23, 2017—​U.S. Voters Oppose GOP Health Plan 3-​1, Quinnipiac University National Poll Finds; Big Opposition To Cuts To Medicaid, Planned Parenthood.”

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D ATA A B O U T T H E   S O C I A L M I N I M U M A N D T H E   U N DE SE RV I NG Despite a shared commitment to a social minimum, we know many Americans are suspicious of certain social minimum programs. In the Harris Poll quoted above, for instance, only 61% of the general populace supported Food Stamps, and that number went down to 46% among self-​identified Republicans. Likewise, a recent Pew Poll showed 37% of Republicans favoring reductions in “aid to the poor.”20 Skepticism increases even further when polls ask about “welfare.” (There is no government program called “welfare,” but respondents probably imagine a program like Temporary Assistance for Needy Families [TANF] or Food Stamps.)21 If we average the results of the General Social Survey from 1973 until 2016, we find that close to 50% of the general population thinks too much is spent on welfare.22 We also know that many Americans worry that social minimum programs are abused by undeserving individuals who could be supporting themselves.23 A  1995 NBC/​Wall Street Journal poll found that 61% of Americans thought poor people 20. Pew Research Center for the People & the Press, “How Republicans and Democrats View Federal Spending.” 21.  Kaiser Family Foundation, “National Survey of Public Knowledge of Welfare Reform and the Federal Budget,” table 14. 22. Data extracted from the National Data Program for the Sciences, “General Social Survey.” 23. Cf. Shaw, “Changes in Public Opinion and the American Welfare State.” Note that Americans worry about some programs more than others. Cook and Barrett found that when asked about recipients of Social Security, Medicaid, and Aid for Families with Dependent Children (AFDC), Americans felt that AFDC recipients were less likely than others to need the benefits, to want independence from the program, and to use benefits wisely (Support for the American Welfare State, p. 98). Americans also felt that AFDC recipients were more likely to have other sources of income if they wanted them, and to be at fault for being in the program.

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could get along without welfare if they tried, with 59% saying that “most able-​bodied people on welfare prefer to sit at home and collect benefits even if they can work.”24 Similar results are found in polls taken in recent years, such as a 2013 update of virtually the exact same survey.25 Americans also worry that welfare programs create need. In a 1985 Los Angeles Times poll, most Americans said that welfare makes poor people dependent, and only a minority said it helps poor people get back on their feet.26 Similar opinions are expressed in very recent polling as well.27 These worries about abuse correlate with opposition to social minimum programs. For instance, in a 1995 poll, 85% of Republicans, as opposed to 62% of Democrats, said that “there are jobs available for most welfare recipients who really want to work,”28 and as we’ve seen, Republicans are more likely to oppose social minimum programs. Other research confirms this result.29 Correlation is not always causation, of course, but in 24. Gilens, Why Americans Hate Welfare, p. 62. Note that the phrasing of the response is taken from Gilens and not from the original poll he is citing. Cf. Page and Shapiro, The Rational Public, pp. 124ff. for further polls of this sort. 25.  For example, NBC News/​Wall Street Journal Survey, “Study #13200.” A  report on this poll, comparing it to the earlier, 1995 poll, can be found here: McClam, “Many Americans Blame ‘Government Welfare’ for Persistent Poverty, Poll Finds.” 26. Lauder and Lauter, “Views on Poverty.” Cf. Gilens, Why Americans Hate Welfare, p. 56. Another example: a CBS/​New York Times survey from 1995 which found that 79% of Americans thought that most recipients were so dependent that they would never get off welfare (Gilens, Why Americans Hate Welfare, p. 37). 27.  See, e.g., Lauder and Lauter, “Views on Poverty”; and commentary in Doar, Bowman, and O’Neil, “2016 Poverty Survey.” 28.  Kaiser Family Foundation, “National Survey of Public Knowledge of Welfare Reform and the Federal Budget.” 29. Compare Page and Jacobs, Class War?, pp. 70ff. In Gilens’s work, he identifies two beliefs that play a pivotal role in the welfare debate: the belief that

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this case there are several reasons to think that the belief that programs benefit the undeserving drives some opposition to social minimum programs. First, support for social minimum programs varies with economic climate. When times are worse, support goes up, and when times are better, support goes down.30 Why? The obvious explanation is that in better economic times, people see welfare recipients as less deserving, and that is why they become more opposed to social minimum programs. Second, there is comparative data on support for social minimum programs. Support for some programs, such as Medicaid, does not vary greatly based on the respondent’s income level. But with programs like welfare, higher income levels correlate with reduced support. Why? Because wealthier people are more likely to believe that welfare creates dependence and ruins the work ethic.31 This seems to at least partly drive their reduced support for social minimum programs. Third, the American public is far more supportive of programs that cannot be abused by undeserving individuals. For instance, a 1995 poll found that an astonishing 96% of people support job retraining for welfare recipients, and 94% support providing child care to poor mothers who leave welfare

welfare recipients don’t really need the benefits and the belief that welfare recipients are primarily African American and that African Americans lack a good work ethic. He summarizes: “Both of these beliefs are strongly related to opposition to welfare: Americans who hold these popular views are strong opponents of welfare spending, while those who reject these beliefs think spending for welfare should be increased” (Why Americans Hate Welfare, p. 60). Gilens provides extensive, illuminating, and important research on the relationship between race and welfare, finding that attitudes toward African Americans are one of the primary drivers of the welfare debate. I discuss these issues briefly below. 30. Gilens, Why Americans Hate Welfare, pp. 46–​49. 31. Gilens, Why Americans Hate Welfare, pp. 53–​59.

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for work.32 Both programs can be used only by deserving individuals because, by definition, they are available only to people trying to support themselves. In contrast, support is markedly lower for programs that can be abused, such as unemployment benefits or welfare.33 Fourth, there is the persistent result that people strongly support programs that help “the poor,” but are highly critical of programs with specific names such as “welfare.” The difference is often a remarkable 30 to 40 percentage points.34 As Page and Shapiro note, these attitudes are not inconsistent with each other. . . . Most Americans don’t like the idea of welfare programs that give cash payments to people, some of whom may not be truly helpless and may thereby be discouraged from helping themselves. . . . But most Americans want to give jobs to everyone who can work; to provide basics like food and medical care to those who cannot otherwise afford them; and to take care of people in categories that clearly cannot help their condition:  the blind, disabled, aged, and the like.35

Having seen how worries about abuse drive certain debates about the social minimum, we should note that this worry doesn’t play a large role in debates about health care. For instance, Americans do not oppose, and even seem to support, the EMTALA law, which requires emergency rooms to treat acute conditions regardless of immediate ability to pay or any other factor, including deservingness. There is also some (very 32. Gilens, Why Americans Hate Welfare, p. 188. 33. Gilens, Why Americans Hate Welfare, p. 28. 34. Page and Shapiro, The Rational Public, p. 126. 35. Page and Shapiro, The Rational Public, pp. 125–​126.

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imperfect) polling on support for health care for the undeserving. Americans do not list the threat of abuse as a primary concern about extensions of the health care social minimum, and positively, polls sometimes indicate support for a universal social minimum.36 Finally, although it is not scientific data, any readers who have watched health care debates over the past thirty years will have undoubtedly noticed that the debates have not centered on abuse by the undeserving. Americans’ attitudes might seem inconsistent, since the threat of abuse seems to sometimes drive them to oppose non-​ health-​related social minimum programs. However, upon reflection this might not be so odd. Americans rarely seem to be in favor of cutting off their fellow citizens from all government benefits. As Elizabeth Anderson points out, even the most strident proponents of contributory obligations do not advocate cutting off undeserving citizens from certain public benefits, such as the right to vote, the use of police and fire services, or citizenship itself.37 So, to make sense of Americans’ attitudes, we would only 36. One poll from the 1990s indicates that 85% of Americans agree that the government is responsible for providing “health care for the sick” (Howard, The Welfare State Nobody Knows, p. 113; the quoted phrases are not from the original polls but instead from the book itself). A 2000 poll showed that 84% agreed that “health care should be provided equally to everyone, just as public education is,” and that 76% affirmed that “health care is a right” (Kaiser Family Foundation, “Kaiser Public Opinion Spotlight,” p. 9). Recent polls show similar results, though the polls are sometimes hard to decipher. For instance, some polls show substantial minorities of Americans saying that it is not the responsibility of the government to make sure all Americans have health coverage, with a majority of self-​identified Republicans agreeing. But the word “responsibility” might be skewing the results, since it might suggest that the government is responsible and individuals are not. Thus notably, even among those who say this is not a government responsibility, almost all favor continuing Medicare and Medicaid, with only a very small minority saying the government should have no role in health care at all. See, e.g., Bialik, “More Americans Say Government Should Ensure Health Care Coverage.” 37. Anderson, “Welfare, Work Requirements, and Dependant-​Care,” p. 246. The examples of police and fire services are mine, not Anderson’s.

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need to figure out why some public programs would be viewed as suitable even for the undeserving. Here it’s not my purpose to explore the reasons for that position, but as I’ll discuss in more detail later on, various arguments might support it. For instance, Menzel and Light’s article “A Conservative Case for Universal Access to Health Care” offers a number of arguments for universal provision which could be applied even to the undeserving, including the argument that lack of health care could result in debilitating medical problems, which would in turn prevent undeserving noncontributors from changing their ways and reentering the workforce.38 We might therefore support provision of medical care to the undeserving, not because they are entitled to it as a matter of distributive justice but because it is a means to our goal of eliminating free-​riding and abuse.

D ATA A B O U T T H E   S O C I A L M I N I M U M AND EFFICACY Although worries about the undeserving haven’t driven recent health care debates, the debates are affected by worries that social minimum programs might be ineffective, inefficient, counterproductive, or unnecessary. To reduce verbiage, I’ll lump these four distinct notions under the heading of worries about “efficacy.” Worries that health care programs are inefficacious has helped drive opposition to proposals to increase health insurance coverage in the United States. Take the Health Security Act proposed by President Clinton. Early in the debate, in late 1993, President Clinton was selling his ideas to the public fairly well, and close to 60% favored his plan. But even then, about 38. Menzel and Light, “A Conservative Case for Universal Access to Health Care,” pp. 38ff.

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half of the country didn’t believe that the plan would improve American health care,39 and 54% said Clinton’s plan was too complicated to work.40 By the time public debate was ending, only 33% of Americans believed the plan would be good for the country.41 These general complaints arose from more specific worries.42 The most common was about cost, a subject I’ll return to later. The second most common worry was that the government would become too involved in health care,43 and a large reason people worried about government involvement was that “69% said that when something is run by the government it is usually inefficient or wasteful.”44 The third most common worry was similar but more direct. Many people said the HSA would simply make the health care system worse.45 In the run-​up to the ACA, worries about efficacy also partly drove the health care debate,46 with many polls suggesting that Americans worried that the legislation would be inefficacious. 39. Jacobs and Shapiro, Politicians Don’t Pander, p. 229. 40. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 14. 41.  Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 8. Cf. Jacobs and Shapiro, Politicians Don’t Pander, p. 229; also Best and Radcliff, Polling America, p. 294. 42. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 11. 43. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 11. 44.  Gilens, Why Americans Hate Welfare, p.  60. Cf. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 13. 45. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 11. 46.  For an overview of some polling, see Blendon and Benson, “Public Opinion at the Time of the Vote on Health Care Reform.”

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For instance, a November 2009 Gallup poll asked why people favored or opposed the legislation. Among those opposed, the most common answers were worries that Gallup classified as “government-​run health care, bureaucracy, government takeover, and socialized medicine,”47 and the reason people worry about government involvement is that they are generally skeptical about the government’s ability to establish an effective universal health insurance system. For instance, a 2007 poll found that 42% of the population was “not too confident” or “not at all confident” that the government could provide quality health coverage to all its citizens.48 These concerns fit with the populace’s general distrust of government and skepticism about its competence.49 In fact, Americans are so pessimistic 47. Newport, “Costs, Gov’t Involvement Top Healthcare Reform Concerns.” One might think this indicates general opposition to any social minimum, but our previous discussion revealed that Americans are quite happy with programs like Medicare and Medicaid. Instead, it’s more likely that Americans worried about the ACA because they thought that it had particular problems of its own. In a Kaiser poll from January 2010, 37% said the ACA would leave the country worse off (Kaiser Family Foundation, “Kaiser Health Tracking Poll”; cf. Blendon and Benson, “Public Opinion at the Time of the Vote on Health Care Reform,” p. 355[5]‌). 48. Blendon et al., American Public Opinion and Health Care, p. 93. Another example:  a 2002 Harris Interactive poll asked Americans who they trust to make decisions about health care, and members of Congress came in last, even after drug companies, with 62% saying they don’t trust Congress (Best and Radcliff, Polling America, p. 293; cf. Jacobs, Shapiro, and Schulman, “The Polls,” p. 423). 49. Distrust of government has been increasing since the 1960s, and right now the percentage who say they trust government always or most of the time is in the 20s (Pew Research Center for the People & the Press, “Public Trust in Government: 1958–​2014”). Polls about “trust” rarely try to tease out the reasons for Americans’ distrust. However, the poll questions usually ask about trusting government to “do the right thing” or some variant thereof, so I will interpret Americans’ distrust to largely reflect worries about government efficacy. See Blumenthal and Morone, The Heart of Power for information on how worries about efficacy and trust in government have shaped national health debates.

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about government efficacy that many believe—​wrongly—​that America spends more on the poor than do other developed countries.50 In their minds, the problem of poverty persists at least partly because government programs are ineffectual. These worries about the government’s ability to improve American health care have persisted even years after the enactment of the ACA. In 2016, for instance, a Kaiser poll found that 42% of Americans believed that the ACA had increased health insurance costs generally.51 A Gallup poll found that over several years, about 16% of Americans consistently think that the ACA has made the health care situation in the U.S. worse, and an additional 35% think it has not made much difference.52 Americans seem particularly worried that programs will be wasteful rather than maximally efficient.53 As we just noted, in one poll 69% of the public said that “when something is run by the government it is usually inefficient or wasteful.”54 A slightly different question asked regularly over a twenty-​year span is “How much of every dollar the federal government spends is wasted?,” and the average answer is almost always between 40 and 50%.55 Americans’ average estimate of administrative

50. Lewis, Constructing Public Opinion, p. 125. 51. Kirzinger, Sugarman, and Brodie, “Data Note.” 52. Newport, “Americans Slightly More Positive Toward Affordable Care Act.” 53. For an overview, see Blendon et al., American Public Opinion and Health Care, pp. 16ff. 54.  Gilens, Why Americans Hate Welfare, p.  60. Cf. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 13; and Page and Jacobs, Class War?, pp. 53ff and 77ff. A slightly different question asked whether government was “almost always” inefficient and wasteful and found that approximately 40% agreed. See Fiorina, Abrams, and Pope, Culture War?, p. 18. 55.  Saad, “Americans.” Importantly, though, Americans may think that “wasteful” spending includes efficient but inappropriate spending. For

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overhead in welfare programs is 53%, though it actually ranges from 6 to 20%.56 In addition to being worried about ineffectiveness or inefficiency, the populace is, for obvious reasons, skeptical about unnecessary or counterproductive programs, and such worries are on the public’s mind in real-​world debates about the social minimum. Jacobs et  al. report that a substantial minority of Americans are always willing to say that “poor people are able to get needed medical care,” with numbers ranging from a high of 48% in 1982 to a low of 25% in 1991.57 And if people believe the poor already have reasonable access to health care, it’s not surprising that they would oppose a seemingly redundant national reform. Americans also express concerns that programs will be counterproductive. As noted above, many think that certain health reforms will make things worse rather than better. In a poll on welfare rather than health, 56% of Americans, including 50% of Democrats and 72% of Republicans, said that welfare programs do more harm than good.58 In sum, then, many Americans oppose specific social minimum programs because they believe those programs are ineffective, inefficient, counterproductive, or unnecessary.59 instance, the American population is notably opposed to foreign aid, and the average American also believes the federal government spends a great deal on foreign aid, with the average answer often coming in around 20% (see the Program on International Policy Attitudes, “Americans on Foreign Aid and World Hunger”). 56. Gilens, Why Americans Hate Welfare, pp. 60–​61. 57. Jacobs et al., “The Polls—​Poll Trends: Medical Care in the United States—​ an Update,” p. 404. 58.  Kaiser Family Foundation, “National Survey of Public Knowledge of Welfare Reform and the Federal Budget.” Compare Schneider, “Polling the Poor and Non-​Poor on Poverty.” 59. I suspect that worries about efficacy partly explain why many Americans prefer incremental change to a wholesale revamp of the health care system,

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D ATA O N   T H E S O C I A L M I N I M U M A N D FISCAL RESPONSIBILITY Another reason that some Americans oppose social minimum programs is that they believe those programs create fiscal risk and in turn threaten other important things, including important social goals or the state of the economy generally. For instance, Kulinski et al. asked people about the facts underlying welfare policy, such as how much of the federal budget goes to welfare or what percentage of the population receives it.60 Most respondents overestimated. Kulinski et al. then gave respondents correct information about the federal budget and measured change in support.61 Average support increased, indicating that at least some opposition is not principled but instead based on worries about cost. When we focus on health care in particular, we find similar results. Research clearly shows that Americans worry about the costs of a health plan, its effects on the deficit and debt, and the effects of deficits and debts on the U.S.  economy. During

even though they believe the system functions very poorly (Conklin, “Health Care,” p. 171). I don’t know of good data to verify this hypothesis, but one poll is suggestive. A 2009 NBC/​Wall Street Journal survey asked people whether they would be more concerned with “not doing enough to make the health care system better than it is now by lowering costs and covering the uninsured” or “going too far and making the health care system worse than it is now in terms of quality of care and choice of doctor.” Five percent did not answer, 44% chose the former, and 51% chose the latter (NBC/​Wall Street Journal, “Study #6098,” p. 18. 60.  Kuklinski et  al., “Misinformation and the Currency of Democratic Citizenship.” See also Wolfe, One Nation, After All, esp. ch. 5; and Cook and Barrett, Support for the American Welfare State, ch. 4. 61. Kuklinski et al. found that when simply presented with correct information, most respondents ignored it and continued on with their false beliefs. Kuklinski et al. then undertook a second study, the one mentioned in the text, which did not allow respondents to maintain their mistaken beliefs.

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the Clinton reform debate, many people opposed the plan because of its overall cost.62 Likewise, even though CBO analyses claimed (perhaps rightly) that the ACA would save money over time, many Americans didn’t believe it. Two months before the bill passed, 60% of Americans thought it would increase the deficit, including 83% of Republicans.63 About 30 to 40% of respondents also affirmed that in light of the U.S.’s financial situation at that time, “we cannot afford to take on health care reform right now.”64 Though Americans report worries about costs, it’s less clear whether these are the source of opposition or just fuel for an existing fire. I know of very little data on this. One poll suggests that people’s worries about “costs” are actually worries about their personal costs, the topic of the next section.65

D ATA O N   T H E S O C I A L M I N I M U M A N D P E R S ONA L   C O S T Some people oppose social minimum programs because of the personal costs. For instance, people sometimes oppose efforts to expand health insurance coverage because they worry about increased taxes,66 losing their own health insurance, or 62. Blendon, Brodie, and Benson, “What Happened to Americans’ Support for the Clinton Health Plan?,” p. 11. 63. Kaiser Family Foundation, “Kaiser Health Tracking Poll.” 64.  See, e.g., Penn, Schoen, and Berland Associates, “Divided We Remain”; and also Kaiser Family Foundation, “Kaiser Health Tracking Poll.” 65. See the Gallup 2009 polling results at Newport, “Costs, Gov’t Involvement Top Healthcare Reform Concerns.” 66. See, e.g., the Penn, Schoen, and Berland Associates poll from August 2009, “Divided We Remain.” See also Blendon et al., American Public Opinion and Health Care, p. 101.

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being locked into a government program that offers fewer choices.67 When Americans oppose health care programs because of personal costs, this might be a failure of moral motivation only. That is, those Americans might believe that a just society would have universal health insurance, but they oppose the program because it’s not in their self-​interest. However, there are also several ways to interpret worries about personal costs as moral concerns. Later I  will focus on the one that is most philosophically interesting, and I will give a brief preview of it here. It could be that Americans think of their duty to support social minimum programs as an associative obligation akin to those we have to friends and family, and they might also believe that we determine the limits of associative obligations in part by the level of sacrifice that various actions would require. For instance, suppose your brother asked for $500. Should you give it to him? The answer depends in part on what he needs. If he wants to buy a high-​definition TV, that’s a weak reason, but if he needs to have his broken arm set, that’s a much more pressing reason. Likewise you’d look at the costs. If giving $500 would merely decrease the amount you spend on fancy coffee for a year, that’s a less serious sacrifice. If giving the money would keep you from making your house payment, that’s far more serious. You’d compare the costs and benefits and decide whether you felt obligated to give him the money. The comparison is not made impersonally, so that you are obligated to lend him money whenever his gain exceeds your loss; instead the comparison is made on a weighted scale that places disproportionate emphasis on your interests. Nonetheless, it’s still true that the limits of obligation are partly a function of the loss imposed on you. If Americans thought of their duty to support a social minimum

67. Blendon et al., American Public Opinion and Health Care, p. 102.

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in the same way, then that would explain why personal cost seems to them to be a morally relevant factor when assessing social minimum programs. Interpreted this way, the moral principle at play would not be that a program’s costliness is a pro tanto reason against it, one that is to be weighed against the pro tanto obligation to support a social minimum. Instead the idea is that the proper level of the social minimum is at least partly a function of whether the benefits of the social minimum programs outweigh the personal costs, when judged on a weighted scale. That is not the only way to interpret the polling results about personal cost, but later I will explain why it is the most philosophically charitable one. Here the point is that the data show that personal cost grounds some opposition to extensions of the health care social minimum.

I M P L I C AT I O N S O F   T H E   D ATA This completes my brief sketch of some of the social science data. The data has several limitations, and in this final section I will describe a few of them and ask how they should affect our views about the connections between the real-​world health care debate and issues of fiscal risk, efficacy, and personal cost. One limitation is that fiscal risk, efficacy, and personal cost are surely not the only reasons Americans oppose certain extensions of the social minimum. For instance, in the debates about the ACA, some critics appealed to the need to resist nonexistent and entirely fanciful “death panels,” a worry that is obviously not about inefficiency, abuse, fiscal risk, or personal cost, but rather about individual rights. Likewise, the least popular component of the ACA was the individual mandate (now repealed), and those who criticized the ACA for including that mandate were obviously appealing to worries about personal freedom.

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For my purposes, it does not matter whether opposition to extensions of the health-​related social minimum is sometimes driven by things other than fiscal risk, efficacy, and personal cost. Recall that the point of presenting the data was to show that those three issues are not just of theoretical interest, but might also have real-​world impact as well. That would still be true even if the public debate is influenced by other factors—​as it surely is. I will note, though, that I do suspect that some factors either play less of a role in health care debates than the three factors that are the subject of this book, or (alternatively) that the additional factors are of less philosophical interest, even if they are operative in the public debate. Personal liberty is a good example. The social science data shows, I think, that issues of personal liberty are not the typical drivers of opposition to extensions of social minimum policies. Moreover, even when issues of personal liberty do become more prominent, as they certainly did in the recent health care debates, they are of less philosophical interest than issues such as efficacy, fiscal risk, and personal cost, because objections grounded in, say, complaints about individual mandates are hard to reconstruct in a philosophically plausible way. The complaints just don’t hold up under scrutiny, because as detailed in chapter one, mandates have both a sound economic rationale and also prevent free-​riding of a sort that most people, of any ideology, find unacceptable. In fact, as detailed below, many people withdraw their objections to mandates once they understand the economic and normative rationales for them. There are also ways for regulated-​ market systems to avoid mandates if they are found truly objectionable, so that is another reason why a mandate-​ based objection to universal health insurance is unlikely to succeed. Given that complaints about individual mandates don’t hold up philosophically, examining them is not as theoretically useful as examining factors like fiscal risk, efficacy, and personal cost, all of which might not

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only be drivers of the real-​world debate but also lead into rich philosophical territory. Even if I am right about factors like personal liberty, some people believe that if we confine ourselves to topics like fiscal risk, efficacy, and personal cost, we ignore what they believe to be some additional, more troubling factors influencing the debate over health care in America. For instance, some people think that opposition to health care reform is driven at least partly by psychological biases such as status quo bias. Others think that the debate is driven by much more nefarious forces and biases—​for instance, what one interlocutor of mine once called “laissez-​faire capitalism . . . pressed upon the body politic by a powerful few . . . deployed to manipulate the cultural and institutional racism still embraced by a vocal minority of the electorate who wield political influence disproportionate to their numbers.”68 Another interlocutor once expressed the opinion that some of those opposed to extensions of the social minimum are strongly influenced by “white ethnocentrism” and an “investment in traditional class and gender hierarchies.”69 Though these specific claims are surely controversial, a great deal of research confirms that biases related to race, gender, and class do influence public policy. For instance, research to that effect is presented in Gilens’s book Why Americans Hate Welfare, which is cited many times in this chapter. And it is certainly vitally important not to ignore the influence of such biases on public policy. However, depending on the exact upshot of the research on prejudice, it might or might not affect the particular point I am making in this chapter. For instance, if the allegation is that the vast majority of people who claim to be 68. From an anonymous review of this work. 69. From an anonymous review of my article “What is the Conservative Point of View about Distributive Justice?,” which contains an earlier version of some ideas presented here.

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concerned about fiscal risk, efficacy, and personal cost actually do not care about those issues, and that in truth they are really motivated by some form of bias, then I could no longer claim that personal cost, fiscal risk, and efficacy are issues influencing the public debate. The case for focusing on those issues would then have to rest on their philosophical interest alone. On the other hand, if the allegation is that some part of the population is motivated by bias, but that another significant part of the population is genuinely concerned about fiscal risk, efficacy, and personal cost, then the point made earlier still stands: these issues not only are of philosophical interest but also help shape the public debate. I will not pursue these issues further here. My goal was to lay out the data that leads some of us to conclude that issues of fiscal risk, efficacy, and personal cost play a real role in shaping public debate about health care, so that readers can make a decision about it on their own. In the end, though, the principal case for examining those issues rests on their genuine philosophical interest—​something that will become clear, I hope, as we now examine each one by one.

Chapter Three

PERSONAL COST

IN THE PREVIOUS CHAPTER, we saw that some Americans ob-

ject to social minimum programs, including certain health care programs, because they believe the programs impose excessive taxes and other personal costs on those who fund them. I’ll call this the objection from personal cost. Below I will argue that the most plausible philosophical reconstruction of this objection would rely on what I will call the personal cost principle—​a principle which says that the social minimum must be set at a level where the benefits to those who use social minimum programs outweigh the costs to those who fund the system, when those are compared on a scale that assigns disproportionate weight to the costs. (A proper social minimum might have to satisfy other conditions as well, but the personal cost principle is agnostic about that.) The personal cost principle, if true, could undergird an objection from personal cost, because the principle implies that if, for instance, the tax increases required by a certain extension of the social minimum are sufficiently high in comparison with the benefits, individuals are not required to pay those taxes, and the extension is unjust. I begin this chapter by showing that the personal cost principle can find a place within several plausible theories of justice, and thus that the personal cost principle is philosophically defensible. If more fully developed, some of these theories might provide a fairly rigorous test for when benefits “outweigh” costs,

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but I  will offer methodological reasons for not presupposing particular versions of such tests when engaging with people who are opposed to extending the health care social minimum. Then, in the central portions of the chapter, I argue that, despite not having a rigorous test for weighing costs and benefits, we can still provide a compelling explanation of why the benefits of a well-​designed universal health insurance system outweigh its costs.

MAKING PHILOSOPHICAL SENSE OF   T H E P E R S ONA L C O S T   P R I N C I P L E Appeals to the allegedly excessive costs of social minimum programs are often portrayed as nothing more than a display of selfishness and the desire to not pay taxes. Sometimes that might be the case, but in this section I argue that the personal cost principle, and therefore the objection built upon it, can be given a plausible moral rationale. Specifically, I will lay out three plausible political theories and show that some version of the personal cost principle can be grounded in each one. Of course, showing that a principle or theory is plausible is not the same as showing that it is ultimately correct, so after discussing plausibility, I will turn to the question of whether the principle should be granted to its adherents during debates about universal health insurance.

Nagel and Equality and Partiality In Equality and Partiality, Thomas Nagel proposes that there are two “standpoints,” as he calls them: “The impersonal standpoint in each of us produces  .  .  .  a powerful demand for universal impartiality and equality, while the personal standpoint gives rise to individualistic motives and requirements which present

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obstacles to the pursuit and realization of such ideals.”1 What is the proper balance between the competing reasons arising from each standpoint? In a later work, “The Problem of Global Justice,” Nagel considers the possibility that the impersonal standpoint carries enough weight that, despite the contravening reasons to pursue personal goals, we must help support the “standards of justice” for everyone in the world. And although he doesn’t specify what these standards of justice are, he indicates that they include the “standards of fairness” and “equality of opportunity,” and surely they also include the kind of social minimum that is required by the egalitarian theories of justice that Nagel clearly favors.2 Put another way: Nagel is considering the possibility that the impersonal standpoint carries enough weight that we must help support robust political institutions and programs for all others on the planet, regardless of whether they are our conationals. Though Nagel does not attempt to definitively disprove this position, he considers another which he clearly favors, the “political view.” According to this outlook, we have minimal duties to help those outside our own country, but much stronger duties toward conationals. We have those stronger duties to conationals because, first, the social rules governing a nation’s basic structure are being imposed in the citizens’ names, and second, because those citizens are “asked to accept and uphold those laws.”3 Given this, citizens are entitled to ask how the institutions show sufficient consideration for all involved, including themselves. What is sufficient consideration? Returning to the earlier work, Equality and Partiality, we find Nagel writing that

1. Nagel, Equality and Partiality, p. 4. 2. Nagel, “The Problem of Global Justice,” p. 119. 3. Nagel, “The Problem of Global Justice,” p. 130.

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a legitimate system is one which reconciles the two universal principles of impartiality and reasonable partiality so that no one can object that his interests are not being accorded sufficient weight or that the demands made on him are excessive. What makes it reasonable for someone to reject a system, and therefore makes it illegitimate, is either that it leaves him too badly off by comparison with others . . . or that it demands too much of him by way of sacrifice of his interests in comparison with some feasible alternative.4

Nagel believes that any legitimate system, so defined, will have many of the conventional features of a liberal political society:  equality of opportunity, a social minimum, and so on. I will not go into that reasoning in detail, because for my purposes, the important upshot of Nagel’s theory is that it reveals a plausible rationale for the personal cost principle. Recall that the personal cost principle says that the benefits provided by a proper social minimum must outweigh the costs, when judged on a weighted scale that assigns disproportionate weight to those bearing the costs. That principle can be taken to embody Nagel’s point that no part of the social minimum should make excessive demands on the personal point of view.5

Waldron, Rawls, and the Social Minimum The personal cost principle can find a place in other major theories of justice as well. Consider a position developed by Jeremy Waldron in response to John Rawls’s work. Rawls argued that the right principles of justice are those that would be chosen by contractors in a fair choice position which he called 4. Nagel, Equality and Partiality, p. 38. 5. Although, as noted below, Nagel rejects some of my assumptions about just baselines, and so he needs at least a modified version of the personal cost principle to balance the personal and impersonal points of view.

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the “original position.” Many of Rawls’s arguments in A Theory of Justice focus on showing that contractors would choose his principles, collectively called “Justice as Fairness,” over a utilitarian principle. But as Rawls himself notes, another key question is whether contractors would choose Justice as Fairness over a “mixed conception.” A mixed conception and Justice as Fairness both have lexically ordered principles of equal basic liberty and fair equality of opportunity as their initial principles, but their third principles differ. Justice as Fairness requires basic institutions that maximize the index position of the least advantaged. In contrast, a mixed conception requires that all citizens be guaranteed a certain social minimum and that average wealth and income be maximized thereafter. Very roughly speaking, a mixed conception is akin to the actual practices in most developed democracies. They (imperfectly) offer a social minimum, though not one that maximizes the position of the least advantaged. In A Theory of Justice, Rawls offered several objections to mixed conceptions.6 One was that contractors cannot even properly define the social minimum principle of a mixed conception. Where is the minimum to be set? Why? In response to those objections, Waldron pointed out that one can define the social minimum using Rawls’s own concept of the “strains of commitment.” The strains of commitment arise whenever individuals in a political society offer that society only “sullen and apathetic allegiance” and perhaps even “regard the institutions of their society with hostility.”7 Waldron suggests that the social minimum should be set at just the level where the strains of commitment disappear—​that is, at the level where all in society can offer “enough active support to constitute an entire social

6. See Rawls, A Theory of Justice, section 49. 7. Waldron, “John Rawls and the Social Minimum,” p. 261.

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structure and sustain it through the ordinary vicissitudes of political life.”8 Interestingly, though Waldron’s position is initially formulated in Rawlsian terms, he later defends it without relying on the Rawlsian contractual apparatus. One of his starting points is the observation that a foundational principle of modern democratic societies is that they seek the “support and not merely the subjection of [their] citizens.”9 Naturally we cannot expect 100% support; there will always be some “pathological” law-​ breakers (as Waldron calls them) who actively undermine a society’s laws and institutions, no matter how well-​constructed those laws and institutions are. However, Waldron’s point is that, to be legitimate, societies must ensure that the reasonable, nonpathological citizens support the society rather than actively resisting the state and its policies, engaging in serious antisocial behavior, or more generally suffering from what I will call “political disaffection,” where they fail to provide their share of the active support needed to maintain a well-​functioning political community and sustain it through the ordinary vicissitudes of political life.10

8. Waldron, “John Rawls and the Social Minimum,” p. 270. 9. Waldron, “John Rawls and the Social Minimum,” p. 267. 10. There is an important complication here that I can only briefly note. It is highly plausible that whether people “resist the state” is a function of environmental factors (e.g., the cost of resistance) as well as the prevailing ethos (e.g., whether the least advantaged have been indoctrinated to think that they do not deserve certain goods, or that they can get them without assistance so long as they work hard enough). It seems to me that Waldron’s theory is incomplete without a way of addressing these issues, and I see two basic directions in which to develop the theory further. One is to say that the level of the social minimum is contingent on these factors as we find them, though that has the seemingly problematic implication that the social minimum may be set lower so long as we indoctrinate people to believe they deserve less. Another

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With this point in hand, Waldron turns his attention to what happens when people—​even reasonable people—​are deprived of basic goods. He notes that it is no accident that we often speak of “needing” these basic goods: Sometimes, “need” is used in a way that connotes, not merely necessary instrumentality, but a certain subjective or appetitive state or condition. To need something is to suffer a lack, but in the sense I am talking about it is also to suffer a lack—​to experience it as a burning frustration and as a crippling and overwhelming debility. If, in Anscombe’s phrase, “the natural sign of wanting is trying to get,” the natural sign of this sort of needing may be the desperate and reckless activity oriented to getting whatever it is the lack of which is so sorely felt.11

Moreover, Waldron points out that the reckless behavior and law-​breaking that might result from need, so defined, is distinct from other antisocial and criminal behavior because the reckless impulsion of action by need is a normal human phenomenon. . . . It is the normal condition of a human who lacks certain things; it is the state that beings like us normally, naturally, and perhaps properly get into when the wherewithal for their health, flourishing, or survival is lacking. Let me appeal to the readers own feelings on a couple of examples. Surely any of us, asked in advance whether he would like therapy to remove the urge to grab others’ surplus food should he be desperately hungry, would repudiate the offer as an insult.12 is to set the line with reference to the hypothetical behavior of some idealized people—​perhaps those who have all the proper rights of protest under a liberal government as well as full information, including both empirical information and moral information about their proper moral standing. 11. Waldron, “John Rawls and the Social Minimum,” p. 264. 12. Waldron, “John Rawls and the Social Minimum,” p. 266.

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Now Waldron is in a position to make his argument for a social minimum. A society is legitimate only if it has the willing support of its reasonable citizens. But even reasonable citizens will become politically disaffected if their needs aren’t met, and so a legitimate society must have a social minimum which meets those needs. Waldron’s theory needs one important addition, I  think. He does not emphasize as much as he should have that political disaffection can also arise when citizens feel that others have shown their interests very little consideration, regardless of whether that puts anyone in a state of “need.”13 In particular, the least advantaged citizens might feel severe hostility toward society when they suffer relative deprivations in well-​ being that could be avoided with fairly minor sacrifices from the more advantaged—​a situation where, as Waldron puts it, their “interests have been neglected or sacrificed for the sake of others.”14 This phenomenon is familiar from everyday life. Consider, for instance, a situation where a person who is struggling financially asks his wealthier sister for a loan so that he can make a down payment on a car that will allow him to cut an hour per day off his commuting time to work. If his sister turns him down because the loan would put her mortgage at risk, he might nonetheless be able to continue the sibling relationship willingly and without hostility, even though the loan was refused. If his sister turns him down just so that she can replace her koi pond with a bigger one, though, he might naturally react by feeling severe anger and a desire to distance himself, at least temporarily, from his sister. This is often the natural reaction when we feel disvalued, and it makes sense. We expect certain people, such as our siblings, to care about us to a certain 13. Though see Waldron, “John Rawls and the Social Minimum,” p. 263. 14. Waldron, “John Rawls and the Social Minimum,” p. 261.

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degree. When they don’t, one feels a need to express dissatisfaction, behaviorally or otherwise, rather than simply going on as though everything is fine. “I can’t be around you right now” is a common response to feeling that one’s relationship has gone awry. Moreover, note that to have these reactions, the brother need not believe that his sister had an obligation to provide him with the loan. Instead he might simply feel that her behavior signals that she cares very little for him or his well-​being. We can imagine him thinking: She knows that because of my long, repetitive commute—​day after day—​I regularly feel boredom, frustration, and discomfort. But instead of doing something about it, she preferred to build a new koi pond. She just doesn’t care about me as much as I would have hoped that she did. Similar things can happen in a political context. Imagine you’re one of the people in our society who works very hard but still cannot afford secure shelter in a safe neighborhood. You then find out that certain perfectly feasible social policies would remedy this, and that those policies would require relatively minor sacrifices from others. It would certainly be sensible to wonder whether the other people in your society cared very little about your well-​being. Or, to give another example, suppose you were one of the homeless, without secure and adequate food, shelter, or medical care. You find out that others could improve your situation at least somewhat with relatively small sacrifices. You might then conclude that others place very little value on your well-​being.15 Conclusions such as these can in 15. Note when relative deprivation results in the feeling that others value us very little, that feeling can, in turn, inspire additional negative feelings—​ones that are even more extreme. This happens because the idea that others care very little about us sometimes leads us into troubling speculations about the people who don’t help us. We wonder why they care so little, and sometimes we end up considering the possibility that they think of us as second-​class citizens, either because of what we are or because of something we’ve done. In a limit case, these experiences can begin to erode our self-​respect, because we not only sense that others think we’re second-​class citizens, but we begin

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turn lead to political disaffection. When people feel that others in their political society care too little about them, they distance themselves from the political system, just as the brother distanced himself from the sister. We know, for instance, the least advantaged in society are less likely to vote, more likely to say that no one represents their interests, less likely to stay politically aware, and so on. Those are behaviors which, if practiced generally, would make it hard for a political society to function well and sustain itself through the ups and downs of normal political life. The sense that some citizens care little about the well-​being of others has led to political disaffection. Furthermore, because human beings are social primates who are naturally sensitive to status, this sort of disaffection is just as natural, I  suspect, as the disaffection that arises in response to Waldron’s “needs.” In fact, it’s interesting to note that, while Rawls is often cited as the paradigm of a political philosopher who thinks that the feelings that result from relative deprivation, such as envy, should play no role in the choice of a social system, even he thought that some of these feelings are so natural and normal that we cannot expect people to set them aside: Sometimes the circumstances evoking envy are so compelling that given human beings as they are no one can reasonably be asked to overcome his rancorous feelings. A person’s lesser position as measured by the index of objective primary goods

to wonder whether they are right. Being in the presence of (what we perceive to be) a lack of respect from others leads us to consider or glom onto the idea that we really do have lower status than everyone else. To return to an earlier example, if you were homeless in America, lacking health care, food, shelter, and so on, you not only might conclude that your fellow citizens care very little about your well-​being but also wonder whether they viewed you as some sort of inferior person. And then, in the most extreme case, you might begin to wonder whether you really are a second-​class citizen. Relative deprivation has damaged your self-​esteem.

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may be so great as to wound his self-​respect. . . . Indeed, we can resent being made envious, for society may permit such large disparities in these goods that under existing social conditions these differences cannot help but cause a loss of self-​esteem.16

How do these insights about relative deprivation affect Waldron’s original argument? His key political premise was that a society is legitimate only if it has the willing support of its reasonable citizens. But we now know that reasonable citizens will become politically disaffected when they suffer relative deprivations that others could prevent with fairly minor sacrifices, and so a legitimate society must set the social minimum so as to avoid deprivations of that sort.17 With Waldron’s reasoning laid out and combined with additional insights, we can see how the personal cost principle again finds a place within a larger framework of justice. We must create a society that citizens can willingly support, either because we are Rawlsians who believe that contractors must design a society that avoids the strains of commitment, or because, like Waldron, we believe that willing support is a requirement for democratic legitimacy. Gaining willing support requires satisfying basic needs, but also providing a level of well-​being which does not leave the least advantaged feeling that others care very little about their lives and well-​being. And as our examples above made clear, whether the least advantaged feel that 16. Rawls, A Theory of Justice, p. 468. 17. An advantage of taking on this insight is that it can help explain why many of us feel, intuitively, that the level of a proper social minimum is not a fixed line that satisfies some objective and invariable list of “needs” but rather a line that adjusts upward as society’s wealth increases. We must fix the social minimum at the level which avoids these intense forms of resentment and hostility toward society, and it may be a natural fact about people that they begin to feel intense hostility toward their conationals whenever they suffer relative deprivations of certain substantial sorts.

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way will be, in part, a function of how much alternate social arrangements would cost the more advantaged.18

The Teleological Welfarist Account of Associative Obligations Let me consider one final framework that could vindicate the personal cost principle. It views obligations to conationals, including our duty to support a social minimum, as an instance of the larger class of duties called associative obligations. Some distinctive features of associative obligations are that they hold only between members of the association and not among people qua people, and that they are often not the result of explicit agreement but instead arise out of the nature of the associative relationship itself. On the face of things, familial obligations certainly look like associative obligations, so described. So do civic obligations, since, despite a long literature that attempts to treat our civic duties as the result of voluntary or quasi-​voluntary agreement,19 it seems as though we acquire our civic obligations simply by being born into a certain civic group. There is an extensive philosophical literature on associative obligations. One promising theoretical account of those obligations might be called, following Seth Lazar, the teleological welfarist account, or TWA.20 The TWA begins with the observation 18. Although I do not personally believe it, it is possible that the least advantaged will always feel resentment and envy so long as others have more than they do, and that the resentment and envy will be intense enough so as to spur social resistance. If so, the theory just sketched will imply that the social minimum should be set, pro tanto, so as to make all people equal. I leave aside this objection because my main reason for considering this theory is to show that objections from personal cost can find a place within a framework of justice, and that conclusion would hold even if the theory implies a pro tanto obligation to set a very high social minimum. 19. See van der Bossen, “Associative Political Obligations.” 20. See Lazar, “The Justification of Associative Duties.” My subsequent exposition of the TWA draws heavily on Lazar’s, to which I’m indebted.

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that certain relationships enhance the well-​being of those who participate in them. For instance, our lives go better when we have friendships, romantic relationships, and healthy parent-​ child relationships. Furthermore, such relationships are not possible unless we give certain kinds of priority to the interests of other people in those relationships. Friendship would not be friendship, for instance, unless one at least sometimes, and in some circumstances, gave a friend’s interests higher priority than those of a stranger. Likewise parents could not have a recognizable and healthy parent-​child relationships unless the parents generally gave their child’s interests higher priority than those of other children. Furthermore, the TWA assumes that morality is, at a basic level, concerned to some extent with making possible rich human lives.21 This does not mean morality is utilitarian and instructs us to maximize human welfare with each act. Instead the TWA works from the more minimal assumption that because morality is concerned with making possible rich human lives, the structure of any proper moral system should not rule out the most basic things that give meaning and value to our lives, including certain kinds of special relationships. These two assumptions, taken together, have significant implications. If the structure of morality should not rule out the basic relationships that give meaning and happiness to human life, and if those relationships are possible only if we sometimes place disproportionate weight on the interests of the people in them, then it follows that morality cannot require impartiality between all people but must instead allow us to favor those with

21.  The assumption is often implicit, though. A  fairly clear statement is in Cottingham, “Partiality, Favouritism and Morality,” p. 363.

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whom we have certain relationships, at least sometimes and to some extent. Morality allows us to be partial. Moreover, if we return to our initial assumption that morality must not rule out features of rich human lives, we see that there is a separate line of argument from this idea, not to permissions for partiality, but to the conclusion that morality should even require us to favor or promote the interests of our special relations at certain times. These are the times when, as Miller puts it, “the relationship could not exist in the form that it does unless the duties were generally acknowledged.”22 The idea here is straightforward. If we have accepted that morality is structured so as to not rule out these relationships, and if we accept that these relationships could not exist without the general acknowledgment of related duties, then these duties will be part of any correct morality.23 Now, why might the existence of a relationship depend on the general acknowledgment of certain duties? There are two possibilities. In some cases, general acknowledgment of certain associative duties is a vital means to achieving the valuable relationships, because unless those duties were generally acknowledged, we probably just couldn’t, in fact, manage to hold together the relationships in question.24 On at least some occasions, though, the duties are constitutive of the relationship. For instance, writing of friendship, Joseph Raz says that a “relationship between two people who enjoy amusing themselves in each other’s company but do not owe each other any special 22.  Miller, “Reasonable Partiality Towards Compatriots,” p.  65. Compare Scheffler, “Relationships and Responsibilities,” pp.  100–​ 101; and Raz, “Liberating Duties,” p. 19. 23. Though the consequent is not strictly implied by the antecedents, since we would need to rule out the possibility that morality does not require us to fulfill the duties but does require that they be generally acknowledged. 24. Cf. Friedman, “The Practice of Partiality,” p. 820.

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duties is not friendship.”25 These differences aside, so long as we accept that duties toward our special relations exist when their general acknowledgment is necessary for the continuation of the relationship in our world as we find it, we arrive at the conclusion that we are in some cases required to do things for those with whom we have associative relationships that we would not be required to do for others. With the fundamentals of the TWA before us, it’s worth noting several subtleties. First, defenders of the TWA often add that for there to be obligations or permissions to be partial to those in a certain group, the relationship itself must not carry other substantial costs to human welfare.26 This is intended to rule out the idea that one could have associative obligations to, say, one’s racist gang. I suspect that qualifications like these could be shown to flow from the more general idea that morality’s structure aims to make possible good human lives. It does so when it makes room for meaningful or valuable associative relationships, but not associative relationships that are generally destructive of the human good.27 Second, given that the TWA says that morality should not rule out relationships that give meaning and value to our lives, does that mean that partiality is allowed only in relationships that offer some unique value? This issue comes up, for example, in discussions of parent-​child relationships. They add value to human lives because they are loving relationships, but of course they are not the only kind of loving relationships. Someone might ask why morality should make room for these kinds of 25. Raz, “Liberating Duties,” p. 19. Lazar tries to straddle the two positions, saying that “for a duty to be justified by the value of a relationship, it must be a necessary condition of the relationship obtaining in our world” (“A Liberal Defence of [Some] Duties to Compatriots,” p. 3). 26. See, e.g., Miller, “Reasonable Partiality Towards Compatriots,” p. 63. 27. Cf. Cottingham, “Partiality, Favoritism and Morality,” esp. pp. 370ff.

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loving relationships in particular. Why not instead make room only for other relationships that provide the same good? Some defenders of the TWA have accepted the call to show that parental relationships provide some unique good.28 Whether these arguments are plausible or not, I think they are unnecessary. We only need to show that parental relationships, or any other relationships, are one central contributor to a good life, given the present contingencies of human society.29 We can see via reductio that this more relaxed standard is the correct extension of the TWA. Suppose it turns out—​as it might turn out—​that no kind of relationship uniquely provides a form of happiness or meaning, and that instead all forms of happiness or meaning are available in at least two kinds of relationships. If morality allowed partiality only in relationships that uniquely provide certain goods, then it would thereby rule out all partial relationships. And that would be not only absurd but in direct contravention with the TWA’s key assumption that morality is structured so as to not rule out relationships which bring happiness and meaning to human lives. Thus the TWA implies instead the more relaxed standard that morality allows partial relationships that are central contributors to a flourishing life in the world as we find it.30

28.  For instance, Cottingham argues that parental love involves weighing the welfare of others higher than your own, contending that that is not typically the case in romantic love. See “Partiality, Favouritism and Morality,” esp. p.  368. For another attempt to show parental love has unique features, see Keller, “Four Theories of Filial Duty,” esp. pp. 267–​268. 29. On this point, see Keller, “Four Theories of Filial Duty,” p. 268. 30. This is compatible with the further idea that there is a better future available to humankind, perhaps one with different typical familial arrangements, and that each of us must work toward it. Note as well that I have not tried to rule out the possibility that if several kinds of relationships each provide a certain good, morality would not rule out some but would rule out others. Although that is a theoretical possibility, I can see no rationale for it.

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Given these general features of the TWA, it’s not hard to see how it might vindicate a fairly commonsense conception of some of the relationships mentioned in passing earlier, such as romantic or family relationships. However, we can also ask whether it’s a plausible account of duties to conationals. For the TWA to entail that we have associative obligations to conationals, it must be true that national relationships contribute to human flourishing in the world as we find it. Why is that? Defenders of the TWA have given a variety of answers,31 but I will develop only one of them here.32 Consider Cottingham: It is . . . plausible to argue that human beings . . . find it difficult to flourish unless they can integrate their lives into at least some network of partiality, some structure of mutual dependence and loyalty, that operates on a wider scale than self-​ directed partiality and philophilic partiality. Complaints about the “rootlessness” among modern city dwellers, and the rise of separatist movements within large nation-​states or federations, provide at least some evidence that, in order to live happy lives, human beings may require, beyond self-​concern and family concern, wider partiality structures of interdependence.33

31. For instance, Lazar has argued that certain forms of liberal national relationships help realize our (pre-​existing) duties of justice toward each other (“A Liberal Defence of [Some] Duties to Compatriots,” esp. pp. 3ff.). Mason has argued that some kinds of national relationships allow us to be part of a collective body in which we enjoy equal status with others, exert control over the conditions of our lives, and contribute directly or indirectly to the laws and policies of the national group (“Special Obligations to Compatriots,” esp. pp. 442ff.). 32. For criticism of these attempts by advocates of the TWA, see McMahan, “The Limits of National Partiality”; and Simmons, “Associative Political Obligations.” 33. Cottingham, “Partiality, Favouritism and Morality,” p. 372.

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And in a similar vein, Miller writes that people want “the opportunity to place their individual lives in the context of a collective project that has been handed down from generation to generation . . . and whose future they could help to determine.”34 At first glance, these authors seem to be making the very plausible point that part of human flourishing involves taking part in large-​scale, collective, and potentially life-​transcending projects. But this point alone does not make the case for the value of national relationships for at least two reasons. One is that even if we were partial only to smaller groups such as family and friends, and impartial toward all others, one might still participate in collective and potentially life-​transcending projects by, say, working in an impartial way toward the relief of the worst forms of global poverty. Another reason is that even if participating in large-​scale collective projects required working toward some national project, nothing in what has been said would explain why individual flourishing requires working toward the large-​scale collective projects of one’s own nation in particular. So if we are to develop this line of thought in a promising direction, we must place the argumentative weight on Cottingham and Miller’s notions of “having roots” and of a project that is “handed down.” We desire to understand the larger social group or groups which shaped our lives in particular, to be bonded to those groups in a meaningful way, and to participate in and further at least some of that group’s ongoing projects and interests. By doing so we understand, affirm, and take part in our heritage, our “roots.” Now it’s relatively easy to concede that people actually do desire national relationships of this sort, but that is not the same as admitting that such relationships add value to a

34. Miller, “Reasonable Partiality Towards Compatriots,” pp. 68–​69.

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human life. The latter point can be backed up, in part, through introspection. After all, how do we determine that human lives would be impoverished without relationships involving intimate love, such as romantic and parental relationships? Simply by imagining lives without these things and then thinking about whether the individuals living those lives are faring well. We can also imagine a life where we have nothing like our current national relationships and the rootedness they provide, and when we do, we feel that such lives are impoverished in significant ways. Moreover, if we want further explanation of why wider partiality relationships that alleviate rootlessness have value, we can ground this idea in various foundational theories of human well-​ being. On hedonistic and desire-​ satisfaction accounts, national relationships can add value to lives because they add pleasure to lives and/​or satisfy what ordinary experience proves are widespread, informed human desires. Objective list accounts are trickier, because one must determine which things are on the list. But it is worth noting, first, that pleasure and desire-​satisfaction are plausibly regarded as at least two things on the list, even if more “objective” things are on it too, and second, objective list theorists typically determine which things are on the objective list by looking at what informed and rational people seek in their lives. And as we’ve already discussed, this includes national relationships that alleviate rootlessness by allowing us to participate in the projects of the community that we come from and that has so profoundly shaped our lives. If participation in national relationships advances human flourishing in the world as we find it, then the next question is what the TWA implies about the permissions and obligations we have toward our conationals, and in particular whether it implies that we have a pro tanto obligation to care for each other by providing a social minimum in food, shelter, and so on. To show that this is an obligation in national relationships, we would have

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to prove that national relationships (of the valuable sort alluded to earlier) could not go on without a generally recognized duty to care for our conationals via a social minimum. Is that so? We can go a certain distance toward that conclusion by noting that the relationships in question require, as a conceptual matter, some level of added concern for the welfare of one’s conationals. Recall that we are interested in not just any old relationship between conationals, but rather one that alleviates a certain sort of rootlessness and provides a sense of participation in one’s heritage. And to be bonded to a group in a way that achieves that goal, one must feel more concern for the welfare of the members of the group than one would for a complete stranger.35 For while one can imagine some (wholly hypothetical) national relationships which involve no care for the well-​ being of one’s conationals—​e.g., national relationships in some imaginary country devoted only to the good of the state and never to the good of its members—​it is nonetheless true that the kind of national relationships that human beings actually form and seek out, the ones which do in fact seem to alleviate the rootlessness and desire for heritage that Miller and Cottingham speak about, involve special concern for the welfare of others in the group. This is why it seems that no real-​world people from, say, England could sincerely claim deep identification with England, their English heritage, and England’s ongoing projects at one turn, but also say that they don’t care to any special degree about the welfare of the English people.36

35. Cf. a similar point in Oldenquist, “Loyalties,” p. 188. 36.  Note that there is surely an interesting debate about whether the world could come to think of itself as one community with a global heritage, and whether one could then have a sufficiently robust feeling of rootedness in that heritage without taking on distinctively national projects. But while that may be possible and even desirable—​an ideal to work toward—​it is surely not easily available to most people in the world as we find it.

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But we cannot stop there, because even if we can reach the conclusion that participants in these kinds of national relationships are obligated to show some added concern for their conationals, it would take additional argumentation to show that they have an obligation to support a social minimum of the sort we ordinarily see in industrialized countries, for several reasons. Chief among them is that we would need to show that conationals are required not only to show special concern for their conationals, but enough concern that they must make the substantial sacrifices required to fund a social minimum.37 I will not pursue that argument farther here, because the theory as developed so far already allows us to see how any duties to support a social minimum that are vindicated by this theory might be constrained by the personal cost principle. To show a particular level of care or concern—​for one’s conationals or anyone else—​is not a matter of doing a specific list of things. Instead whether we have shown the appropriate level of care 37. There are two other reasons worth noting. (1) So far we have shown only that conationals should place special weight on their conationals’ welfare, but we have not yet offered any concrete theory of what advances human welfare. And although it is perhaps a remote possibility, there are certainly theories of human welfare which would not be compatible with social minimum policies. In a certain kind of militaristic or warrior society, for instance, it might be thought that offering aid of certain sorts to one’s conationals actually decreases their welfare, perhaps because it renders them objects of charity or compassion, takes away their honor, or prevents them from dying a noble death of struggle. (2) A complete case for the social minimum would also have to respond to theories of justice, such as right-​libertarianism, which sometimes accept that we do have a moral duty to care for our conationals, but that it is wrong for the state to enforce this duty via social minimum policies. Although I don’t have the space to fully bridge these gaps here, I think it is fairly easy to see how they can be bridged. The first issue requires only that we defend an account of human welfare in which we sometimes advance individual well-​being through government programs that prevent hunger, illness, and so on, and surely that is manifestly plausible. The second issue requires that we lodge compelling objections to right-​libertarianism, and that territory is well-​explored in the philosophical literature.

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or concern is at least partly a function of the costs and benefits of any proposed action. Returning to a familial example, if I would give my brother money for a new interview suit only when it costs me slight luxuries, that shows one level of care and concern, but if I do it even though the loss of money means I won’t be able to get my car repaired, that shows a greater level. The personal cost principle can be understood, therefore, as a principle whose truth follows from the more general theoretical points that we have an associative obligation to show a certain level of care and concern for our fellow citizens, and that the level of care and concern displayed in any given action are to be partly judged, as always, by looking at the costs and benefits.

G R A N T I N G T H E   P E R S ONA L COST PRINCIPLE DURING P H I L O S O P H I C A L   D E B AT E The previous section argued that the personal cost principle can find a place within several reasonable views about political justice. However, that is not the same as establishing that the principle is true, so when critics of universal health insurance appeal to the principle as part of an objection from personal cost, there are still two ways to respond. One is to argue that the principle, though reasonable, is false. Another is to grant the truth of the principle, if only for argument’s sake, and then argue that it does not lead where critics of universal health insurance want it to. Of course, there would be nothing wrong with trying to argue that the personal cost principle, or the theories upon which it might rest, are false, and doubtless some will prefer that way of dealing with the objection from personal cost. I will avoid that route, though. My reasons are partly pragmatic. I think that the objection from personal cost can be debunked without entering tangled debates about fundamental political

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principles, and I  think such arguments are more likely to be convincing than ones which try to disprove the principle outright. In addition, there are methodological reasons to think that arguing over the truth of the personal cost principle is not likely to yield what philosophers would consider to be a good argument, at least when that notion is understood in a certain, common way. Explaining this point requires a brief detour into philosophical methodology.

Other-​Oriented Political Philosophy Philosophical argumentation is often other-​oriented: our goal is to offer arguments which should be accepted by our audience, were the audience to react rationally to the evidence presented. Notice that this is not the same as having the goal of merely persuading others, a goal that might be furthered by giving bad arguments that happen to be psychologically convincing. Instead other-​oriented philosophical argumentation aims to lay out reasoning that ought to be convincing to reasonable audience members. This other-​orientation is familiar in philosophy, I  think. Imagine that an author was trying to argue for the permissibility of some kinds of abortions, for instance, and that he gave an argument like this one: 1. A woman’s right to do what she wants with her body, including having an abortion, outweighs any competing rights to life that a fetus might have. 2. There are no other competing considerations that would override a woman’s right to do what she wants her with body. 3. So, a woman may permissibly have an abortion.

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Using conventional textbook definitions, this might be a good argument—​ perhaps the two premises are correct and provide strong support for the conclusion. But most philosophers would consider this argument a failure if it were put forward in the context of the typical contemporary debate about abortion. The reason is that we know many reasonable people reject the first step, and perhaps the second step as well, and the argument doesn’t give them any reasons to change their view. Thus even if they react rationally to the evidence presented to them, the argument should not convince them. Contrast this argument with Judith Thomson’s famous argument for abortion rights in “A Defense of Abortion.” Part of Thomson’s argument consists in putting forward a memorable case of an ailing violinist and then eliciting the audience’s considered judgments about it. I  won’t go into a full analysis of Thomson’s work here, but even leaving those details aside, we can recognize that one reason the paper is justly famous is that Thomson found an example that elicits similar considered judgments from many people of otherwise different ethical outlooks while also having the potential to help resolve vexed questions about abortion. In other words, she went at least some distance toward offering an argument that should convince a wide range of audience members, were they to react rationally to the argumentation presented. If our debate over the personal cost principle is to be other-​ oriented in the sense just defined, then any successful arguments against the principle must be ones that should convince the target audience to give it up, were they to react rationally to the evidence presented. And since, as we’ve seen, the principle might be embraced as a consequence of several prominent theories of justice, a successful other-​oriented argument against the principle would need to be one that should convince people to give up those theories, as well as any other theories that sanction it. Can we give such an argument?

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Sometimes philosophers appear to express the view that arguments of this force and generality are possible. For instance, in his earlier work, Rawls seemed to express the hope that if people properly employed his favored argumentative method of wide reflective equilibrium, then all or almost all people would come to accept his political theory, Justice as Fairness. And though less explicit, other egalitarian philosophers such as Nagel and Dworkin write as though they have the same optimistic outlook. But I have doubts. All the major political theories have well-​developed arguments in favor of them, and they also have well-​known problems, including problems of internal coherence and problems with their justifications.38 As a result, choosing between them is not a simple matter. Instead it involves a complex series of judgments about whether a theory is on the whole meritorious and how it compares to others. Consider the process of evaluating even just a single known problem with a given theory. Since the major theories of justice are not outright contradictory or based on obviously invalid arguments, the problem will no doubt be a subtle one, and our evaluation will depend on matters of judgment that will vary among reasonable people. For instance, if the argument for a theory has a gap, we have to ask whether we think it’s a minor gap that can probably be filled, even if it hasn’t been so far, or whether we think it’s a gap that is unlikely to be filled and thus a serious strike against the theory. Likewise, if a theory lacks development in one respect, we must decide whether this is a minor issue, perhaps easily correctable, or whether the problem is likely to prove intractable. Because these are matters of complex judgment, reasonable people will disagree about the severity of the problems for any given theory. And in fact this is just what 38. These merits and drawbacks are widely discussed by political philosophers, and I won’t repeat them here. One good overview is Kymlicka, Contemporary Political Philosophy.

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the philosophical literature shows. Surely philosophers count as reasonable people informed about political theory, and yet they disagree about which political theory is the best, with some accusing a theory of having major problems and others equally convinced that the problems are tractable. If these general observations are accurate, then they should change our outlook on whether there really can be a general, other-​oriented argument against the personal cost principle. To show that everyone should reject the principle, one would need to provide arguments against several highly plausible theories of justice in which the principle finds a place, such as Nagel’s or Waldron’s or the TWA. These would need to be arguments which are not only convincing to us, given our own starting points and judgments, but arguments which diverse audience members should accept, if they reacted rationally to all the evidence presented. But for reasons just given, I suspect that such arguments will prove elusive. The points I have made about methodology are not uncontroversial. My hope is that they help readers understand why, in the rest of this chapter, I will try to address the objection from personal cost, not by attempting to refute the personal cost principle itself, but rather by showing that its proper application would not lead us to reject universal health insurance. Doing so seems like the best way to engage in the kind of other-​oriented argumentation that many philosophers strive for.

Which Personal Cost Principle Are We Granting? I have made the case for granting the personal cost principle during our discussion of universal health insurance. We should note, though, that the theories given above seem to vindicate slightly different versions of the personal cost

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principle—​versions that are distinguished, most importantly, by the content they give to the notion of “weighing.” On the one hand, Nagel’s theory and certain versions of the TWA do not yield a very precise notion of weighing. Nagel tells us only that a system must not demand “too much of [someone] by way of sacrifice of his interests,” but offers nothing more precise.39 The TWA might lead to an interpretation of the personal cost principle that is similarly imprecise, at least when the TWA is understood in one particular way. Recall that the theory says that we have associative duties to conationals which are either constitutive of the conational relationship or without which we simply could not hold those relationships together. If we focus on the duties constitutive of the conational relationship, then as I argued earlier, we can perhaps arrive at the conclusion that we must show more concern for conationals than for strangers, but the TWA framework itself doesn’t imply anything more specific than that about the level of concern. (Though further argumentation might.) On the other hand, Waldron’s theory yields a notion of weighing that is at least somewhat more precise. Earlier we noted that when more-​advantaged individuals could improve the welfare of less-​advantaged individuals with comparatively little sacrifice, these economic disparities can lead to political disaffection. Waldron argued that we should eliminate such feelings when they are both natural and so severe that they undermine the proper functioning of a liberal democracy. In light of these two points, we can conclude that, according to Waldron’s theory, the benefits of a program outweigh the costs at the point where not providing the benefits would lead to the natural political disaffection that undermines the proper functioning of liberal democracy. A similar line of reasoning might

39. Nagel, Equality and Partiality, p. 38.

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apply when considering the implications of certain versions of the TWA. Understood one way, that theory says that associative relationships involve those duties whose general acknowledgment is necessary to hold the relationships together—​an idea that is actually quite similar to Waldron’s idea that we should look for the set of policies which is needed to maintain the proper functioning of a liberal democratic society. At first it might seem advantageous for my argument to focus on the more specific version of the personal cost principle. After all, it seems as though it would be easier to argue that the benefits of a well-​designed universal health insurance system outweigh its costs if we have a fleshed-​out method for weighing costs and benefits. However, focusing on that precise version of the personal cost principle would not ultimately be fruitful, for several reasons. First, although the method of weighing costs and benefits is more precise, we lack the data that would allow us to employ it as part of our overall argument for universal health insurance. The precise version of the personal cost principle says that we must provide those social minimum benefits—​and only those benefits—​which prevent the kinds of natural political disaffection which undermine the proper functioning of a liberal democracy. Would a social minimum like that include health insurance? If so, what kind? In theory those questions might have answers, but to my knowledge, the data needed to answer them does not presently exist, and so any argument relying on this particular version of the personal cost principle is bound to be inconclusive. Second, relying on one particular version of the personal cost principle would not further the goal of giving an other-​ oriented argument. For reasons given above, other-​oriented political philosophy should not focus on a cherry-​picked set of theoretical frameworks that favor universal health insurance. Instead other-​oriented political philosophy must try to address

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all the reasonable views held by the opposition, including those that give rise to the less precise version of the personal cost principle.

Which Benefits and Costs? Even if we don’t presuppose one particular notion of “weighing,” we can ask which costs and benefits should be weighed against each other. Suppose, for instance, that someone would have to pay $60 per year in new taxes to support an expansion of food support for low-​income families. When comparing benefits and costs (on a weighted scale), do we compare the total benefits and burdens to all people who contribute to or receive help from the program? Or, alternatively, do we look only at the benefits and costs of each individual’s contribution? Moreover, either way, do we look at the marginal cost and marginal benefit of the extension of the social minimum, or do we look at the total costs and benefits of the program which is now being extended? Or of all food-​support programs? Or of all social minimum programs combined? In this context, we would ideally look at the cost to each individual and not the total cost to all, as well as the benefits of that person’s contribution rather than the total benefits provided by the program as a whole. Otherwise, our moral rule would ignore individuality in an illegitimate way. Imagine an extension of the social minimum funded in a grossly inegalitarian way, placing a massive tax burden on a few specific individuals—​ maybe individuals who aren’t even particularly wealthy—​and an almost negligible burden on everyone else. If we compared only total costs and total benefits, the program could appear to have an acceptable ratio of costs to benefits. But it would only seem that way because, by looking at totals, we ignored

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the heavy tax burden on specific individuals.40 Similarly, if we decide to look at individual costs, it would seem that we should compare those to the benefits of individual contributions rather than the total benefit of the entire social minimum program, since otherwise the burden on any given individual would almost always be swamped by the total benefit, and individuals might be required to make sacrifices so burdensome that no plausible theory should countenance them. For instance, imagine that a particular extension of the social minimum was very burdensome on individuals—​e.g., a tax increase of $5,500 per year for a middle-​class family with total income of $50,000. The significant utility loss brought about by the $5,500 could be improperly swamped by the benefits if we judged the individual loss against the total effects of an entire well-​run social minimum program that provided important benefits to a large population. Assuming our cost-​ benefit calculations focus on individuals, we then face the other questions listed above. When deciding whether we have an obligation to support a given extension of the social minimum, do we look at the marginal cost and marginal benefit of the extension alone, or do we look at the total costs and benefits of the particular food-​support program which is now being extended? Or of all food-​support programs? Or of all social minimum programs combined? Intuitively, we seem to evaluate our associative obligations with reference to major categories of interests, in two ways. First, when judging the extent of our associative obligations, we look at our entire contribution toward a general interest of

40. Which is not to say that it might not be just to place heavy taxes on a few individuals only, if those individuals were fabulously wealthy and everyone else was not. The point is that comparing benefits and burdens in the way described in the text could lead us to place heavy taxes on individuals whether or not they were wealthy in that way.

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one sort—​e.g., an interest in security or health—​rather than evaluating each marginal contribution to that interest on its own. For example, suppose my down-​on-​his-​luck brother asks for $100 per month so he can rent a slightly better apartment. If I want to know whether I have done enough to help secure his interest in proper housing, it’s surely relevant that I already give him a large amount of money toward his rent each month, and he’s asking for $100 on top of that. (Otherwise one could simply break down any marginal increases into small subparts that individually produce no real utility loss to individuals at all, and one’s obligations might continually increase with virtually no limit.) Second, contributions to one kind of interest are not, in most cases, an excuse for ignoring other categories of interests. The fact that I contribute a great deal to my brother’s housing—​or even his “utility” in general—​does not mean that I am suddenly exempt from calling him on his birthday or from making reasonable efforts to ensure that he has health care.41 Now that we see which costs and benefits would be relevant to the personal cost principle, we can also see that if someone levied the objection from personal cost against universal health insurance, the objection would be that the individual’s total costs for health care social minimum programs outweigh the total benefits produced by that individual’s contribution. And since the polling information from chapter two showed that the objection from personal cost is almost always directed at certain extensions of the health care social minimum (and not the existing social minimum in health care), we can assume,

41. I say “reasonable efforts” because the fact that one is spending money on multiple categories of interests makes it more likely that a new contribution to any area will be excessively burdensome, since one’s previous spending has presumably reduced one’s disposable income and increased the likelihood that the new spending cuts into an area of fundamental concern and is therefore excessively demanding.

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in this context, that the individual’s costs for all existing health care social minimum programs are outweighed by the benefits of the individual’s contribution, and that the objector’s claim is that once we introduce the additional costs of universal health insurance, things reverse and the costs of the health care social minimum now outweigh the benefits.

Compelling Explanations We now know something about which benefits and costs are to be weighed. That does not specify the meaning of the “weighing” relation itself, and in fact I’ve said that in an effort to give other-​oriented arguments, this chapter will not presume a specific understanding of “weighing.” And yet without that theoretical apparatus, how can we weigh costs and benefits against each other? To see how it might happen, even when beginning with only a vague notion of weighing, let’s consider another place in bioethics where we must make difficult comparisons without an algorithm or formula—​indeed, where conversations often start with vague ethical concepts. Suppose an Alzheimer’s patient with no prior expressed wishes about treatment was unable to make decisions for herself, and a medical team had to decide what was in her best interest. She can be allowed to die from her late-​stage cancer in three months. Alternatively, she can be given chemotherapy that will extend her life by a few months, though it cannot cure her cancer, and in the process it will cause severe pain. What is in her best interest overall? We have no formula that takes in information about patients and allows us to compute what’s in their best interest. Still, as the team reasons through this decision, we can imagine them making a variety of points. Someone might point out that additional life is normally taken to be a good thing, and others might point out that even if extended life is a good thing, it

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is less of a good thing, and perhaps not a good thing at all, to live longer in a state of severe mental debility and severe pain. Examples might be brought to bear to make the point. Someone else might point out that at the end of life, most of us want various important events to take place: we want to say goodbye to our friends, for instance, and to make peace with anyone from whom we are estranged. At that point another member of the team might point out that the patient’s Alzheimer’s makes it much harder for her to say some form of meaningful goodbye to her friends, but to the extent that it’s possible, it can be done within three months, even without any extension of lifespan. This dialogue would continue—​I won’t lay it out completely here. The point is that once the dialogue is concluded, it’s perfectly possible, though not certain, that the parties will have collectively articulated a set of points that constitute what I’ll call a compelling explanation, one that leads all or almost all reasonable people to conclude that it’s not in the best interest of this patient to be given the painful chemotherapy. How and why does that happen? At a general level, it happens because of two things. First, the discussion lays out various facts and clarifies their moral significance. Second, at the end of that discussion, the participants recognize that they are addressing what I will call an “unbalanced case,” one where it is clear how various moral factors compare, even if the participants don’t have—​or at least cannot articulate—​any quasi-​ formula or algorithm for making such comparisons. Often, though not always, that happens because the participants recognize that some considerations are minor, others are not, and so even without any precise formula for comparing moral considerations of this sort against each other, it’s clear that some factors outweigh, override, or otherwise take precedence over others. In the situation with the Alzheimer’s patient, for instance, the discussion might help some or all individuals recognize that

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they already accept, or should accept, that mere biological life per se is not in a patient’s interest. Likewise, participants might recognize that they already accept or should accept that, other things equal, life in severe pain is less of a good thing than life without it. Once they have these and other points before them, they can draw on their pre-​existing moral ideas about how to compare certain aspects of a life and form a judgment about the patient’s overall “best interest,” concluding that extension of lifespan is clearly not in this patient’s best interest. For instance, the people who were originally inclined to support chemotherapy might continue to believe that life in itself is always to some degree a good for the person living it, but they form the judgment that this good is minor and therefore outweighed by the much greater bad that the patient will experience if her lifespan is extended. At first blush, nonalgorithmic arguments like this can seem incomplete, but in fact we make use of them all the time without doubting their force. Consider a second example, one familiar from discussions of pro tanto obligations. Suppose I’ve made a promise to meet someone at my office, but on my way I happen across a situation where I can help apply CPR and save someone dying on the street. This creates a conflict between my pro tanto obligation to keep my promises and my pro tanto obligation to help others. How can we explain why the obligation to help others takes precedence over the obligation to keep promises? One important factor is that failing to fulfill my obligation to help others could result in a very serious setback to someone’s interests, perhaps even death, and that as a result, failing to help would also worsen the lives of others, including the victim’s family. In contrast, failing to fulfill my obligation to keep my promise will not (in normal situations) set back anyone’s interests to a remotely comparable degree. Additional factors are at play as well. If we fail to keep the appointment, we can schedule it at another time, whereas if we fail to help the victim, there

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is no later time when the object of the obligation, helping this man, can be achieved. Furthermore, one problem with breaking appointments is not just that other people’s time is wasted, but that by wasting their time, you display a lack of respect for them and their interests generally. In this case, though, you can explain to the promisee why the promise was broken and thereby make it plain that you did not fail to appear because of any lack of respect for him. Proper apologies also serve this function (among others), showing that we understand the importance of the problems we created for the promisee, as do certain pseudo-​ compensatory actions, like offering to schedule the next appointment at a time of his utmost convenience. “Let me show you that I value your time,” we are saying, “by offering to give up whatever parts of my own valuable time are necessary to make this convenient for you.” Other factors might be highlighted during this argumentative process—​once again I won’t try to list them all here. The key point is that once all of the important factors are laid out, all parties to the debate might conclude that, in this case, the obligation to help others takes precedence over the obligation to keep the promise. We do that not because we have some algorithmic or even semiformal procedure for resolving conflicts between pro tanto obligations. Instead this is a case where the factors in favor of keeping the promise seem clearly less important, morally speaking, than the factors in favor of helping the accident victim. Like the case of the Alzheimer’s patient, the key is that this case is an unbalanced case, one where we can understand and explain why the moral reasons in favor of one course of action are substantially less significant than the reasons for another. And that is true even though, in tougher cases, where the moral reasons are more evenly balanced, the same sorts of reasoning might not allow us to resolve the dilemma, and we would need more argument, and perhaps more theory, to do so.

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Finding this kind of compelling explanation constitutes clear progress. When we first notice that there is no algorithm or quasi-​formula for making certain ethical decisions, two worries immediately occur to us. One is that we will be left with only some form of “intuition,” and a second is that, as a consequence, reasonable people will therefore draw different conclusions in the same situations. But neither need be the case. Even when we don’t have a formula for making a particular ethical decision, people can often provide reasons for making one decision rather than another. Moreover, it is perfectly possible that once those reasons are articulated, our worries about intractable disagreement will disappear because all or almost all reasonable people will arrive at the same conclusions. As with the case of the Alzheimer’s patient or the accident victim, dialogue about universal health insurance can lead to a compelling explanation of why the benefits of a well-​ designed universal health insurance system outweigh its costs. Specifically, the debate about the personal costs of universal health insurance is, as I will now argue, an unbalanced case, because once we discuss the costs and benefits of a well-​designed universal health insurance system, as well as their moral significance, we can agree that the benefits outweigh the costs, even if we give disproportionate weight to the latter. I begin with a discussion of the benefits and their significance.

B E N E F I T S O F   A U N I V E R S A L H E A LT H INSUR ANCE SYSTEM Universal health insurance systems are not all the same, of course. For instance, single-​payer and regulated-​market systems eliminate uninsurance or reduce it to extremely low levels, whereas a quasi-​universal system like the ACA leaves tens of millions uninsured. Here we can make some generalizations

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that apply to both regulated-​market and single-​payer systems. To a lesser extent, they apply to quasi-​universal systems as well.

Reducing Uninsurance Prior to the ACA, millions of uninsured Americans didn’t receive proper treatment for medical problems. As a result, they experienced pain, suffering, and sometimes death. I make this obvious point because there’s a common myth that the uninsured somehow receive adequate medical treatment. For instance, one poll found 56% of Americans saying that in their community, people without insurance can get needed medical care, although most admit that it’s lower-​quality care than the insured get.42 I don’t know of any research about the origin of this belief. In my experience this view almost always rests on a misunderstanding. People have heard that anyone can “receive care” in an emergency room, and they sometimes conclude that people can receive care for any medical problem and that the care is free. In such people’s minds, the only real problems for the uninsured are the long lines in emergency rooms. However, those beliefs are myths. Some uninsured people, especially in rural areas, may live too far from a medical center to use it as a source of regular care, and their area may not have low-​cost clinics either. Even if an emergency room is nearby, care isn’t free. The uninsured usually receive a bill from the emergency room. (And since health insurers negotiate lower rates with hospitals, the uninsured are often billed two to four times more than the insured.)43 Moreover, emergency rooms won’t provide care for all problems. The law only requires them to treat acute problems, such as impending death, organ failure, 42. Best and Radcliff, Polling America, p. 295. 43. Kaiser Family Foundation, “The Uninsured,” p. 9.

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or imminent delivery of a baby.44 Consider then someone with a progressing cancer. They aren’t dying right now; instead they need weekly chemotherapy treatments. If that person seeks care in an emergency room, the hospital is unlikely to offer regular chemotherapy. They will treat the person’s acute problems and then discharge them without further treatment.45 Furthermore, even if we focus only on treatments emergency rooms do provide, research shows that the uninsured receive worse care.46 The uninsured suffer serious problems.47 They don’t receive effective preventive care. They are less likely to have their medical conditions diagnosed. They forgo needed care and medications. Most importantly, more of them die, relative to insured people. And these are simply the medical effects. The uninsured suffer added family stress during illness, and lack of insurance often leads to financial ruin and bankruptcy.48 These effects can be measured. A  2009 Kaiser Family Foundation report showed:49

44. See U.S. Centers for Medicare and Medicaid Services, “Emergency Medical Treatment & Labor Act (EMTALA).” 45. Cf. Hadley et al., “Covering the Uninsured in 2008,” which points out that the uninsured get about half the treatments, measured in dollars, as the average insured person. 46. Rosen et al., “Downwardly Mobile.” 47. A good survey is the Institute of Medicine’s six-​volume study of the uninsured from 2002, updated in the report America’s Uninsured Crisis. The list of medical effects that follows comes from p. 82. For a review of the literature published since the 2002 Institute of Medicine report, see McWilliams, “Health Consequences of Uninsurance Among Adults in the United States.” 48. Himmelstein et al., “Medical Bankruptcy in the United States, 2007.” 49.  Kaiser Family Foundation, “The Uninsured,” pp.  7–​10. Cf. McWilliams, “Health Consequences of Uninsurance Among Adults in the United States.”

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• Nearly 25% of uninsured adults said they have forgone care in the past year because of cost, compared with only 4% of adults with private coverage. • Anticipating high medical bills, many uninsured could not follow recommended treatments. Over 25% of uninsured adults said they didn’t fill a drug prescription in the past year because they couldn’t afford it. • The uninsured were less likely than the insured to obtain all recommended services for injuries and chronic conditions. • Uninsured children were much more likely than insured children to lack a regular source of care, to delay care, and to have unmet medical needs. They had higher rates of preventable hospitalizations and missed diagnoses of serious health conditions. • The uninsured were less likely to receive timely preventive and diagnostic care. Consequently, uninsured patients were diagnosed in later stages of diseases, including cancer, and die earlier than the insured. • Problems exist even when people lack insurance for only a short time. Those uninsured for less than six months were more likely than the insured to report having an unmet need for medical care or a prescription drug in the past year.

And as for nonmedical effects:

• In 2004, 14% of the uninsured spent more than 10% of their family income on out-​of-​pocket health care costs. • The uninsured were about three times as likely as those with health coverage to live in a household having difficulty paying basic monthly expenses such as rent, food, and utilities.

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• Medical bills may force uninsured adults to exhaust their savings. In 2009, 20% of uninsured adults used up all or most of their savings paying medical bills. • Unprotected from medical costs and with few assets, the uninsured are often unable to pay off medical debt. Almost 25% of uninsured adults reported that a collection agency had contacted them about unpaid medical bills in the past year.

The most commonly cited statistic comes from a 2002 Institute of Medicine study, which surveyed the existing scientific literature about the effects of uninsurance. The study found that 18,000 Americas died each year because they lacked health insurance.50 A later, 2009 study put the number at 45,000 deaths per year.51 Public debates concentrate on the medical and financial effects of uninsurance, but other effects are also important. Anyone who has ever suffered a major medical problem—​even with good insurance—​knows it can quickly consume your life. For instance, in “A Conservative Case for Universal Access to Health Care,” Menzel and Light point out that lack of insurance impairs people’s ability to take responsibility for themselves and their family, because untreated illness stops them from working. Untreated illness can also stop people from participating as full democratic citizens, because those with serious, untreated illness must spend their time managing their condition. These are costs not only to the uninsured themselves but to anyone who values personal responsibility, civic involvement, and democratic participation. Finally, uninsurance

50. Committee on the Consequences of Uninsurance, Care Without Coverage, p. 165. 51. Wilper et al., “Health Insurance and Mortality in US Adults,” p. 4.

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results in large economic costs such as lost work hours and disability payments.52 Obviously, one benefit of universal health insurance is that it would reduce uninsurance and the many negative effects I have listed here. The extent of those benefits will depend on the particular universal health insurance system. Even the ACA, with all its gaps, has helped reduced the official U.S. Census measure of the uninsured from approximately 47  million in 2009 to 28  million in 2016, though not all changes are attributable to the ACA.53 True universal health insurance systems would reduce the uninsurance rate much farther.

Reducing Underinsurance It’s easy to assume that the uninsured suffer problems and that the insured don’t. However, insured people can be “underinsured” in various ways:



• Insured people could lack coverage for catastrophic incidents. For instance, a severe car accident can lead to hundreds of thousands or even millions of dollars in medical bills, but policies could cap the annual and lifetime limits, thus leaving the “insured” with massive bills. • Insured people could have pre-​existing medical conditions which are not covered by their plan. • Plans could fail to cover certain services. At the extreme, they might exclude entire categories of services.

52.  It is difficult to estimate such costs, but one attempt is the Institute of Medicine’s Hidden Costs, Value Lost. This report is from 2003. 53.  U.S. Department of Commerce, Census Bureau, “Income, Poverty, and Health Insurance Coverage in the United States: 2009” and “Health Insurance Coverage in the United States: 2016,” table 1.

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• Deductibles could be so high that plan members cannot afford them and consequently might not receive needed medical care.

Studies done prior to the ACA found that between 5% and 10% of the insured were underinsured.54 The underinsured suffer many of the same problems as the uninsured. They don’t fill needed prescriptions, they forgo recommended treatments, and they don’t see a doctor even when they think they should. They face problems with medical bills and are often contacted by collection agencies.55 One can also assess the quality of American insurance plans indirectly. Take the literature on medical bankruptcy. “Medical bankruptcy” doesn’t have a standard definition, but all studies reveal problems. One study found that about 50% of bankruptcy filers in 2001 cited medical causes for their bankruptcy. There were 1.458 million filers, and since all members of a household are affected by a bankruptcy, this implies that around two million Americans suffered the effects of a bankruptcy related to medical causes. Importantly, 75% of filers had insurance when their illness began, suggesting that American insurance at the time was often so low-​quality that it couldn’t stave off bankruptcy. A  later study by the same authors relied less on self-​ reports and more on objective measures. It found that 57% of bankruptcy filers in 2007 had medical debts over $5,000 or 10% of pretax income; 75% of those filers had health insurance, indicating severe problems with their insurance plans. One benefit of universal health insurance is that it could help reduce all of these negative effects of underinsurance.

54. Schoen et al., “Insured But Not Protected,” p. 294. 55. Schoen et al., “Insured But Not Protected,” p. 295.

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Benefits for the Insured Leaving aside the uninsured and underinsured, let’s focus on those with good insurance. It’s natural to assume that these people’s health needs are largely met and that their situation would not improve under a universal health insurance system. However, that’s a mistake for several different reasons. First, well-​ designed universal health insurance systems would offer many Americans better coverage. One examination of regulated market systems done prior to the ACA concluded that “the basic plans would seem very generous even to Americans with high-​quality American insurance. In the Netherlands, for example, the basic plan must cover all ‘essential health care’ including GP appointments, hospital care, prescribed specialist care, hospital stays, ambulance services, post-​natal care, some prescription drugs, and rehabilitation care such as physical therapy, occupational therapy, and diet advice.”56 Universal health insurance proposals are often designed this way on purpose. The single-​payer MFA (Medicare for All) proposal offers all Americans coverage through Medicare, which is better than many Americans receive right now. Likewise, Emanuel’s voucher system offers every American the same high-​quality insurance received by members of Congress. Insurance would also be portable. That’s a big benefit, because some people are locked into undesirable jobs merely because they want or need the health benefits. They cannot accept alternative offers even if those jobs better match their skills, provide higher pay, offer a better location, and so on. There’s a third reason why universal health insurance would benefit the insured. Although the insured might have good insurance at a given time, they risk losing their insurance, 56. Daley and Gubb, “Health Reform in the Netherlands,” pp. 2–​3.

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especially if it is employment-​based or privately purchased. This risk was very real for Americans prior to the ACA. Consider how easily people with employer-​based insurance could lose it. First, you get a serious illness. You can’t work, so you use up all your sick days and vacation days. At that point, your company has to lay you off. Your employer-​sponsored insurance disappears, and though under the Consolidated Omnibus Budget Reconciliation Act (COBRA), you might be entitled to continue on the same plan, the costs usually go up, and you might not be able to afford it. You can try to purchase insurance on the private market, but that will often be too expensive, especially since you are ill and unemployed. Another option is to look for a public program, but you may not qualify, or you may have to deplete all your assets before you qualify. At best you’ve used up your money, and at worst you die before you get medical care. These problems are underdiscussed in America. Prior to the ACA, people with employer-​based insurance often felt secure with their health plan. But for most of us that security was an illusion. We could take advantage of employer-​sponsored insurance only so long as we were healthy enough, and lucky enough, to remain employed. Before leaving the topic of the insured, we should note that many Americans want a “choice” of doctor and health plans, and they often fear that a universal health insurance system would take away choice. It’s important, then, that even though American insurance plans often offer many choices of doctor, the American system does not offer many choices about insurance plan. Prior to the ACA, it was clear that many of the uninsured, 15% of the population, had no choice, because they had no plan at all. But even if we restrict ourselves to insured people, we find that 28% of the population used Medicare, Medicaid, and veterans’ health programs, and they effectively had no choice. At least 36% people with employment-​based insurance had no choice, and that amounts to another 18% of the

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population. Thus 61% of the American populace had no choice at all. Overall, many of the problems described in this section would be remedied, to at least some extent, by various universal health insurance systems.

The Significance of the Benefits of a Universal Health Insurance System So far I have given a largely factual description of the benefits of universal health insurance. But a compelling explanation for why the benefits outweigh the costs involves not only laying out those benefits but discussing their moral significance. On that score, it is vital to remember—​and appreciate—​the important fact that universal health insurance systems reduce suffering and death and therefore improve a core element of human well-​being in a very clear, substantial, and important way. There are other weighty benefits of universal health insurance as well. Insured Americans would gain because they would no longer have the problem that if they lose their job, they could lose their insurance and then face all the same risks as the uninsured, such as untreated medical conditions or medical bankruptcy. They would also be protected against being priced out of the insurance market in the future. These goods are once again intuitively quite important, and that intuition is backed by any plausible theory of human welfare. (I will say more about such theories below.) In addition, there is another philosophical insight that should be brought to bear on our evaluation of the benefits of universal health insurance: the insight that we often underestimate the extent and nature of others’ suffering and the benefits we produce by alleviating it.57 This point requires a bit of 57. The text follows reprints and builds upon work from my article “Moral Transformation and Duties of Beneficience,” which was first published in

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explanation. Let me begin with some simple examples unrelated to politics or health care. In our daily lives, we often have to decide how much we should do for others. We have to decide whether to give to charities, whether to attend a long speech by an acquaintance who would like to see friendly faces in the audience, whether to politely excuse ourselves from a tedious conversation with a lonely person who clearly wants to keep talking. We have all made our own decisions about how much to do for others in these and other situations, and those judgments can seem like sound weighings of our own interests against theirs. However, at times we become aware of others’ lives in a way we normally aren’t. Perhaps we come face to face with a homeless person, seeing a vivid manifestation of his suffering in his eyes and his expression. Perhaps we finally follow our parents’ instruction and truly consider “How would I  feel if someone did that to me?” Or perhaps folk wisdom inspires us to deeper reflection. “Be kinder than necessary,” one saying goes, “for everyone you meet is fighting some secret battle.” At such times we vividly contemplate what it would be like to be one of the poor, or to feel the nervous need for friends in the audience, or to be truly lonely. Sometimes this new understanding feels like a matter of having the right perspective, in an almost visual sense. To paint with proper perspective is to represent things accurately, and after this moral experience, we realize that we have spent much of our time caught up in relentless, distorted, and narcissistic thinking, and we come to see the reality that we are only one creature among so many, and that others suffer just as painfully as we do. For some of us, this whole experience can seem like a spiritual or moral revelation. Sophia, 2017, advance online publication, 23 June 2017. I thank RightsLink Permissions Springer Customer Service Centre GmbH and Springer Nature for permission to reuse that material.

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This folk experience can be usefully examined and evaluated. For instance, when talking about what he calls “the moral insight,” Josiah Royce points out that during our everyday lives, we often fail to fully “realize” other people—​that is, during our own thinking, we don’t correctly conceptualize others’ internal mental states, such as their pains, sorrows, and so on.58 This imperfect realization can take many forms. Sometimes our thinking takes no account of others’ inner lives at all, treating other people with as little concern as we might treat inanimate objects.59 That is probably rare, though, and more often we fail to fully realize others by letting their inner lives enter into our thinking in some partial way. One form of partial realization is considering only some parts of people’s mental lives but not others, especially by leaving out those parts that are unrelated to our own interests. For instance, we might want to know whether others are making sarcastic remarks about us (which requires us to think about their intentions) but not think about the pains and troubles that have led them to this perhaps uncharacteristically bad behavior.60 Another form of partial realization involves misconceiving those parts of their mental lives that we do consider, especially by thinking that their suffering, pain, and related negative experiences are somehow less painful to them than they actually are. Royce puts this idea nicely, I think, saying that we sometimes do not treat another “as real, even as thou thyself art real. He seems to thee a little less living than

58. See ch. 6 of Royce, The Religious Aspects of Philosophy. 59. On this, compare Royce, The Religious Aspects of Philosophy, pp. 150, 157. 60.  Cf. some of Royce’s remarks about the train conductor (The Religious Aspects of Philosophy, p. 150).

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thou. His life is dim, it is cold, it is a pale fire beside thy own burning desires.”61 And: Thou hast regarded his thought, his feeling, as somehow different in sort from thine. Thou hast said: “A pain in him is not like a pain in me, but something far easier to bear.” Thou hast made of him a ghost, as the imprudent man makes of his future self a ghost. . . . So, dimly and by instinct, thou hast lived with thy neighbor, and hast known him not, being blind. Thou hast even desired his pain, but thou hast not fully realized the pain that thou gavest.62

Royce’s descriptions ring true. We all know, abstractly and propositionally, that others have mental lives no different from our own, and yet we also regularly fail to correctly conceptualize others’ mental lives, and we make decisions that do not properly take into account the effects of our decisions on others. For instance, we might be considering whether it’s okay to skip a friend’s musical performance. Our minds are vividly aware of the costs that attending bring to us, but we don’t fully imagine our friend’s disappointment when we don’t show up. The contrast to these incomplete realizations is, of course, a complete one: we think about all the aspects of others’ mental lives, and we keep in mind that their pains, sorrows, and so on, are just as intense as our own. Many things can spur such realizations. We might simply notice that we are incompletely realizing others’ mental lives, and we might take steps to do better, either in this particular instance or by training a new set of habits. Earlier I noted other things that can spur full realization too, including incidents where we witness vivid manifestations of others’ suffering. 61. Royce, The Religious Aspects of Philosophy, p. 158. 62. Royce, The Religious Aspects of Philosophy, p. 159.

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Full realization of others’ suffering makes us more fully aware of the benefits of our actions. In discussing the social minimum and universal health insurance, it can help prevent us from underestimating the intense and severe suffering of the less fortunate members in our current system, and it can help us properly understand the benefits brought about by our contributions to a social minimum in health care.

C O S T S O F   A U N I V E R S A L H E A LT H INSUR ANCE SYSTEM As noted earlier, when we measure the costs of universal health insurance, we should focus on the costs borne by individuals rather than by society in aggregate. Yet studies of monetary costs often don’t give individual costs, and when they do, they give costs for an average individual in a given subgroup, not a formula that allows specific individuals to calculate their own personal costs. What I will do here is identify categories of costs that affect individuals and apply those costs to representative individuals whenever possible.

Monetary Costs of Moving to Universal Health Insurance The most obvious costs of universal health insurance are financial. Any evaluation of costs must look at estimates of individuals’ increased or decreased tax payments and other financial changes under a given system. Some universal health insurance proposals include very rough estimates. For instance, Emanuel funds the voucher system with a VAT tax. He estimates the VAT at 10% and says the median household would pay “under $4500” in VAT taxes, although Medicare taxes remain in place, and households must

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continue to pay those as well.63 (Emanuel doesn’t spell out his calculations, but they seem reasonable.)64 It’s not enough to know numbers like this, though. If we were actually faced with a plan like Emanuel’s and wanted to calculate our net costs under the system, we would need to remember that the VAT costs replace a large part of what most individuals currently pay for their own health care, and they also replace any taxes individuals pay to fund systems replaced by the voucher system, such as state and federal taxes that fund Medicaid. When calculating the monetary effects of a universal health insurance system like Emanuel’s, there is another thing we must be careful not to overlook: the potential for universal health insurance to result in increased salaries. This is a vital point, because it shows that some universal health insurance systems would be less costly to individuals than they first appear. Why would universal health insurance affect salaries? Most Americans get their insurance from their employer, and both they and their employer pay some of the cost. In 2017 the average cost of an

63. Emanuel, Health care, Guaranteed, pp. 95 and 113, respectively. 64. The 10% rate is slightly higher than it would need to be if we taxed almost all expenditure in the U.S. (At the time of Emanuel’s publication, 10% of the $14T GDP would have amounted to $1.4T per year, and Emanuel said he needs to raise $1T for his system, so long as his system maintained the Medicare revenue stream.) Assuming he planned to tax all expenditure, we can then look at the BLS data on income levels and expenditures. (For instance, U.S. Bureau of Labor Statistics, “Untitled Document.” The U.S. Congressional Budget Office also estimates income and comes up with slightly different numbers:  “The Distribution of Household Income and Federal Taxes, 2008 and 2009,” supplemental table 3. The differences are due to differences in methodology: Garner et al., “The Consumer Expenditure Survey in Comparison.”) A VAT tax would change expenditure patterns, but making a simplifying assumption that it wouldn’t radically change them, we can try to calculate the effects on individuals, and if we apply Emanuel’s 10% number to the expenditure numbers, we find that the result is indeed a payment below $4,500 for the median household, with the lowest 20% of households paying an average of about $2,000 and the top 20% paying slightly under $10,000.

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employer-​sponsored family plan was $18,764, with the employer paying $13,049 and the employee paying $5,714.65 Suppose we enacted a universal health insurance system and employers got out of the health insurance business altogether. Would employers simply keep the $13,049? No. Economists predict that most if not all of the money would be passed on to workers in increased wages. Economists would give a technical proof of this, but here’s an intuitive version. From the employer’s perspective, it doesn’t matter whether they pay a person in salary or health benefits—​it’s all money out of the same coffer. For instance, if employers are willing to pay a person of certain skills $30,000 in salary and $5,000 in health benefits, then the market has decided that the person’s work is worth $35,000 in total. Now imagine that we enact a universal health insurance system, and the employer no longer has to pay health benefits. The employee’s total cost to the employer has, momentarily, dropped to $30,000. But the employee’s work is still worth $35,000 per year, so another firm should be willing to pay the person more money. This will pressure the original employer to offer a raise and return the market salary to $35,000, or at least something close.66 What we see, then, is that according to the standard predictions, universal health insurance would cause many workers’ salaries to go up. And if so, this compensation should also be deducted from the effects of the VAT or other taxes that fund the system. It is likely that for some number of people, universal health insurance would be a net financial gain rather than a loss. So far I have focused on the costs of a system like Emanuel’s. There are cost estimates for other systems too, including

65. Kaiser Family Foundation, “Employer Health Benefits,” p. 2. 66. For reasons why the whole cost might not be reclaimed by employees, see Reinhardt, “The Economics of Privately Sponsored Social Insurance.” Note as well that if the money were passed along as income, it would be taxable as such.

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single-​payer systems.67 When thinking through those estimates, individuals would need to be cognizant of the same complications listed above. Finally, the calculations just given tell us what individuals might pay for the health insurance provided by a universal health insurance system. Such insurance would be an improvement for many Americans. However, the wealthiest and best insured might presently have better insurance than is offered in a universal system. To maintain their present level of coverage, they would need to buy supplemental insurance, and the price of that insurance would be one of the costs of a universal system.

Non-​Monetary Costs: Choice Another possible cost of a universal health insurance system, though not a monetary one, is a restriction in choice of health insurance plan. That loss of choice can impact individuals in various ways. For instance, under the ACA, some low-​cost and low-​coverage plans were canceled, forcing individuals to buy higher-​coverage plans at higher rates. Effects like this are important, but since they primarily amount to increased financial costs, they don’t raise distinct problems from the ones mentioned in the previous section. However, even apart from its effects on individual insurance costs, loss of choice can seem troubling. Under single-​ payer, for instance, individuals would have no choice of basic insurance plan. Is this an independent problem? It might be less of a problem for most people than it seems, because while most of us want choice of doctors and hospitals, very few of us 67.  Some of the most detailed come from Edith Rasell’s 1999 article “An Equitable Way to Pay for Universal Coverage,” which is unfortunately now quite out of date.

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care whether we can choose our insurer, so long as we’re happy with our coverage. Thus some might argue that it doesn’t matter whether we lack choice of insurer in a well-​functioning single-​ payer system. However, we should also keep in mind that there are benefits to having a choice of insurance plan. Some have argued that competition among insurers increases efficiency, which, if true, would presumably have downstream effects on individuals. A more visible benefit is that choice of plan allows people to change insurer if they are dissatisfied. If people don’t like their particular benefit package, or even lesser components of the plan such as the customer service or appeals system, then it is beneficial to be able to change to an alternative plan. Note, though, that if we want to foster choice of plan, regulated-​market systems do better than the pre-​ACA system. Individuals in a regulated-​market system may purchase health insurance from any private company. In fact, most Americans would have more plans to choose from. We saw earlier that before the ACA, about 61% of the population had no choice at all. In addition, even people with a choice—​e.g., those with a choice through their employer—​were often given only near-​identical plans to choose from. All these facts would change under a regulated-​market system. In the regulated-​market system of Switzerland, for instance, citizens may choose any plan, and they typically choose from among about 85 insurers.68 Universal health insurance also increases two other kinds of choice. The first is choice of job. Prior to the ACA—​and to some extent, even now—​many Americans faced “job lock”: they could not leave their jobs for fear of losing their current health insurance. Under a universal health insurance system, individuals could choose their employer on the merits of the job, knowing they have access to health insurance no matter what.

68. Herzlinger, “Why Republicans Should Back National Health Care.”

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In addition, universal health insurance could increase choice of doctor. Many Americans are restricted to the limited range of physicians who take their insurance. That might still be true under a regulated-​market system, but a single-​payer system would allow Americans to see virtually any physician at all.

Non-​Monetary Costs: Waiting Lists Americans worry that universal health insurance will result in waiting lists. Waiting lists might simply be inconvenient, but they can impose health costs too, because individuals might suffer while waiting, and if the list is long enough, they could suffer permanent effects or even death from lack of treatment. Allegations about wait lists are usually directed at Canada’s single-​payer system, and many studies seem to confirm longer wait times in Canada. For instance, a study from 2000 found that the average wait time for nonemergency surgery was 1.5 months in Canada and 0.9 months in the U.S.69 (The number is an average, so wait times for specific procedures could be longer.) Another study from 2013 showed that 29% of Canadians reported waiting 2  months or more to see a specialist, while the same was true of 5% and 10% of insured and uninsured Americans, respectively.70 That same study showed that 33% of Canadians waited six days or more to see a doctor or nurse the last time they needed care. Only 21% of insured Americans did, though 40% of uninsured Americans did as well. On the face of things, longer wait times should be counted as a cost of the Canadian system when compared to the American one.

69.  Anderson and Hussey, “Multinational Comparisons of Health Systems Data, 2000,” p. 9. 70. Schoen et al., “Access, Affordability, and Insurance Complexity Are Often Worse in the United States Compared to Ten Other Countries,” p. 5.

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However, we must note several key qualifications. One is that waiting lists are a function of funding. If a system lacks MRI machines or hospital beds, these can be purchased. None of the proposed American universal health insurance systems reduces spending levels to Canada’s, so it’s improper to automatically assume an American plan would have waiting lists. Of course it’s possible that the plan will later underspend. We can’t know how likely that is, but note that America’s current problem is sometimes just the opposite: we are not good at limiting certain kinds of government spending. Second, we should note that Canadians report better access to certain services than Americans. For instance, they have an easier time getting care on weekends or after normal business hours.71 Third, in a later chapter I will argue that the data on wait times is highly misleading, overlooking the likelihood that wait times are currently worse in America than in Canada. Finally, we must remember that Canadian-​ style single-​ payer is not the only form of universal health insurance. The regulated-​market systems in Switzerland and the Netherlands have no waiting lists to speak of,72 and the Dutch have better access than Americans in many respects, including seeing a doctor quickly and getting care outside normal business hours.73

71. Schoen et al., “Toward Higher-​Performance Health Systems,” p. w725. 72.  For statistics on the Netherlands, see Davis, Schoen, and Stremikis, “Mirror, Mirror on the Wall,” p.  10. On the Swiss, see Organization for Economic Cooperation and Development and World Health Organization, “OECD Reviews of Health Systems.” 73. Schoen et al., “Toward Higher-​Performance Health Systems,” p. w725.

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Non-​Monetary Costs: Health Insurance Mandates The ACA originally required that if people were not covered by a government plan, they had to purchase health insurance on the private market or pay a financial penalty. This was known as the “health insurance mandate.” The penalty for noninsurance was reduced to zero in 2018, effectively ending the mandate for the time being, but other regulated-​market systems use mandates, and many health economists think that mandates, or something like them, should be part of such systems. The reasons were given earlier, in chapter one, and the essence of the explanation is that regulated-​market systems will either collapse or become dysfunctional without them. This purely factual observation can be used as part of a justification for mandates. If we want universal access to health insurance, and if we have rejected single-​payer systems (perhaps because we find them inferior to other systems), then the other major model is a regulated-​market system. But once we decide on a regulated-​ market system, then for economic reasons, we must have an individual mandate or something like it. Importantly, there is evidence that people’s assessment of the “personal cost” of mandates is affected by their understanding of the rationale behind them. For instance, during the debate about the ACA, many Americans objected to mandates, but most retracted their objections once they were told why regulated-​market systems need mandates.74 This is understandable. If one feels that a proposed universal health insurance system forces one to buy insurance for no reason, then the system can seem to impose unnecessary personal costs in a way a mandate-​free system doesn’t. But once one recognizes that in 74. Blendon et al., American Public Opinion and Health Care, p. 102.

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practice there is no mandate-​free system available, the calculus changes. (Naturally if the only options all involve mandates, the loss of freedom under a mandate can still be considered a cost—​ just not one that is avoidable under an alternative system.) I should note as well that there are clever ways to modify mandates and render them less intrusive on individual freedom. The resulting policies might not even deserve to be called “mandates” at all. For instance, during the debate about the ACA, Paul Starr suggested a modified mandate which would require people to buy insurance or explicitly opt out.75 People who opt out would forgo the benefits that flow from the health legislation; for instance, they would not benefit from guaranteed issue or community rating but would instead be at the mercy of the private insurance market. In another vein, Emanuel and Fuch’s system has a mandate of sorts, since it requires individuals to pay taxes, in return for which they receive a voucher for health insurance. Though in some ways similar to ordinary mandates, Emanuel and Fuch’s proposal has the advantage that it does not directly require people to purchase a product from a private company. Finally, a recent Republican health proposal, the American Health Care Act (AHCA), tried to avoid the problem of mandates by providing “continuous coverage incentives.”76 If people have gone without insurance for more than 62 days, then when they next enroll in an insurance plan, they must pay a 30% surcharge. It is unclear whether this financial penalty would have been large enough to maintain the levels of enrollment necessary to make the health care markets under the AHCA function properly, but the general idea is similar to Starr’s and could work in principle.

75. Starr, “Averting a Health-​Care Backlash.” 76. U.S. Congress, H.R. 1628, esp. section 133.

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Non-​Monetary Costs: Loss of Insurance In a single-​payer or true regulated-​market system, everyone would have access to insurance. However, a commonly heard complaint about the ACA is that some people who were insured before the ACA were no longer able to afford coverage once the ACA was enacted or that they were only able to obtain worse coverage. It is hard to get good data that verifies this claim, and I will not wade through all the conflicting studies. Take, as just one example, the RAND study “Changes in Health Insurance Enrollment Since 2013.” It finds that about 5.3 million people who were insured in September 2013 were uninsured in March 2014. What this study and others don’t tell us, though, are (1) whether such people would have had insurance had the ACA not been enacted and (2) whether they lack insurance because the ACA has somehow rendered it unaffordable.77 Despite these limitations, there are numerous reports of problems finding affordable coverage under the ACA, some of which seem to be related to the ACA’s insurance regulations.78 Obviously, if a universal health insurance system modifies a previously just situation, thereby making health insurance unaffordable to people who previously had it, then this is a large cost to the individual.

Baselines Before leaving the subject of costs, we must make one methodological note. When thinking about costs—​and benefits too—​ they must be judged with reference to the correct baseline. If 77.  Carman and Eibner, “Changes in Health Insurance Enrollment Since 2013,” p. 5. 78.  For example, Luhby, “Before Obamacare, some liked their health care plans better.”

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people stand to lose something under a universal health insurance system, for instance, but it was something to which they were never entitled, then they cannot legitimately count this as a cost at all. Consider again our domestic comparison. Suppose my brother needs $500 for some pressing but not vital concern. It might seem that I can judge the “cost” of giving him the money merely by looking at what I stand to lose—​either fancy coffee, a missed house payment, or what have you. But if in fact I have the $500 only because I supported an unjust division of an inheritance between him and myself, then I cannot claim the $500 loss as a loss relative to a just baseline. The overall lesson is that we should not begin to judge costs and benefits without first asking what a just baseline is. When evaluating social minimum programs, it’s natural to assume the baseline is the distribution of wealth and income before the social minimum programs are enacted. But is that baseline just? I think it can be, but that is not uncontroversial, and some philosophers deny that pre-​ redistribution baselines have any moral significance whatsoever, arguing that it’s improper to assume that people are entitled to their pretax or pre-​redistribution income. So let’s begin by asking whether any pre-​redistribution baselines are appropriate points of comparison. The most forceful rejection of pre-​redistribution baselines in recent years comes from Murphy and Nagel in their book The Myth of Ownership. I  find it hard to definitively pin down all their objections, but Murphy and Nagel often suggest that the idea of a pretax baseline is conceptually confused. They say that pretax income has “no reality, except as a bookkeeping figure,”79 and that some people who refer to pretax incomes are offering positions that are “deeply incoherent.”80 Specifically, Murphy 79. Murphy and Nagel, The Myth of Ownership, p. 36. 80. Murphy and Nagel, The Myth of Ownership, p. 32.

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and Nagel object to people who conceive of the amount they receive in their paychecks (or something similar) as money that is generated without the help of government at all, since “the modern economy in which we earn our salaries, own our homes, bank accounts, retirement savings, and personal possessions, and in which we can use our resources to consume or invest, would be impossible without the framework provided by government supported by taxes.”81 Murphy and Nagel’s point is correct, but their objection does not apply to the kinds of calculations we would make during an evaluation of the objection from personal cost. In that context, if an individual were asking how much of her “pretax income” she should have to give up to support universal health insurance, “pretax income” would refer to the income she holds before she makes payments to support the social minimum, not to income that she would hold prior to all government function. To avoid confusion in the future, I’ll now refer to this baseline as “pre-​social-​minimum income.” When we define the baseline that way, the resulting theory does not fall victim to Murphy and Nagel’s objection. It is perfectly coherent to describe a situation in which individuals earn income with no social minimum in place, and then to measure the sacrifices required by the social minimum relative to that baseline. But that doesn’t mean we’ve entirely escaped the problems raised by Murphy and Nagel’s observations. To see why, let’s remember that, by hypothesis, anyone who participates in a debate about the personal costs of universal health insurance also supports what I’ll call basic institutions such as courts, a banking system, and all the other standard (non-​social-​minimum) government programs that Murphy and Nagel mention. In other words, we are not having a debate about whether to reject the

81. Murphy and Nagel, The Myth of Ownership, p. 8.

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idea of government or its basic functions altogether. But now why are we required to support these basic institutions? We cannot give the answer that we might give for social minimum programs—​that is, we cannot say that the individual costs of these basic institutions are outweighed by the benefits when the costs and benefits are measured relative to the pre-​social-​ minimum baseline, because the pre-​social-​minimum baseline already presumes that the basic institutions are in place. Instead we have to give a different justification for the basic institutions, one that either makes use of a different baseline from the one we use when justifying social minimum programs, or one that references no baseline at all. The danger is that our political outlook begins to look scattered, with very different arguments justifying different aspects of government policy. In fact the outlook might look so scattered that some would be tempted to reject it, including any of its underlying principles, such as the personal cost principle. However, I don’t think this concern is a good reason to reject the personal cost principle. There are simply too many well-​ developed political theories that might account for our duty to support basic institutions in a reasonable way. For instance, we might try to argue that the benefits of the basic institutions outweigh the costs when measured against a different baseline, perhaps a Hobbesian state of nature. Or we might give an entirely different justification that does not rely on cost-​benefit calculations at all. Still, even if there is no general objection to making comparisons with baselines, there are some baselines that are morally inappropriate. Let me give one illustrative example that must be kept in mind during health care debates. We noted above that if America moved to a true universal health insurance system like a single-​payer or regulated-​market system, the level of coverage might be lower than some individuals had previously. As a result, they would have to purchase supplemental

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insurance. It’s possible that on the face of things, the cost (in taxes) of the universal health insurance system and the additional costs of the supplemental insurance will exceed, for some people, what they were previously paying for health insurance. But whether that previous state is a proper baseline for comparison depends on whether their previous insurance costs were fair. And they might not be, given the way the insurance marketplace currently works. Consider employer-​ provided coverage. Normally, when an employer pays an employee $10,000 in salary, the employee must pay taxes on this amount. However, when an employer provides an employee with $10,000 worth of health benefits, the employee doesn’t have to pay tax on the $10,000. Although politicians like to describe this as a “tax break,” it is really a subsidy.82 Why? Consider the real-​world effect of this tax break for the $10,000 health expense. When the government does not collect tax on the $10,000, it must get the money from somewhere else, and so someone else ends up paying taxes to subsidize the health care tax breaks of people with employer-​sponsored plans. Ironically, this often means that people without employer-​ sponsored care—​many of whom have no health insurance at all—​ subsidize other people’s employer-​ sponsored care. This subsidy costs a great deal—​in 2007, the total was $200 billion.83

82. I should note that by calling it a “subsidy,” I am not claiming that it appears as an official tax credit in the federal tax code. Some have proposed tax credits to increase coverage, but at the moment tax credits for medical expenditures are very limited. Instead my point, explained further below, is that the tax “break” for health insurance is really a transfer of money from one party to another. This is widely recognized in policy analysis, where tax breaks for health insurance, mortgage interest, and so on are referred to as “tax expenditures.” 83. See Kaiser Family Foundation, “Tax Subsidies for Health Insurance,” but also U.S. Agency for Healthcare Research and Quality, “Health Care Costs and Financing.”

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Making things worse, the benefits are unevenly disbursed, with greater benefits going, not to poorer people, but to wealthier ones. This happens because wealthier people tend to be offered more expensive health plans, so the value of the tax subsidy is greater for them. In addition, wealthier people tend to be in higher tax brackets, so the value of the subsidy is greater still.84 Here I  can’t go into a complicated argument about the right way to distribute taxes and subsidies. However, almost everyone agrees that the subsidy for employer-​sponsored coverage is unjustified: it’s offered to some and not others for no coherent reason, and it subsidizes the wealthy more than the poor. Assuming that the subsidy is unjustifiable, people with employer-​sponsored insurance are therefore partly financing their insurance via unjustified government policies. This means they cannot straightforwardly count their current coverage as a proper baseline. This is just one example of the need to pay attention to proper baselines when evaluating any objections from personal cost. Whether the pre-​redistribution baseline is just or unjust is something we would need to judge case by case, by looking at the specific features of the baseline with respect to which the proposed universal health insurance program is to be judged. I will assume throughout the rest of the chapter that the costs of a universal health insurance program, as discussed in the previous section, were all incurred relative to a just baseline, but I make that assumption for simplicity’s sake only. Doing so will allow us to more clearly identify and resolve the other issues that come up when we assess the costs and benefits of universal health insurance. Before leaving the subject of baselines, we should note how our judgments about those baselines relate to the judgments we

84. Kaiser Family Foundation, “Tax Subsidies for Health Insurance.”

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make when we apply the personal cost principle. For reasons already given, one cannot properly apply the personal cost principle without knowing what a just baseline is, and of course that means that some theory will operate in the background when we employ the personal cost principle, telling us what a just baseline is. Does that mean, though, that that theory is doing the real work during our evaluations of personal cost, and that the notion of “weighing” is not doing any further work? Not at all. Anyone who advocates the personal cost principle has a two-​stage model of how we should make decisions about social minimum policies. First we use a background theory of justice to determine a set of pro tanto entitlements to, among other things, income and wealth. Our obligations to support a social minimum are then a function of those economic holdings—​ specifically, we are obligated to help provide food, shelter, etc. to our conationals whenever the benefits outweigh the costs, as judged on a weighted scale. The picture is akin to the one we ordinarily use, I think, when judging things like our financial obligations to siblings and other family members. We each have income and wealth to which we have a pro tanto entitlement. We decide whether we are obligated to give a sibling a loan based on whether the cost to us is outweighed by the benefits to the sibling, as judged on a weighted scale. The weighing still plays a vital role—​perhaps the vital role—​in determining the extent of our obligations, though it can be done only once we have determined, on some other basis, that our background holdings are just.

The Significance of the Costs of a Universal Health Insurance System Now that we have a factual description of the costs, we should assess their moral significance. When doing that, an obvious first point is that we should not judge the seriousness of a

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personal cost in mere dollars but rather in terms of how the loss of dollars affects one’s life. For instance, if a tax to support the social minimum means that some low-​or middle-​income people can no longer afford health care of their own, that’s a more serious imposition on their life than a quantitatively equivalent tax on higher-​income earners that requires only that they buy a slightly less well-​appointed car or take a different vacation. These considered judgments can be reconciled with many philosophical theories. In fact, all that is really required is to recognize the distinction between money, measured quantitatively, and well-​being. Furthermore, we also have widely shared considered judgments about which costs are more serious than others. Death, severe suffering, and severe pain are clearly things that greatly affect someone’s well-​being. So are other things that are not as straightforwardly biological as these. For instance, losing close personal relationships or the personal projects and endeavors that give meaning to life constitute serious reductions in well-​ being too. These considered judgments can be systematized into a more general framework. For instance, one widely celebrated list of important aspects of a good life comes from Martha Nussbaum. Nussbaum’s list includes activities and states such as being alive; being healthy; having bodily integrity; using the senses, imagination, and mind; exercising the emotions; reasoning about one’s good and morality; having important affiliations and relationships; living harmoniously with other species; engaging in recreation; and having some measure of control over one’s material and political environment.85 This list might or might not be complete, but the fact that there is widespread consensus on at least the general features of such a list reveals that we have many shared judgments about these issues.

85. Nussbaum, “Women and Cultural Universals,” pp. 41–​42.

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A list like this raises many questions, of course, and for our purposes, one of the most important concerns the weight that should be given to specific personal projects. Suppose someone’s great passion is collecting stamps that are very rare and very expensive, and that paying taxes to support a social minimum would prevent this pursuit. Can such a person claim that he may never be morally required to give his money to others—​ via the social minimum or even via charitable giving—​on the grounds that it impairs one of his central life projects? It would seem not, and this considered judgment can help us clarify our general understanding of personal costs. A  good human life involves deep involvement with the kinds of personal projects that yield meaning and satisfaction, but that is not the same as saying that giving up any one particular project vastly reduces well-​being. Whether that happens depends on whether the projects are adjustable or replaceable. The man who collects very rare stamps could, we suspect, adjust his goals and preferences so that he would gain just as much satisfaction from collecting other kinds of stamps (and perhaps merely appreciating from afar the most expensive ones), or by adopting an entirely different hobby that was less expensive, and so having to give up on his particular hobby, practiced in one particular way, does not necessarily involve a large reduction in well-​being. Similar things might be said for those who claim that they couldn’t have the human good of “play” without this vacation or this car. As a matter of fact, they can. This is far from a complete list of the insights we can draw upon when evaluating the moral significance of the personal costs of a universal health insurance proposal, but even these help us make progress. For instance, above we looked at the common allegation that the ACA changed things so that some individuals who were previously insured were unable to afford insurance in the ACA system. To know whether this is correct,

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and whether it should be counted as a cost of the system at all, we would have to investigate several things:

• Whether the affordable insurance, pre-​ACA, was part of a just baseline. • Whether the new insurance is truly unaffordable or just more expensive than the person would like it to be. • Whether the new insurance is unaffordable because of the ACA, or whether it would have been unaffordable regardless, given general increases in health care costs.

But if the ACA did indeed deprive some people of health insurance that they could afford in the just baseline, then this is a large cost imposed by the system, since loss of insurance can cause suffering and death and so reduce or take away central elements of well-​being. In fact, given the magnitude of this cost, I anticipate that, without more theoretical apparatus than I want to rely on here, we will be unable to provide a compelling explanation for why the costs of a system like this outweigh its benefits, and so my subsequent remarks will all concentrate on well-​designed universal health insurance systems which would not leave individuals without insurance.86 On the other hand, if the main cost of a universal health insurance system was an increase in individual taxes, then we must evaluate the seriousness of this burden carefully. Cost estimates for such plans, cited above, show that for middle-​income and low-​income Americans, such plans might reduce their total health care costs. Upper-​middle-​class and upper-​income

86. Note as well that since there are perfectly workable universal health insurance systems which do not cost anyone their insurance, then any health system that deprived people of justly held insurance would run afoul of a principle governing the social minimum which we have not previously discussed: the principle that for the personal costs of a social minimum program to be justified, they must not be higher than realistically necessary.

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earners would probably see an increase. To be generous to those who make the objection from personal cost, let’s focus on the people who would see the greatest increase. The top quintile of Americans, whose average income in 2009 was $149,951, might see an average net tax increase of thousands and thousands of dollars under something like Emanuel’s plan or a single-​payer plan with similar funding. How serious is this cost? Though this tax is substantial in dollars, it is unlikely to really affect a well-​off family’s ability to obtain or pursue any fundamental parts of human well-​being. For instance, even a substantial tax will not seriously affect any of these elements of well-​being:  being alive, being healthy, having bodily integrity, exercising the emotions, reasoning about one’s good and morality, living harmoniously with other species, or having some measure of control over one’s material and political environment. On the other hand, one can imagine realistic ways in which it affects a person’s ability to use the senses or imagination (e.g., by limiting the amount spent on some artistic hobby), to have important affiliations (e.g., by making certain memberships impossible), or to engage in certain forms of recreation and play (e.g., by precluding certain vacations). But here again, we saw earlier that a person cannot claim that such losses are serious effects on well-​being merely because they make particular activities impossible, the ones that individuals are currently using to satisfy these fundamental needs. Instead the question is whether the activities are replaceable or alterable so that the same fundamental needs are still fulfilled. Is that possible? At this point there is only so much we can continue to reason in a general way—​the details of each person’s individual situation obviously make a difference. But it is difficult to believe that earners in upper income brackets could not both pay the tax increase and also find very satisfying and fulfilling affiliations, recreational activities, and ways to exercise their senses and imagination. That is not to say that these aren’t real costs,

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and I don’t mean to downplay the impact of losing thousands of dollars of income. I  certainly wouldn’t want to. But I  see no plausible argument that these monetary losses impair the pursuit of the important aspects of human well-​being in any substantial way. So far we’ve largely considered the tax effects of universal health insurance systems. However, such plans would also restrict choice, either choice of insurance plan in a single-​payer system, or the choice to opt out of insurance without penalty under a regulated-​market system with an individual mandate. These losses of freedom are costs as well, at least for those who value the freedom to do these things. If a single-​payer system emulated Canada’s performance, there could be an increase in waiting lists, although if we are presuming that our system would emulate Canada’s, we must also remember that, despite any waiting lists, Canada’s system produces better health in the population than America’s and is better liked by those who use it. (I will fully document those claims in the next chapter.) A final note on costs. Obviously, when individuals add up their personal costs, they must calculate net costs. For example, if a universal health insurance system increased one tax on an individual by $5,000 per year, but decreased another tax by $4,000, then clearly the tax cost of the plan to that individual is $1,000, not $5,000. This point is not likely to be overlooked when dealing with financial effects, but people do overlook it when calculating the total net costs of universal health insurance, including its nonfinancial effects. For instance, let’s continue with our earlier example of well-​off individuals who might see net financial costs under a universal health insurance system of thousands and thousands of dollars. When such individuals calculate their net costs, financial and nonfinancial, they must remember that even if they presently have good insurance, a universal health insurance system still provides them with some of the benefits listed earlier. For instance, the

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existence of a universal health insurance system allows them to take any job they want, without worrying about job lock. It protects them against losing their insurance if it becomes unaffordable or they lose their job. The same benefits accrue to family members and other loved ones, so if individuals feel their own well-​being is tied to whether those other people receive core medical care, those are further benefits as well. And while all these benefits cannot be easily assigned a numerical value, they nonetheless must be taken into account when individuals assess the cost of universal health insurance to themselves. The only exception would be for individuals who are so very, very wealthy that they receive no significant benefit from health insurance and could easily pay the costs of medical care on their own. However, given that serious illnesses and injuries can cost hundreds of thousands of dollars—​or even millions if their effects extend significantly over time, as often happens with expensive, chronic conditions—​that group of people will be very small. It will also be the group that can most afford tax increases while still pursuing all of their important life projects.

C O M P E L L I N G   E X P L A N AT I O N The previous information about benefits and costs is complete in some ways and incomplete in others. Sometimes we don’t have full information, even on a concrete system like the ACA. Moreover, the information is about aggregates and representative citizens, so we can only approximate the costs to each individual and the benefits produced by their contributions. Despite these limitations, though, we do have good general information about the kinds of costs and benefits that would be produced by various extensions of the health social minimum, and we have examined their moral significance. The next question is whether these facts and arguments combine to produce

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what we earlier called a compelling explanation—​in this case, an explanation of why the benefits of a universal health insurance system outweigh its costs. When thinking through that issue, it’s important to keep in mind what attempts at compelling explanation aim to do, and how those explanations work when successful. For instance, suppose we need to decide whether a certain course of action is in a patient’s best interest or whether one moral requirement overrides another, as we did in the situations described earlier. We begin by laying out the facts of the situation and discussing their moral significance. In the case of the Alzheimer’s patient, we discuss what the end of her life will be like, as well as the moral significance of living extra time in pain, of additional life itself, and so on. In the case of the choice between keeping an appointment and administering CPR, we lay out the consequences of each choice, discuss the moral significance of not administering CPR and of missing the appointment, elaborate the possibilities for redress, and so on. These facts and arguments constitute our explanation for why this is an unbalanced case, one where some moral factors are substantially less significant than others. The hope is that once reasonable audience members take in this information, they too will recognize that the situation in question is an unbalanced case, even though there is no quasi-​formula or algorithm for making those comparisons. If we achieve this, we have a successful compelling explanation. Sometimes we have observational evidence that the reasons and arguments we have provided as part of our explanation lead all or almost all reasonable audience members to a certain conclusion. For instance, most philosophers who teach or write about ethics know from experience that, after an informed discussion, people are highly likely to recognize that it is more important to administer CPR than to keep a trivial promise, and those bioethicists who have worked in clinical settings know

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that group deliberation often results in consensus on cases like that of the Alzheimer’s patient. However, things are slightly different with arguments about health care policy like the ones under consideration here. We have given an explanation of why the benefits of universal health insurance outweigh the costs, but we have no observational evidence confirming that all or all reasonable audience members would draw the conclusion we feel is warranted by that explanation. Even if we have no direct observational evidence, though, we can still reason about whether all or almost all members of our target audience should see the factors as unbalanced in a certain direction, and when doing so, we must make sure to focus on the right hypothetical. For those of us who regularly discuss American health care with others, it’s easy to conjure the image of people who object to the personal costs of universal health insurance and who are unmoved by the kinds of considerations about costs and benefits given in this chapter. However, our question is not whether we have produced considerations that would be persuasive to people who use the objection from personal cost disingenuously, as theoretical covering for pure selfishness, or even to those who put it forward earnestly but who cannot or will not rationally and honestly consider the information about costs, benefits, and their moral significance. Instead the question is whether the considerations put forward in this chapter should be compelling to those who ask, in an honest way, whether the benefits outweigh the costs now that they know more about them and have heard philosophical arguments about their significance. In the remainder of this section I will provide two interconnected arguments for thinking that, in light of what we have said about costs, benefits, and their moral significance, reasonable people should conclude that the benefits of a well-​designed universal health insurance system outweigh its costs. The lynchpin of both arguments is that people who offer the objection from

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personal cost believe that the benefits of other social minimum policies outweigh their costs, and as we will see, this gives substance to the notion of “weighing” and restricts what conclusions can and cannot be reasonably drawn about well-​designed universal health insurance programs.

Interpretations of Weighing The personal cost principle asks us to weigh costs and benefits while giving disproportionate weight to those who bear the costs. Perhaps the most natural way to understand this is as follows. First we assess the costs and benefits in terms of their agent-​neutral effects on well-​being. For instance, perhaps one person suffers a cost of 1 utile while another gains 2 utiles. (A utile is a hypothetical unit measure of well-​being.) A multiplier of some magnitude is then applied to the costs. Perhaps it is 3. The upshot is that the cost is 3 utiles while the gain is 2—​i.e., the costs outweigh the benefits on this weighted scale. A view of this general sort is discussed by Samuel Scheffler in The Rejection of Consequentialism. Scheffler’s project was in part to explain what a moral theory would look like if it gave people a prerogative to not maximize the agent-​neutral good with every act. One possibility, which he rejects, is that morality might contain a “protected zone” which requires agents to maximize the good some percentage of the time but allows them to do anything at all the rest of the time.87 The main alternative to this, Scheffler says, is a theory which “would allow each agent to assign a certain proportionately greater weight to his own interests than to the interests of other people. It would then allow the agent to produce the non-​optimal outcome of his choosing, provided only that the degree of its inferiority to each

87. Scheffler, The Rejection of Consequentialism, p. 17.

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of the superior outcomes he could instead promote in no case exceeded, by more than the specified proportion, the degree of sacrifice necessary for him to promote the superior outcome.”88 This multiplier interpretation of the notion of weighing is the natural one, and it might even be hard to see what the alternative is, but there is an egoist interpretation as well. Roughly, egoism is the view that, morally or rationally speaking, we should always do what maximizes our self-​interest. (To simplify discussion, I will ignore the difference between moral and rational egoism hereafter.) If egoism were framed in terms of weights, costs, and benefits rather than reasons, then egoist theories would say that when making comparisons between benefits and costs, agents should assign weight only to the benefits and costs which affect their own self-​interest. For instance, if we wanted to know whether the benefits of driving a friend to the airport outweighed the costs, then we would look only at the benefits and the costs to ourselves, and the costs and benefits experienced by the friend would receive weight only derivatively, if those effects somehow rebounded to us, affecting our self-​interest. An egoist interpretation of the personal cost principle would say that whether the benefits of something—​including a social minimum policy—​outweigh the costs depends on whether the costs to oneself are greater or smaller than the benefits to oneself. Benefits and costs to others do not factor into the principle directly at all, and for that reason it’s unclear whether this egoist interpretation should really count as an interpretation of the personal cost principle, given that the principle requires us to weigh costs to self against benefits to others. However, perhaps an egoist interpreter of the personal cost principle could point out that costs to others do receive weight indirectly, insofar as

88. Scheffler, The Rejection of Consequentialism, p. 20.

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they rebound to affect the egoist agent, and that since they receive weight only in those situations, they generally receive “less weight” than direct costs and benefits. As a final alternative interpretation, consider a view defended by Parfit in On What Matters. Parfit begins by considering a position he attributes to Sidgwick which he calls the “Dualism of Practical Reason.”89 Roughly, it amounts to the view that we always have sufficient reason to do what is moral, and we always have sufficient reason to do what maximizes our self-​interest. According to Parfit, Sidgwick’s argument for this view begins with the observation that we can think about the world from our own personal point of view or from the point of view of a hypothetical impartial observer. Viewed from our personal point of view, we always have most reason to maximize our self-​interest. From the impartial point of view, we have most reason to do what is moral. There is no third point of view from which to compare the self-​interested and moral reasons, so we always have sufficient reason to do what maximizes our self-​interest and to do what is moral. Parfit accepts much of what Sidgwick says but revises the theory somewhat. At a general level, he endorses the idea that “when one of our two possible acts would make things go in some way that would be impartially better, but the other act would make things go better either for ourselves or for those to whom we have close ties, we often have sufficient reasons to act in either of these ways.”90 He notes that the word “often” is vague, and in my view, he never fully clarifies what he means by it. His one clear example of when the reasons to help others outweigh the reasons to promote self-​interest is a situation

89. Parfit, On What Matters, vol. 1, p. 131. What follows summarizes arguments on pp. 131ff. 90. Parfit, On What Matters, vol. 1, p. 137.

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where we can “save ourselves from one minute of discomfort rather than saving a million people from death or agony.”91 In addition, it’s notable that Parfit does not say that self-​interested reasons routinely outweigh moral reasons or vice versa. These examples and remarks suggest a view—​one we can consider whether or not Parfit clearly commits to it—​according to which we have sufficient reasons to do what maximizes self-​interest except in cases where the competing considerations are highly imbalanced. Adherents of that view might offer a very strong asymmetry interpretation of how we should “weigh” benefits and costs in the personal cost principle, saying that benefits of one’s contribution to a social minimum policy outweigh the costs only if the former are huge and the latter very small. That would be the view that comports with their general idea that it is rational to maximize self-​interest in all but the most asymmetrical cases. With these possible interpretations before us, it’s not hard to see that people who level the objection from personal cost almost surely cannot adopt the very strong asymmetry interpretation of weighing. If they did, they would have to maintain that the reason we are not required to support universal health insurance is that the benefits and costs of that system are not strongly asymmetrical. At the same time, though, these people support many current social minimum policies, and so they would have to maintain that the costs and benefits of these policies are strongly asymmetrical, with the benefits of one’s contribution dramatically outweighing the costs. These two positions are incompatible, though, since as we’ve seen, the benefits and costs of a universal health insurance program are very similar to the costs and benefits of existing social minimum policies.

91. Parfit, On What Matters, vol. 1, p. 135.

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Objectors might try to escape this problem by reminding us that the core of the very strong asymmetry position is the idea that we almost always have sufficient reason to both act morally and in the way that maximizes our self-​interest. In light of that, objectors could claim that there are sufficient self-​interested reasons to not support existing social minimum policies or a universal health insurance system, but that there are also sufficient moral reasons to support them. Furthermore, they could explain their support of the existing social minimum programs as a choice to act on the sufficient moral reasons in favor of such programs, even though they make a different choice when it comes to universal health insurance programs, opting to act on the sufficient self-​interested reasons to not support them instead of the sufficient moral reasons in favor. However, while this is a consistent position about the reasons had by individuals, it does not escape the problem just outlined. The philosophical position we are debating is not about what individuals have reason to do but about what programs the government may justly enact. Specifically, the position under consideration is that the level of the social minimum is partly determined by whether the individual costs are outweighed by the benefits produced by those costs, and that benefits outweigh costs only when the relation between these two is strongly asymmetrical. However, if individuals have sufficient self-​interested reasons to both support and not support existing social minimum policies, then the costs and benefits of those programs are, by definition, not strongly asymmetrical, and therefore they should not be part of the social minimum. This is incompatible with the objectors’ idea that those programs should be part of that minimum, even if the objectors believe they have, individually, sufficient reason to support them. Could personal cost objectors instead adopt the egoist understanding of “weighing”? Almost surely not, and for similar reasons. Egoists focus principally on the direct effects of

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things on themselves. This does not mean that they must oppose all social minimum programs. For instance, they might endorse at least a very minimal safety net on the ground that it prevents social chaos, promotes economic efficiency, and has other effects that are good for them. The question is how these egoist personal cost objectors can explain their support for existing social minimum policies. To do so, they would need to maintain that the benefits of those programs to others somehow rebound strongly enough to the egoists themselves that it is in the net interest of the egoists to support them. And yet since the benefits and costs of a universal health insurance program are essentially the same as those of other social minimum programs, the egoists would then be stuck with the conclusion that we should support a universal health insurance program as well, undercutting their own objection from personal cost. In addition, it’s hard to see how advocates of the objection from personal cost could embrace the egoist interpretation at all, since egoism amounts, in my view, to the idea that we have no real moral duties to our compatriots at all, and that is not the view held by the mainstream Americans who support the social minimum.

Limits on “Outweighing” We’ve arrived at the conclusion that the only viable interpretation of the weighing relationship is the multiplier interpretation. What is a sensible and reasonable multiplier for objectors to use in the personal cost principle? I will not try to give a number—​I doubt there is one—​but we can know, at a more general level, that those who give the objection from personal cost cannot plausibly regard certain kinds of costs as outweighing the benefits. For instance, we know that when comparing the benefits and costs, those worried about personal costs cannot consistently

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maintain that they should not have to pay anything to support an extension of the health care social minimum. Doing so would be inconsistent, since in chapter two, on poll data, we saw that people who level the objection from personal cost are not libertarians who object to social minimum programs in principle. Suppose instead that objectors claimed that the costs of a universal health insurance system outweigh the benefits because those who pay the costs will not be able to obtain certain core parts of the human good. That might be plausible in a system that rendered health insurance unaffordable for some who might otherwise justly have it, but it is implausible as a claim about well-​designed universal health insurance systems. For reasons given earlier, no core part of the human good is rendered inaccessible by the kinds of costs associated with a well-​ designed universal health insurance system. But what if objectors claimed that the costs of a universal health insurance system outweighed the benefits because, in light of the costs, they will have to pursue certain elements of the human good in different, less expensive, and possibly less extensive ways? This position is again inconsistent. Objectors have already acknowledged that the amounts they pay for some existing social minimum programs—​perhaps thousands and thousands of dollars—​are justified by the benefits that the programs create. And those costs are justified, they agree, even though this loss of money already requires certain sacrifices of them: they must give up specific projects that they could have otherwise undertaken—​projects that might have contributed to basic human goods like use of the senses and imagination, having important affiliations, or engaging in certain forms of recreation and play—​and seek alternative projects that provide those same fundamental goods, possibly to a lesser degree. In light of this, the only position open to objectors is that, when it comes to a well-​designed universal health insurance system, an important moral line is crossed when the costs of

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the health care social minimum, financial and otherwise, move past the level they happen to be at right now and increase to the level required for the universal system. In particular, they must embrace the view that even though the benefits of our existing health care programs outweigh the costs, things reverse under a universal system, with the costs outweighing benefits when judged on a weighted scale which allows the costs to be multiplied to some degree.

Comparing Benefits and Costs Now that we have substantially narrowed what can be plausibly claimed about the weighing relationship, we can give two interconnected arguments for thinking that, after hearing the information from above about costs, benefits, and their moral significance, reasonable people should conclude that the benefits of a well-​designed universal health insurance system outweigh its costs. The first argument picks up on the point that the only position open to objectors is that an important moral line is crossed when the costs of the health care social minimum, financial and otherwise, move from the level they happen to be at right now and increase to the level required for a universal system. Such a position looks strained for several reasons. First, consider again the benefits and costs of a well-​ designed universal health insurance system. That system provides substantial benefits to others—​benefits that are identical, in kind, to the benefits produced by other health-​related social minimum policies that all parties to the debate agree are justifiable. In addition, a well-​designed universal health insurance system is a net benefit to many, and so there is no question for them of whether the costs outweigh the benefits. That might be true even of fairly wealthy earners, since any moral assessment must look not at a single cost but at the net costs, and we saw

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earlier that universal health insurance provides very substantial benefits even to individuals who are insured under our present situation, such as a guarantee of never losing one’s insurance for oneself and one’s loved ones. As a consequence, those who experience net costs under a well-​designed universal health insurance system are likely to be, at most, a comparatively small group of substantially well-​off earners who place very low value on the guarantee that they and those they are close to will never become uninsured. Moreover, these costs would not affect central components of human welfare in any substantial way, and—​importantly—​would once again be no different in kind from the costs imposed by other social minimum policies that are, by hypothesis, justifiable. For instance, all parties to the debate agree that such programs are justifiable even though their costs require us to pursue certain elements of the human good in different, less expensive, and possibly less expansive ways. The costs of a universal health insurance system are no different in kind from these, but instead just an extension of the same kinds of costs for more of the same kinds of benefits that other social minimum policies provide. The fact that the benefits and costs are no different in kind from those of justifiable social minimum programs puts pressure on the view that an important moral line is crossed when the costs of the health care social minimum, financial and otherwise, move from the level they happen to be at right now and increase to the level required for a universal system. After all, in some sense no moral line has been crossed, since for reasons already given, personal cost objectors cannot maintain that universal health insurance affects certain areas of the human good in an entirely new manner. Instead they are confined to the position that universal health insurance requires a comparatively small number of well-​off earners to pursue fundamental human goods in different and possibly less expansive ways, and their view must be that such costs—​although justifiable as costs

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of our current social minimum programs—​are now just burdensome enough that they outweigh the benefits produced by those individuals’ contributions to a national health insurance system. This then highlights a second, additional strain on the position, which is that its advocates must maintain that our current spending on health care is at this crucial but very subtle tipping point, and that seems improbable. It cannot be that our citizenry has, via the democratic process, set our current level of health care spending at the equilibrium point by rationally comparing benefits and costs, since they almost always lack the time to become experts in the relevant areas of health policy, and therefore almost no ordinary citizens could properly estimate the personal net cost or benefit of our existing health care programs. Instead the current arrangement of our health care system is the result of a long and tangled political process that does not seem to have been centered, or even substantially focused, on reaching a crucial equilibrium point where the personal benefits of the system exactly or just barely outweigh the costs. Nor does one need to appeal to the history of our health care system to make this point. The question is whether it is plausible that the costs and benefits of our current health system are in close enough balance that any substantial increase in costs, for similar benefits, reverses the balance for that small group of earners who do not receive a net benefit from the universal insurance system. However, that view entails that if the benefits of our current programs were to diminish to any significant degree or its costs increase to any significant degree, then the existing health care social minimum programs would no longer be justified, and I doubt that honest interlocutors will find that this is what they believe. So that is a first argument for thinking that, in light of what we have said about the costs and benefits of a universal health insurance system, as well as their significance, reasonable people

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would conclude that the benefits of a well-​designed universal health insurance system outweigh its costs. It appeals to the fact that to believe otherwise requires the highly strained position that any substantial increase in health spending takes us beyond a tipping point for that group of well-​off citizens who see no net benefit from a health insurance guarantee, even if the costs and benefits are no different in kind from those in our current programs. Importantly, though, even if some honest objectors maintained that we are at that tipping point, there is an additional argument that the benefits of some well-​designed single-​ payer or regulated-​market universal health insurance systems outweigh the costs, one that functions as a kind of backstop to our previous argument. Suppose, hypothetically, that when it comes to the specific proposals for universal health insurance systems that we’ve discussed so far, the costs to some outweigh the benefits. If personal cost is our real concern, the next logical step is to try to identify an alternative universal health insurance system with monetary costs low enough that they are outweighed by the benefits. For instance, suppose a person concluded that the monetary costs of providing everyone with insurance equivalent to that of members of Congress outweighed the benefits of that plan. In that case, the person should consider a reformulated proposal with a lower benefit level and thus a lower level of taxation. The benefit level can be ratcheted downward until the person finds a level of monetary and other sacrifice that he or she deems acceptable. Some objectors might try to resist this argument by claiming that the costs of any extension of the health-​related social minimum are excessive if they take us beyond the costs that were being paid under some nonuniversal system, such as the pre-​ACA system. But even that would not justify a cost-​ based objection to universal health insurance. The way the pre-​ ACA system distributed its public benefits was not defensible. Of course, here I have not gone into the details of exactly what

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a just social minimum would look like; that discussion is not central to my focus on fiscal risk, efficiency, and personal cost. But on any reasonable construal of a pro tanto requirement to provide a social minimum to (at least) all deserving citizens, the pre-​ACA system is clearly unjust, because it distributes benefits in a completely unjustifiable way, one that often does not track any morally relevant feature of our political landscape at all. For instance, as we saw in an earlier chapter, prior to the enactment of the ACA, 8.1  million of the uninsured were children, who are surely deserving on any sensible understanding of that concept, and yet the pre-​ACA system guaranteed health insurance to others and not to those children. Or, to give another example, demographic breakdowns show that uninsurance correlates with factors that have little to do with whether a person is, in any sense, deserving of a health care social minimum.92 Unmarried people are more likely to be uninsured than married people, partly because a spouse provides an increased chance of getting medical benefits through the spouse’s employer. Nonwhites are more likely to be uninsured than whites. Men are more likely to be uninsured than women. Southerners are more likely to be uninsured than people in New England. And employees of small firms are more likely to be uninsured than employees of large firms. The upshot, then, is that even if one believes the costs of any proposed extension of the health-​related social minimum are excessive, the only reasonable position is to seek a further alternative to the pre-​ACA system, one that distributes the pre-​ACA funds more justly. Specifically, we would look at the sum total of payments into the health care social minimum, and since we have ex hypothesi agreed to a pro tanto obligation to provide

92. All following from Committee on the Consequences of Uninsurance, Coverage Matters, pp. 67ff.

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a health care social minimum to all citizens, these payments should be used to fund the most robust universal health insurance program possible with those funds. Such a program might offer lower benefits than certain real-​world universal health insurance systems, like the example systems we have considered from Canada, Switzerland, or the Netherlands, but it would still need to be a universal system that provides access to some level of health insurance to everyone.

CONCLUSIONS I began the discussion of personal cost by explaining why the personal cost principle is philosophically plausible. After that we examined the costs and benefits of a well-​designed universal health insurance system as well as their moral significance. I  then argued that the benefits of a well-​designed universal health insurance system outweigh the costs, and so personal cost does not provide reason to withhold our support from well-​designed universal health insurance systems. In the next chapter, we turn to issues of efficacy.

Chapter Four

EFFICACY

MANY AMERICANS EXPRESS CONCERN THAT social min-

imum programs might be ineffective, inefficient, counterproductive, or unnecessary. For convenience, I’ll group these four distinct notions under the heading of concerns about “efficacy.” This chapter focuses on three specific worries about efficacy that are often raised in debates about universal health insurance: that universal health insurance would not improve aggregate national health, that it would reduce medical innovation, and that it would produce waiting lists. We’ll see that the first is best addressed using purely factual information but that concerns about innovation and waiting lists require philosophical analysis.

FIRST EFFICACY C ONCERN: I N C R E A S I N G A G G R E G AT E   H E A LT H In recent health care debates, America never seemed close to adopting a full-​ fledged regulated-​ market or single-​ payer system. But reform proposals like these do come up in political discourse. For instance, single-​payer is still regularly discussed during health care debates, and major elements of the Democratic Party support it. As noted earlier, some Republican and conservative theorists cite the regulated-​market systems of Switzerland and the Netherlands as models for reform.

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Whenever large-​scale reforms are discussed, one worry is simply that these systems will not do as good a job at promoting health as the current American system. In fact some Americans seem to think these alternative systems would be catastrophic. For instance, many Americans say universal health insurance systems are “socialism,” a label they associate with the horrific economic failures of the Eastern Bloc and the Soviet Union. And these worries fit with Americans’ more general attitudes toward government involvement in major sectors of the economy. In one poll, 62% said they don’t trust Congress to make health care decisions.1 In essence, many Americans seem to worry that universal health insurance would be counterproductive by taking us farther from the goal of promoting aggregate health. This argument rests on two mistaken ideas. The first is that failure to maximize aggregate health is a decisive objection to a health plan—​a premise that seems wrong on the face of things, since the system that maximizes aggregate health might create serious injustices, such as leaving some without reasonable access to health care at all. I  won’t pursue this line of response until later, though, since it is unnecessary. The argument also rests on the empirical premise that universal health insurance would reduce aggregate health, and as we will see, that claim is incorrect.

Data on Universal Health Insurance Systems and Health Outcomes Studies show that universal health insurance systems are far from being a disaster. On average, they outperform the U.S. system while costing significantly less.

1. Best and Radcliff, Polling America, p. 293. Cf. Jacobs, Shapiro, and Schulman, “The Polls,” p. 423.

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Health policy experts generally use three kinds of data to measure the performance of health systems. First, they examine outcomes that are supposed to reflect overall population health, such as infant mortality and life expectancy. I will call these the “standard measures” because they are the most commonly used. Second, policy experts measure health outcomes for particular diseases and disorders, such as the five-​year survival rate for patients with breast cancer. Third, they ask people how much they like their health system. Strictly speaking, when we ask people how much they like their health system, we are measuring satisfaction, not performance. The hope is that satisfaction tracks performance at least somewhat. We could look at other measures too. For instance, many health policy articles discuss “capacity and process measures” such as the number of hospital beds or the number of physicians per capita. These numbers are important, but I’ve left them aside while discussing overall performance. Hospital beds and physicians are good only insofar as they improve health rather than, say, being unused or ill-​used. We should measure performance directly.

Assessments of Health Systems: Standard Measures Let’s look at each of the three data sets, beginning with standard measures: infant mortality, life expectancy from birth, and life expectancy from later in life. The U.S. is usually compared with OECD countries, a group of thirty-​five developed democracies. Start with infant mortality, as represented in table 4.1. Infant mortality measures the number of children who die under age one.2 2. For an analysis of the U.S.’s high infant mortality rate, see MacDorman and Mathews’s “Behind International Rankings of Infant Mortality.” This article

Table 4.1

INFANT MORTALITY, DEATHS PER 1,000 LIVE BIRTHS, 2015 (OR NEAREST YEAR) Finland Slovenia Japan Iceland Czech Republic Norway Sweden Spain Estonia Austria Korea Israel Germany Denmark Italy Portugal Slovak Republic Switzerland Luxembourg Australia United Kingdom Belgium Ireland OECD AVERAGE France Netherlands Greece New Zealand Poland Hungary United States Canada Chile Turkey Mexico

1.6 1.7 1.9 2.0 2.0 2.3 2.3 2.4 2.5 2.6 2.6 2.7 2.8 2.9 2.9 2.9 3.1 3.1 3.2 3.2 3.2 3.4 3.4 3.6 3.7 3.9 4.0 4.0 4.0 4.1 4.4 4.7 6.7 10.0 12.5

Source: Data from Organization for Economic Cooperation and Development, “Health at a Glance 2017,” p. 59.

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Higher numbers are bad; they indicate that more infants die during that period. Or consider table 4.2, which shows life expectancy from birth. The low numbers are worse; they indicate shorter life. The U.S. performs poorly again, falling below the average and beating only countries which are not even remotely our economic peers. These measures are imperfect, because things other than health care influence them. For instance, America’s lower lifespan might partly result from our high obesity rates rather than an inferior health system. We shouldn’t totally write off these measures, though. Even though outside factors partly influence life expectancy and infant mortality, the health care system influences them too, and so the bad results at least suggest that our health care system may be worse than some other systems. In addition, note that even though obesity might make America’s health system look worse than it is, other factors work the other way. For example, almost all European countries have higher smoking rates than the U.S. There is another set of data which is similar to lifespan data but less often used:  the data from the World Health Organization’s Global Burden of Disease (GBD) project.3 The project’s goal was to examine the health effects of over 100 diseases. Previous studies had often measured only the years of life lost to various diseases (usually by comparing the age at death to a global standard life expectancy). The GBD went beyond this by making use of age-​standardized “disability-​adjusted life years,” or DALYs.4 Roughly, the goal of using DALY measurement is also addresses the common criticism that infant mortality is measured differently across countries. 3. World Health Organization, The Global Burden of Disease. 4. The measurements are age-​standardized to control for different countries’ differing age distributions. Without that correction, different mortality rates might be due to differences in age distribution rather than other factors.

Table 4.2

LIFE EXPECTANCY AT BIRTH, 2015 (OR NEAREST YEAR) Japan Spain Switzerland Italy Australia Iceland France Luxembourg Norway Sweden Israel Korea New Zealand Canada Finland Netherlands Ireland Austria Portugal Belgium Greece United Kingdom Slovenia Denmark Germany OCED AVERAGE Chile United States Czech Republic Turkey Estonia Poland Slovak Republic Hungary Mexico

83.9 83.0 83.0 82.6 82.5 82.5 82.4 82.4 82.4 82.3 82.1 82.1 81.7 81.7 81.6 81.6 81.5 81.3 81.2 81.1 81.1 81.0 80.9 80.8 80.7 80.6 79.1 78.8 78.7 78.0 77.7 77.6 76.7 75.7 75.0

Source: Data from Organization for Economic Cooperation and Development, “Health at a Glance 2017,” p. 49.

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to account for not only the years of life lost due to a disease but also the health-​related quality of life that is lost when a disease affects people but does not kill them. For instance, DALYs provide a way to place a numerical disvalue on the effect of living with, say, an amputation due to diabetes. Naturally the DALY calculations are highly controversial, but they or something like them are nonetheless widely used among health economists and policy experts, and they have a good claim to being one of the best means for measuring overall health impairments. Results of the GBD study are shown in table 4.3. If we exclude deaths due to accidents and similar causes that are largely unrelated to health care, focusing only on problems resulting from communicable diseases, noncommunicable diseases, maternal conditions, and nutritional problems, we find that in 2008, the U.S. lost 11,377 disability-​adjusted life years per 100,000 people to these causes. The OECD average was 10,206, so the U.S. is again worse than average. In fact there are only eight countries worse than us, and they are all substantially poorer countries with less than half of our per-​capita GDP: Slovakia, Hungary, Estonia, Poland, Mexico, Turkey, Latvia, and Chile. The GBD numbers have the same limitations as regular lifespan numbers—​factors other than the health system affect them. To try to get around this limitation, some analysts look at life expectancy from later in life, usually age 65. The thought is that an older person’s lifespan is more strongly influenced by the health care system than other factors. In addition, looking at life expectancy from age 65 also reduces the influence of other extraneous factors. For instance, the U.S. has higher rates of homicide and vehicle accidents than other countries.5 Since 5. See Ohsfeldt and Schneider, The Business of Health; and O’Neill and O’Neill, “Health Status, Health Care, and Inequality.” For a response to the former, see Organization for Economic Cooperation and Development, “OECD Economic Surveys.”

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Table 4.3

DALYS LOST PER 100,000 PEOPLE, 2008, FROM COMMUNICABLE DISEASES, NONCOMMUNICABLE DISEASES, MATERNAL CONDITIONS, AND NUTRITIONAL PROBLEMS Japan Iceland Italy Switzerland Spain Greece Sweden Australia Israel Norway Austria Netherlands Germany New Zealand Canada France Belgium Finland Luxembourg Ireland Slovenia OECD AVERAGE United Kingdom Denmark Portugal Czech Republic Korea

7059 8083 8176 8410 8610 8638 8710 8772 9013 9156 9216 9322 9325 9378 9400 9460 9534 9606 9641 9938 10171 10206 10277 10277 10287 10418 10722 (continued)

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Table 4.3 CONTINUED United States Poland Chile Slovakia Estonia Hungary Mexico Latvia Turkey

11377 11451 11630 12263 13144 13495 13607 13700 14933

Source:  Data from World Health Organization, “Disease and Injury Country Estimates.”

homicide and accidents disproportionately affect younger people, we can partly filter them out by looking at life expect­ ancy from 65. Unfortunately, using these measures, the U.S. still has middling performance, as shown in table 4.4. The U.S. health system is now slightly below the mean. All but one of the countries with worse results are substantially less wealthy than the U.S., having per capita GDPs less than half of America’s.6 To make things worse, one problem with looking at life expectancy from age 65 is that American seniors are almost universally insured, but the rest of our population isn’t. This means we can’t take life expectancy from 65 as a good measure of the system’s total performance. Instead that measure cherry-​ picks the best-​insured part of the population. Overall, the U.S. is below average on all standard measures. 6.  Organization for Economic Cooperation and Development, “Gross Domestic Product (GDP).”

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Table 4.4

LIFE EXPECTANCY AT AGE 65, 2016 (OR NEAREST YEAR) Japan France Spain Switzerland Australia Italy New Zealand Iceland Luxembourg Korea Norway Canada Israel Sweden Finland Greece Portugal Belgium Netherlands Austria United Kingdom Ireland OECD AVERAGE Slovenia Germany Denmark United States Chile Estonia Poland

21.9 21.5 21.0 20.9 20.9 20.6 20.4 20.4 20.4 20.3 20.3 20.2 20.2 20.2 20.1 19.9 19.9 19.9 19.8 19.7 19.7 19.7 19.5 19.5 19.5 19.4 19.3 18.5 18.1 17.9 (continued)

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Table 4.4 CONTINUED Turkey Mexico Czech Republic Slovak Republic Latvia Hungary

17.8 17.7 17.7 16.9 16.6 16.4

Source:  Data from Organization for Economic Cooperation and Development, “Health at a Glance 2017,” p. 201.

Assessments of Health Systems: Particular Medical Issues One sometimes hears evaluations of health systems that focus on specific diseases and disorders. For instance, opponents of universal health insurance will often point out (correctly) that some citizens of other countries travel to the United States when they need certain forms of high-​tech, cutting-​edge care, or that the U.S. offers particularly good treatment for certain diseases such as cancer. Ultimately, I agree with other policy experts that there is no way to use the existing data on specific diseases and disorders to reliably evaluate overall health systems. To illustrate this, I’ll walk through some of the data and its limitations. One very good source of raw data is the OECD’s “Health at a Glance” report. If we take the most recent report, from 2017, we find data from the U.S. and other OECD countries on many different medical issues. The raw data often has problems—​for instance, different countries sometimes collect the data in different ways, so we cannot be sure it’s comparable. But even if we set aside those sorts of issues, the main problem is that it’s impossible to find a way to use the data on separate health issues to formulate an overall evaluation of a whole health system.

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One method, which is clearly flawed, is to simply fixate on whatever data is convenient for one’s purpose. Some pundits do this dishonestly, focusing only on the data (e.g., cancer data) that makes America’s system look good. And even intellectually honest people can fall into that trap. If you’re worried about cancer, you might fixate on the cancer numbers and ignore the others. Or if your child has asthma, you could fixate on the asthma rates only. Once we avoid this problem and try to compile the data into an overall evaluation, we run into several obstacles. First, the data concerns many specific medical issues, and so it is at best a very partial snapshot of a larger health system. Second, the data tends to focus on some problems more than others, and there is no data on certain important problems at all. Finally, even if we were happy extrapolating from this limited and skewed data, we would find that it concerns different conditions, and so there is no good way to combine the data together. For instance, if we know that the U.S. has a five-​year net survival rate for colon cancer that is roughly 65%, versus 63% in the Netherlands, how can this data be combined with or compared to the very different fact that the rate of obstetric trauma in vaginal delivery with instrument is 3.2 per 100 cases in the Netherlands but 9.6 in the U.S.? In fact, how can we compare the U.S.’s higher five-​year net survival rate for colon cancer with even a much more closely related fact, like the fact that the Netherlands has a five-​year net survival rate for rectal cancer that is better than the rate in the U.S.? I see no legitimate way to overcome these and other problems. Some might wonder whether the data consistently reveals that the U.S. system is superior, even if there is no way to perfectly compile it. It doesn’t.7 For instance, if we compare the U.S. head

7.  The evaluation to follow uses all the quality measures from the “Quality of Care” section of the OECD “Health at a Glance” report, though I have excluded any measures for which there is no U.S. data.

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to head with Canada, Switzerland, and the Netherlands—​the three countries I have used as examples in this book—​then we find that the U.S. outperforms Canada on 13 of the 22 measures for which both have data, is outperformed by Switzerland on 13 of 24 shared measures, and is also outperformed by the Netherlands, which is better on 13 of their 22 shared measures. Overall, the data seems mixed.

Assessments of Health Systems: Self-​Reports A final way to assess health programs is by asking people how much they like their country’s system. Polls don’t always yield precisely the same numbers, but the overall trend is clear. If polls ask only about quality of care, then Americans rate their care about as high as people in other countries.8 However, when people are asked about the health system as a whole—​including the cost and extent of coverage—​Americans like their health system far less than almost all of the surveyed foreigners with a universal health insurance system.9 Consider this Harris Poll from 2008, before the ACA was enacted.10 It asked people from 10 developed countries whether their health care system works “pretty well” and needs only “minor changes,” whether it needs “fundamental changes,” or whether it needs to be “completely rebuilt.” (Participants could also answer “don’t know” or decline, thus percentages may not sum to 100.) Table 4.5 lists countries in rough order of best to worst.11

8. Blendon et al., American Public Opinion and Health Care, p. 43. 9. For an overview, see Blendon et al., American Public Opinion and Health Care, pp. 40ff. 10. See also Blendon et al., American Public Opinion and Health Care, ch. 1. 11. Harris Interactive, “Health Care Systems in Ten Developed Countries.”

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Table 4.5

POPULACES’ OPINIONS ABOUT CHANGES NEEDED TO THEIR HEALTH SYSTEMS

Netherlands France Canada New Zealand Australia Spain Germany Britain USA Italy

Only Minor Changes

Fundamental Changes Needed

Rebuild Completely

42% 29% 26% 26% 24% 22% 16% 16% 12% 11%

49% 47% 60% 56% 55% 61% 61% 60% 50% 66%

9% 15% 12% 17% 18% 12% 17% 15% 33% 20%

Source: Harris Interactive, “Health Care Systems in Ten Developed Countries.”

Interestingly, no one really likes their health system. Even in the best-​performing country, the Netherlands, fewer than half of people said their system needs only minor changes, and in most systems the number is below 25%. But even though all people griped about their health systems, the U.S. system produced far more complaints than most. First, more Americans said the system needs to be completely rebuilt; 33% of Americans believed this, but the next closest number was Italy at 20%. Second, when you sum the number of people who wanted “fundamental changes” or “complete rebuilding,” the U.S. was again near the bottom; 83% of Americans fell into these categories, leaving us second-​worst. In contrast, 72% of Canadians fell into those categories, and only 58% of the Dutch did. Third, note that the number of Americans who said the system needs only

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Table 4.6

POPULACES’ OPINIONS ABOUT CHANGES NEEDED TO THEIR HEALTH SYSTEMS Only Minor Changes United Kingdom Switzerland Netherlands Australia New Zealand Norway Sweden Canada Germany France United States

63% 54% 51% 48% 47% 46% 44% 42% 42% 40% 25%

Fundamental Changes Needed 33% 40% 44% 43% 45% 42% 46% 50% 48% 49% 48%

Rebuild Completely 4% 7% 5% 9% 8% 12% 10% 8% 10% 11% 27%

Source:  Schoen et  al., “Access, Affordability, and Insurance Complexity Are Often Worse in the United States Compared to Ten Other Countries.”

minor changes was dismally low. Our 12% beat the Italians, who were at 11%, but we lagged far behind Canada, 26%, and the Netherlands, 42%. Other polls show differences, of course,12 but the U.S. never performs well. Consider this 2013 Commonwealth Fund poll, which surveys a slightly different group of countries. Table 4.6 is in rough order from best to worst.13 This shows the same trends. More Americans say the system needs to be completely rebuilt than citizens in any other country. 12. One good source of polls is The Commonwealth Fund, “Surveys.” 13. Schoen et al., “Access, Affordability, and Insurance Complexity are Often Worse in the United States Compared to Ten Other Countries.”

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The U.S. is the worst when we sum the people who want “fundamental changes” or “complete rebuilding.” Only a quarter of Americans say that the system works well and needs only minor changes.14

Summary of the Assessments of Health Systems We’ve looked at the three ways to analyze health systems: standard measures, particular medical outcomes, and self-​rating. Universal health insurance systems are clearly not complete disasters on any measure, and the U.S. is clearly not the leader on any measure either. In fact, countries with regulated-​market and single-​payer systems, such as Canada, Switzerland, and the Netherlands, consistently outperform the U.S. on these measures. So far, we’ve examined and set aside one concern about efficacy—​the concern that universal health insurance will be ineffective at maintaining or improving aggregate health. That claim can be disproven with data alone, but now I will turn to another claim about efficacy which can only be refuted through philosophical analysis.

SEC OND EFFICACY C O N C E R N :   I N N O VAT I O N Let’s turn to another common objection related to efficacy.15 We’ve seen that the universal insurance systems in Canada, Switzerland, and the Netherlands seem to produce health outcomes that are at least comparable to America’s. 14. Cf. Blizzard, “Healthcare System Ratings.” 15. This section reprints and builds upon work first published in Rajczi, “A Critique of the Innovation Argument Against a National Health Program,” and I thank John Wiley and Sons for permission to reuse that material.

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However, some critics of universal health insurance claim that appearances are deceiving.16 They say that, as the U.S.  moves closer and closer to universal health insurance, things might be fine in the short run, but over time the system will kill medical innovation. They predict that in the next 10, 20, or 50 years, we will or at least could miss out on important medical developments, and our overall health situation will be worse than if we had continued with our current system. A little alternate history illustrates this worry. Let’s compare two situations, the present as we now know it and an alternate history where we adopted universal health insurance 50 years ago. Right now we know the U.S. system has problems. It provides inequitable access, and many suffer and die from lack of medical care. But some critics say things would not have been better if we had adopted a universal access system long ago. They allege that the system would have stifled innovation and now we might not have MRI machines or CABG surgery for heart disease. So in the alternate history, our universal health insurance system might provide services more evenly, but those services would be vastly inferior to our actual ones. Overall, the critics allege, we’ve done better with the current system. One can project the same worries into the future. In one possible future, we maintain something like our current system, or even revert back to something closer to the pre-​ACA system. The result is (allegedly) innovation but unequal access. In another possible future, we adopt a universal health insurance system. The result is (allegedly) less innovation but better access. The critics say that the first future is better overall. Notice that this argument assumes that only certain options are live: a universal health insurance system and something like our current system or the system pre-​ACA. If we grant this, we 16.  For a statement of the argument to come, see, e.g., U.S. Council of Economic Advisers, “Economic Report of the President.”

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must then assess this argument’s other three main ideas. The first is the allegation that universal health insurance would stifle innovation. The second is the assumption that our current system will continue to innovate. The third is the claim that limiting innovation would be unjust. Let’s consider each in turn.

Innovation in a Universal Health Insurance System The first key idea is that universal health insurance systems reduce innovation. This claim has no firm evidence behind it. To show that universal health insurance systems reduce innovation, a person would need, at a minimum, economic forecasting of two things: the amount of innovation that would occur without universal health insurance, and the amount that would occur if we switched to a particular universal health insurance system. But I don’t know of a single place where anyone even attempts a complete, detailed analysis of these two things. (Perhaps the analysis is too difficult and we can’t predict how major changes in health policy will affect innovation, but then one can’t claim that universal health insurance stifles innovation!) The analyses that exist are incomplete. Take as an example Michael Tanner’s article “The Grass Is Not Always Greener: A Look at National Health Care Systems around the World,” which was written in 2008, right before the election of President Obama, at a time when ideas like the Affordable Care Act were already being proposed by the major Democratic candidates. I  choose this article not because I  think it’s bad, but because I think it is a very detailed and fact-​based critique of universal health insurance. But when the time comes to prove that universal health insurance systems hurt innovation, Tanner lists only three facts:  18 of the last 25 Nobel Prizes in Medicine went to Americans or individuals working in America,

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U.S. companies have developed half of all new major medicines introduced worldwide over the past 20  years, and Americans played a “key role” in 80% of the “most important medical advances of the past 30 years.”17 Let’s suppose these facts are true. They suggest Americans are among the world’s leading medical innovators, but we must still ask whether American innovation would be reduced in a universal health insurance system. It is hard to see why a switch to a universal health insurance system would affect at least some forms of innovation. According to a 2006 study, the U.S.  accounts for 51% of all global spending on medical research, but only 32% of that is from the private sector, while 60% is public funding and 8% is from non-​profits.18 The last two are not necessarily affected by any change to universal health insurance. The question, then, is whether adoption of universal health insurance would affect the 32% of American spending that comes from the private sector. When making their case, critics seem to assume that America’s high profits lead to private-​sector innovation. For instance, President Bush’s Council of Economic Advisors wrote in 2004 that “unfettered by government price controls or access restrictions, innovative products, talented health care practitioners, and skilled health care professionals are rewarded in the marketplace. This leads to technological advances by encouraging investment in new products and research.”19 The Council offers a case study of price regulation in drug markets, arguing that “pharmaceutical companies tend to avoid or delay introducing 17. Tanner, “The Grass Is Not Always Greener,” p. 5. 18.  De Francisco and Matlin, eds., Monitoring Financial Flows for Health Research 2006. See also Baker and Chatani, “Promoting Good Ideas on Drugs” for interesting remarks on the possibility of replacing some private-​sector research with publicly funded research. 19.  U.S. Council of Economic Advisors, Economic Report of the President, p. 191.

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new drugs in countries with price controls.”20 And this reasoning makes sense. Imagine you’re a medical entrepreneur and you’re considering putting funds into a research project. To know whether this is a good gamble, you must know the odds of developing something new as well as the return on investment if your product gets to market. If a universal health insurance system lowered profit margins, it would reduce the expected return on investment and disincentivize some entrepreneurship.21 But that’s an “if,” and so we must actually try to figure out whether a universal health insurance system will lower profit margins and thereby affect innovation. If we take the Affordable Care Act as our example of a quasi-​national system, then as the effects of the act permeate through the health care industry and become measurable, we might eventually have data that will answer the question. If we are discussing larger-​scale reforms, like the move to a full regulated-​market or single-​payer system, then things are much harder to forecast. We’ve already seen that the advocates of universal health insurance propose to fund their systems at high levels—​in fact, the same levels as our current system. Equal spending levels don’t automatically translate into equal profits, because universal health insurance systems could partly pay for expanded coverage by reducing profits. But now we return to the point that this needs to be calculated, not just asserted, and to my knowledge, no one has tried to calculate this. In the end, then, we simply don’t know whether these sorts of universal health insurance systems would reduce innovation. However, since the possibility is live, we should explore the other steps of the critics’ argument. 20.  U.S. Council of Economic Advisors, Economic Report of the President, p. 193. 21.  On this general economic phenomenon, see, e.g., Acemoglu and Linn, “Market Size in Innovation”; Finklestein, “Static and Dynamic Effects of Health Policy”; Blume-​Kohout, “Market Size and Innovation.”

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Innovation in Our Current System When people object that universal health insurance would stifle innovation, they presuppose that our current system would innovate better. But would it? Once again I don’t know of rigorous analyses, but there are reasons to think that our system might innovate less well than a universal health insurance system. Entrepreneurs innovate when they think the health system will offer suitable profit margins on new technologies. That was true of the U.S. market for a long time; we were willing to pay increasing amounts for high-​technology care. For instance, total national health spending went from about 5% of GDP in 1960, to 9% in 1980, to 14% in 2000, to almost 17% in 2012.22 Individuals experienced that same rise personally. In 2011 adjusted dollars, the average cost of an employer-​sponsored PPO plan for a family of four was $10,136 in 2001, and in 2011 it was $19,393.23 It was projected at the time that that trend couldn’t continue. Almost every policy analyst agreed (and still does) that we must curb spending on Medicare and Medicaid. Individual increases of this magnitude couldn’t continue either, and indeed the increases have slowed.24 In response to new limitations, medical entrepreneurs might try selling new technologies to a smaller customer base—​ the wealthy—​at higher margins. That might maintain current levels of innovation. But then middle-​class Americans wouldn’t be able to afford the innovations, so from the average citizen’s 22.  U.S. Centers for Medicare and Medicaid Services, “National Health Expenditure Data,” esp. the report “NHE Summary.” 23. Reinhardt, “Would Privatizing Medicine Lead to Better Cost Controls?” See also the Milliman report cited therein, “2011 Milliman Medical Index.” Milliman figures are in actual dollars and not adjusted for inflation, so I have adjusted the 2001 figure. 24. Girod, Hart, and Weltz, “2017 Milliman Medical Index.”

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perspective, the American system wouldn’t be out-​innovating a universal health insurance system. In contrast, there are reasons to think that a universal health insurance system might be able to provide ordinary people with more innovations. First, to keep innovating and providing those innovations at reasonable cost, we need to find a way to continue spending on new technology without running out of money. That requires cutting spending in other areas, such as ineffective treatment. As we noted in our overview of health systems from chapter one, universal health insurance systems are at least designed to cut nonessential costs. Second, we must not lump all “innovations” together and assume they are all worthwhile. Some companies spend vast sums developing “copycat” drugs that don’t improve on existing drugs, and some companies develop new technologies that don’t improve over old ones. Universal health insurance systems might more effectively cut back this useless “innovation,” because all systems incorporate a technology assessment board that either excludes ineffective treatments or at least disseminates enough information to incentivize work on innovations that improve patient care.25 Thus a universal health insurance system might be able to cut useless spending and steer funds where innovation is needed. In sum, if we want to enjoy innovation in the future, it’s possible that the best choice is a universal health insurance system that could bring down nonessential health costs and direct money into the development and distribution of cutting-​edge technologies. But just as with the projections about innovation, I regard this claim as speculative, since we lack data to refute or confirm it with any certainty. If we want to rebut objections that 25. Cf. Emanuel, Fuchs, and Garber, “Essential Elements of a Technology and Outcomes Assessment Initiative”; and Robinson and Smith, “Cost-​Reducing Innovation in Health Care.”

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revolve around reductions in innovation, we must approach them philosophically.

Comparing Innovation and Access So far we’ve seen that there’s no firm evidence that universal health insurance systems would innovate less well than our current system, but since it’s a possibility, let’s consider the philosophical implications. Suppose our options are maintaining something like the pre-​ACA system and having more innovation, or adopting something akin to a universal health insurance system and risking reduced innovation. Which should we choose? Critics of universal health insurance often presuppose that we should pick the first option, but to my knowledge, none say why. However, I’ll speculate on their behalf. Let’s compare two hypothetical futures, one with a universal health insurance system and one without. For simplicity’s sake, assume that society is divided evenly into two groups, the better-​off and the worse-​off. In 50  years, the worse-​off might fare better under a universal health insurance system than under the pre-​ACA system, judged on a cardinal scale of health-​related well-​being. However, the better-​off might fare better under something like the pre-​ACA system. Moreover, the aggregate gains to the better-​off might outweigh the losses to the worse-​off, leaving average health-​ related well-​ being higher under our current system. Using some artificial numerical assignments, and making the artificial assumption that the groups are equal in size, an example of this outcome is shown in table 4.7. But if critics are imagining this scenario, then their argument is ethically flawed. They would have to argue that society should aim for the future with the highest average level of health-​ related well-​ being, even when this leaves many people, both now and in the future, without the social minimum of health care that, by hypothesis, we agree there is pro

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Table 4.7

ONE HYPOTHETICAL ASSESSMENT OF THE EFFECTS OF INNOVATION Universal Insurance System in 2060

Pre-​ACA System in 2060

Worse-​off: 4 Better-​off: 5 Average Well-​being: 4.5

Worse-​off: 3 Better-​off: 9 Average Well-​being: 6

tanto reason to establish. We wouldn’t endorse that policy with other services that we feel obligated to provide to citizens. For instance, we agree we shouldn’t deny some people basic police protection just so we can put the resources elsewhere and drop the average level of crime, now or in the future. Nor should we raise the average level of education by leaving some citizens with little or no education at all. It’s easy to multiply cases like this, where we have clear and very forceful intuitions against maximizing policies. The advantage of the intuitive appeal is that its considerable force can be felt by people with divergent political philosophies. If necessary, though, the intuitions could also be backed by further argumentation. One option would be to put forward and defend one of the many theories of justice that prioritize provision of a social minimum. But in this case that approach seems unnecessary, since it is hard to identify a plausible version of any liberal political theory which includes a pro tanto obligation to provide access to a social minimum while also endorsing the innovation-​maximizing policies described above. Take, for instance, a rather generic form of liberalism that does not countenance any general government duty to increase the welfare of its citizens, but says instead that the government should leave society to run itself except in specific situations—​e.g., when

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government intervention is necessary to protect individuals from harm and from discriminatory behavior that fails to treat them as individuals and political equals, to ensure access to a social minimum, and so on.26 In such a framework it is easy to explain why the innovation-​maximizing policy is unjust, because there is no general duty to maximize well-​being through noninterference with the market, and in fact the theory explicitly says that the behavior of individuals in those markets—​the kind that is presumably producing the innovation—​may be altered or regulated to protect individuals from harm, to prevent discrimination, and—​importantly—​to ensure a social minimum. For the proponents of maximizing innovation, a more promising liberal theory would be one which also contains a pro tanto obligation for the government to advance the welfare of its citizens. They might then claim that this pro tanto obligation is stronger than the pro tanto obligation to provide reasonable access to a social minimum, at least in this case. However, this line of argument does not seem promising. Saying why will require a brief discussion of methodology. In the philosophical literature, we find roughly three models of how to resolve conflicts between competing pro tanto principles. Following Henry Richardson, we can call the first intuitive balancing. Here some moral faculty is exercised to determine which of the competing considerations are more weighty, and this method presumes that there can be no helpful, rational explanation of why one set of considerations is more important than the other: “The deliberator is unable to articulate his or her reasons for weighing matters differentially,” perhaps because the weighting is (metaphorically) something one simply “sees.”27 This

26. See, e.g., Talisse, Engaging Political Philosophy. 27.  Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 297.

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method might be correct, though it does have the obvious downside of leaving certain aspects of morality inexplicable. Another alternative is what Beauchamp and Childress call justified acts of balancing, or simply justified balancing. This is the process of “finding reasons to support beliefs about which norms should prevail.”28 Finally, we have Richardson’s option of specification. Richardson’s definition of specification is fairly technical,29 and I will not repeat all of its nuances here, but its main features are that during the process of specification, we narrow the extension of the original, unspecified norm to a subclass of cases, without extending it to any new ones;30 and we also gloss the determinables by adding clauses that spell out “where, when, why, how, by what means, to whom, or by whom the action is to be done or avoided.”31 For instance, one possible specification of the principle “Respect the autonomy of patients” might be “Respect the autonomy of patients by following their advance directives whenever they are clear or relevant.”32 Specification can help resolve (what seemed to 28. Beauchamp and Childress, Principles of Biomedical Ethics, p. 20. 29. See Richardson, “Specifying Norms as a Way to Resolve Concrete Ethical Problems,” pp. 294ff. 30.  Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 289. 31.  Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 289. 32.  Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 290. Notice that there are many things that we might naturally call “specifying a principle” that are not in fact what Richardson has in mind. A  principle about respecting autonomy, for instance, could be made more “specific,” in the ordinary sense, by saying what autonomy is. However, that is not specification in Richardson’s sense. (Cf. Richardson’s example on pp. 289–​ 90 of “Specifying, Balancing, and Interpreting Bioethical Principles.”) Nor is merely working out a principle that is a consequence of our original norm, as might happen when we deduce “it’s wrong to lie” from “it’s wrong to do anything with the intent of deceiving.” (This example comes from Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 288.)

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be) conflicts among principles and bring them to bear in guiding action. For instance, Richardson considers a bioethical dilemma where medical personnel have to decide whether “to withhold nutrition and hydration from a severely malformed newborn so as to let [him or her] die.”33 Assuming for the sake of argument, as Richardson does, that withholding artificial nutrition and hydration (ANH) is perceived to count as killing, then the medical personnel might feel pulled in conflicting directions by three norms. Two tell against withholding ANH. One is the prohibition against killing innocent people. Another is the duty to benefit those over whom one has responsibility, which tells against withholding so long as we assume the infant’s life is not so terrible that he or she is better off dead. However, if the parents want to withhold ANH, then at least one principle speaks in favor of withholding—​the principle that says we should respect the reasonable choices of parents. Now imagine that the medical personnel go through the specification process (to be discussed in more detail below) and arrive at a specification of the last principle which says that one should respect parental choices about their children so long as the parents respect the children’s rights. This, Richardson says, might remove the conflict by revealing that a proper principle of respect for parental rights does not push us toward withholding ANH. Here I  won’t try to decide whether balancing or specification is the best way to resolve conflicts between pro tanto principles, since the arguments we put forward to justify our balancing or specification would be similar and involve applying whatever method of philosophical argumentation we think is best.34 In my view that is wide reflective equilibrium, 33.  Richardson, “Specifying Norms as a Way to Resolve Concrete Ethical Problems,” p. 303. 34. Richardson sees this, arguing for the superiority of specification over justified balancing not by saying that there is a method for specification which is unavailable to the advocates of justified balancing, but on other theoretical

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which roughly speaking works as follows. In any reflective equilibrium process, wide or narrow, we begin by identifying our considered judgments, the moral judgments in which we have greatest confidence. These can be of any level of generality, either propositions about specific actions, action-​types, or general moral ideas like “All people are moral equals.” We seek to identify a set of moral principles that coheres with and explains all these considered judgments. When doing so we “work back and forth,” to use Rawls’s phrase, modifying either the considered judgments or the theory in order to bring them all into the most plausible coherent state. During a wide equilibrium process in particular, our theorizing is informed by an evaluation of “other plausible conceptions . . . and their supporting grounds.”35 So defined, some have alleged that wide reflective equilibrium is near-​vacuous, telling us little more than to look at all the arguments for various moral theories and pick the theory that is best.36 There is some truth in that charge, and in fact one way to justify using the method is by highlighting the fact that it subsumes most forms of argumentation that philosophers would put forward. But reflective equilibrium does have features that distinguish it from other methods. Among the key features are that considered judgments about cases—​“intuitions,” as they are sometimes called—​can serve a justificatory role in reflective equilibrium, as well as the fact that no considered judgment, about a case or about a very abstract principle, is immune from revision. The first of these two features is particularly important

grounds. See Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” especially his criticisms of Beauchamp and Childress. 35. Rawls, “The Independence of Moral Theory,” p. 8. 36. Cf. Scanlon, “Rawls on Justification”; Singer, “Ethics and Intuitions.”

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for the issue we are currently discussing. As noted earlier, we have widely shared considered judgments that we shouldn’t deprive some people of basic goods such as police protection, education, and so on merely to provide greater benefits of the same type to other citizens. These considered judgments will serve as inputs into our reflective equilibrium process, pushing us toward the conclusion that the right balancing or specification of our principles will prioritize provision of a social minimum. The considered judgments are not immune from revision in that process, but they are firm enough that it would take substantial competing considerations to displace them. Moreover, although it’s impossible to prove that there could never be considerations which would overturn our confidence in the considered judgments in question, it is very hard to see what those additional, theoretical considerations might be, since abstract considerations either seem to favor the same policy or at least don’t point in one way rather than another. For instance, during a reflective equilibrium process we might appeal to the need to treat all people as moral or political equals, or to treat all people as individuals rather than as components of aggregates, but these considerations would not seem to displace our considered judgments that the pro tanto obligation to provide a social minimum takes priority over any pro tanto obligation to advance citizen welfare generally. Indeed, these very general remarks find confirmation in the fact that, when we survey the major political theories developed by philosophers using a reflective equilibrium process—​ or indeed any other argumentative method—​we find almost none which both endorse a social minimum and also endorse depriving some members of that social minimum merely to maximize aggregate welfare. The only apparent exception would be a theory which says that we should balance or specify our pro tanto principles by looking at the deeper moral theory that underlies them and that the correct moral theory is a particular

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kind of act-​utilitarian theory37—​one that (1) employs a conception of well-​being such that, when all effects of policies are taken into account, the policies lead to the utility assignments earlier, and (2) employs a straightforward agent-​neutral rule requiring us to maximize overall well-​being, at least among our citizen population. Here I  can’t repeat the very lengthy debate about whether we would arrive at that sort of utilitarian theory in reflective equilibrium, but perhaps two observations will suffice. First, utilitarian theories of this kind are among the ones most widely rejected—​rejected, in fact, because they seem to lead to results like the one we are considering here, where some disadvantaged people are left in terrible conditions just to increase the well-​being of others and therefore maximize the aggregate well-​being of the larger group. Second, even utilitarians feel the force of that problem, so they have been at pains to argue that the correct form of utilitarianism, whatever it is, does not have features (1) and (2). Sometimes they do that by asserting that a correct understanding of well-​being will show that leaving the least advantaged in a disadvantaged state is not actually utility-​ maximizing. For instance, they might argue in this case that people without health insurance suffer so much that leaving them without health insurance doesn’t in fact maximize utility. Sometimes the utilitarians appeal to secondary effects as well, arguing that once those are taken into account, it is not utility-​ maximizing to leave the least advantaged in their disadvantaged state. For instance, they might argue in this case that once we take into account not only the suffering of the uninsured but also the pain of knowing that our fellow citizens are dying from 37. Note that if we are attempting to balance a pro tanto obligation for the state to provide a social minimum against other pro tanto duties, then we have already assumed that certain philosophies, such as right-​libertarianism, will not result from a proper reflective equilibrium process. Naturally one could question that assumption, but in that case we would enter another debate, one about the legitimacy of right-​libertarianism.

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lack of preventable medical problems, the fear of knowing that we could possibly fall into that group, and so on, then leaving people uninsured doesn’t actually maximize utility. Finally, utilitarians sometimes try to escape the problem by rejecting the straightforward agent-​ neutral act-​ utilitarian rule, hoping to thereby escape the conclusion that we should leave the least advantaged in their severely disadvantaged state. Whatever the solution, though, the overall point is that even those sympathetic to utilitarianism seem to realize how difficult it will be to argue for the kind of act-​utilitarian theory that would make trouble for our conclusions here, one with features (1) and (2). So far I  have been considering versions of liberal theory that treat the unregulated social environment as a default and sanction government intervention only when various pro tanto principles favor it. That is not the only kind of liberal theory, though. Rawls’s theory, for instance, contains a principle, the difference principle, which says we should arrange society’s basic institutions so as to maximize the index position of the least advantaged, then of the next-​least advantaged, and so on. Obviously, though, any theory which gives priority to the welfare of the least advantaged will not sanction the innovation-​ maximizing policies either. Nor would egalitarian theories like Dworkin’s, which make the case for a social minimum irrespective of whether its provision is utility-​maximizing. Overall, then, the situation is that our considered judgments speak against the innovation-​maximizing policies, and these considered judgments seem either backed by, or at least not contradicted by, our theoretical options. However, I am not sure how troubled advocates of innovation would be by this result, because I suspect that when people advocate for maximum innovation, they are not actually imagining the cardinal health rankings given above. Rather they think everyone would be better off under the current system in 50 years, because innovations (allegedly) trickle down to even the worst-​off. An example of that situation is shown in table 4.8.

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Table 4.8

ONE HYPOTHETICAL ASSESSMENT OF THE EFFECTS OF INNOVATION Universal Insurance System in 2060

Pre-​ACA System in 2060

Worse-​off: 4 Better-​off: 5

Worse-​off: 5 Better-​off: 10

In this hypothetical, maintaining the pre-​ ACA system makes all future people better off than they would be under a universal health insurance system. But if this is what critics predict, one problem is that their speculations about the future are totally undefended. I’ve never seen any analysis that tries to predict the medical care we’ll have any significant distance into the future, much less an analysis that predicts that everyone would be better off under something like the pre-​ACA system, including the people who will lack insurance. Moreover, suppose for the sake of argument we grant that everyone will be better off with the pre-​ACA system in, say, 20 or 50  years. Even so, we don’t actually escape the arguments considered a moment ago, since even if all are better off in the medium-​to long-​distance future, millions of people will be worse off under our current system in shorter timeframes—​one year, five years, or even 10. The worst-​off in our system will continue to suffer and die, and a universal health insurance system (or even an approximation of one like the ACA) could prevent some of that suffering and death.

Summary In sum, critics sometimes claim that universal health insurance would stifle innovation. We’ve seen that there is no good analysis showing that well-​funded universal health insurance

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systems would reduce profits and stifle innovation. We cannot rule out that they would, though, and so the philosophical issues become key. I have argued that even if we grant that a universal health insurance system would reduce innovation, we should not focus solely on that one factor. Our choice would be between high innovation without universal access and lower innovation with it. The latter is morally preferable, since otherwise we fail to give proper priority to the provision of a decent minimum. Considering the objection from innovation has, I think, revealed some general lessons about how we should approach all moral debates about the efficacy of health systems. But before exploring those larger insights, let me consider the third and last objection related to efficacy.

THIRD EFFICACY C O N C E R N :   WA I T   T I M E S In debates about health reform, some people claim that if we adopt a single-​payer system, we will end up with long waiting lists for care.38 Likewise, the current debate about whether to keep, modify, or repeal the ACA also raises issues about wait times.39 Opponents of the ACA sometimes allege that it will eventually create a doctor shortage, and the insured will have to wait longer for care. Wait times come up in debates about national health policy in other industrialized countries as well.

38. The text that follows reprints and builds upon work from my article “Wait Times and National Health Policy,” which was first printed in the Journal of Medical Ethics. I thank BMJ publishing Group Ltd. for permission to reuse that material. 39. Lowrey and Pear, “Doctor Shortage Likely to Worsen with Health Law.”

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To know whether this worry is legitimate, we have to start with the data on wait times. Let me first present the data as one might normally encounter it in a health policy discussion, and after that I will point out a serious problem with the way these surveys measure wait times. Take, for instance, a 2010 survey by the Commonwealth Fund, which measured wait times before the ACA. Table 4.9 shows how this data might be presented, as it was by some authors. Here we can see that compared with the systems of other industrialized countries, the U.S. system does not actually do a very good job at allowing patients to see doctors on short notice, and it also requires people to wait six days or longer with a fairly high frequency. In fact, the regulated-​market systems in Table 4.9

WAIT TIMES IN 2010 Waited 6 days or more Switzerland Netherlands New Zealand United Kingdom Australia Germany France United States Sweden Norway Canada

2% 5% 5% 8% 14% 16% 17% 19% 25% 28% 33%

Same-​or next-​ day appointment 93% 72% 78% 70% 65% 66% 62% 57% 57% 45% 45%

Source:  The Commonwealth Fund, “The Commonwealth 2010 International Health Policy Survey in Eleven Countries.”

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Switzerland and the Netherlands have no waiting lists to speak of,40 and the Dutch have better access than Americans in many respects that are not reflected in this chart, including getting care outside normal business hours.41 Still, if the comparison is with Canada alone, it is true that the U.S. does a better job of offering same-​or next-​day appointments, and we do better at preventing waits of six days or more. Of course, this does not imply that if the U.S.  adopted a single-​payer system, we would thereby adopt Canada’s wait times. Wait times are partly a function of funding, and all the major proponents of single-​payer in America propose continuing to fund our system at high levels per capita when compared with other countries, including Canada. Still, the critics probably fear that a single-​payer system would lead to reduced funding, and if so, then the U.S. might incur increased wait times. Now, though, we should scrutinize how wait times are counted in surveys like the one just mentioned, in order to make sure they are capturing all factors that are normatively relevant to our decisions about health policy.

How Wait Times Are Counted A variety of agencies collect data on wait times, and their collection methods are not all the same. Nonetheless, most collection methods have one methodological aspect in common: they typically measure wait times only for those people who are able to get medical appointments, thus excluding uninsured people 40.  For statistics on the Netherlands, see Davis, Schoen, and Stremikis, “Mirror, Mirror on the Wall,” p.  10. On the Swiss, see Organization for Economic Cooperation and Development and World Health Organization, “OECD Reviews of Health Systems—​Switzerland 2011.” 41. Schoen et al., “Toward Higher-​Performance Health Systems,” p. w725.

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who never seek appointments because they cannot afford them. Another way to put the point is this. If uninsured people cannot afford care, then they are on a sort of “waiting list” of their own—​ one that might last years or even a lifetime. But these waits are not counted in surveys that look only at people who got an appointment and ask how long it took to get that appointment. Later I will say why this methodological characteristic matters. First let me offer an example of it. Consider again the Commonwealth Fund International Health Surveys. This data, which comes from one of the most respected health policy research organizations, is used as a basis for academic research on health policy and is even used by the OECD in its evaluations of worldwide health systems. The Commonwealth Fund polls people in order to determine their level of “access to doctor or nurse when sick or needed care.”42 The poll question itself is “Last time you were sick or needed medical attention, how quickly could you get an appointment to see a doctor or a nurse? Please do not include a visit to the emergency room.”43 And respondents are asked whether they “[obtained] an appointment”: On the same day The next day In 2 to 5 days In 6 to 7 days In 8 to 14 days After more than two weeks Never able to get an appointment

42.  Schoen and Osborn, “The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries,” p. 11. 43. The Commonwealth Fund, “Questionnaire, IHP 2010,” p. 5. The phrase “emergency room” is sometimes modified for those in other countries.

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Not sure Decline to answer44 How would an uninsured person respond to such a question? Some uninsured people seek medical care despite their lack of insurance, so they may simply pick one of the time spans on the list. But consider uninsured people who forgo care and never seek treatment, perhaps because they cannot afford the cost. How would they respond to such a question? I cannot prove that the uninsured respond to questions like this one in a specific way—​ the Commonwealth Fund has no data on that. In theory it is possible that when asked to think about “how quickly” they got to see a doctor or nurse, the uninsured think about their most recent episode of forgone care (i.e., where they never sought medical attention at all) and respond that they were “never able to get an appointment” for that care. However, it is plausible that many uninsured people ignore episodes of forgone care when answering this poll question. Instead, when asked about how quickly they got to see a doctor or nurse, they think only about the last time they actually saw or attempted to see a doctor. And if so, then all their intervening episodes of forgone care are not being measured. In case that seems speculative, consider a clearer case. The Commonwealth Fund also asks questions about specialty care that is sought after a referral.45 Now imagine an uninsured person who would have been referred for specialty care if she had seen her general practitioner but never went to her general practitioner at all because she could not afford appointments of any sort. When asked to think about the last time she waited to see a specialist, she will not count the hypothetical time she would have waited to see the specialist her GP would 44. The Commonwealth Fund, “Questionnaire, IHP 2010,” p. 5. 45. The Commonwealth Fund, “Questionnaire, IHP 2010,” p. 10.

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(hypothetically) have referred her to, had she been able to afford visits to her GP and specialists. Instead she will think only of specialty visits that did in fact occur. Thus the data excludes the waits resulting from forgone care with specialists. So that is the methodological characteristic shared by many surveys of wait times: they ignore the waits that the uninsured experience during episodes of forgone care. We can make this characteristic even clearer by considering an alternative way we might count waiting lists. When the uninsured forgo care, they may never seek treatment and may suffer a medical problem for their whole lives. Alternatively, they may eventually seek treatment, perhaps because they become insured, because their condition grows worse, and so on. Imagine that we knew (which we don’t) how long these “waits” typically last. That is, imagine we knew (1) at what point the uninsured would normally seek care if they were not facing cost-​related access problems, and (2) the time when they do in fact receive care (if at all, using death as the endpoint otherwise). One could then factor these “waits” into calculations for waiting times. To give an extremely simplified example, we might survey 10 Canadians about their wait times for elective surgery. Suppose the average comes to 1.5 months.46 Suppose we also survey 10 Americans. One is uninsured and never gets surgery. Standard surveys therefore exclude him from their calculations entirely, because they measure wait times only for people who succeed in getting treatment. Suppose the remaining nine have an average wait time of 0.9. Standard surveys report the data as follows: Canadian wait times are 1.5 months on average, American wait times are 0.9, and the U.S. has shorter waiting lists. But the alternative method I am presenting would place a value on the 46.  This and the subsequent 0.9 for Americans are the actual findings in Anderson and Hussey, “Multinational Comparisons of Health Systems Data, 2000.” It is based on older Commonwealth Fund data.

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wait time of the uninsured person. Maybe it was a woman who had breast cancer and would have benefited from mastectomy but who was uninsured and could not afford care. Two years later she dies. Her wait time is 24 months. If the woman’s wait time was added to the data above, then the U.S. wait time would be 3.2  months on average, much longer than the Canadian average. Now, nothing I have just said is a critique of the accuracy of the data provided by the Commonwealth Fund or any other organization. They have chosen to calculate wait times in a certain way, and I assume they are doing so correctly. My points are instead that we must understand that they are counting the wait times of those who can obtain appointments, and, second, that they are failing to count something else that one might usefully count: the wait times experienced by all patients, including those who cannot obtain care. Notice, by the way, that this problem does not affect measures of American wait times only. Even in countries striving for universal access to health insurance, there are various waits that will not be counted in standard wait time surveys. Countries with “universal” health insurance do sometimes have uninsured populations—​often among illegal immigrants or noncitizens.47 If one thinks these populations should be insured, then their wait times should be counted but are instead being overlooked. Countries with universal health insurance also have limits on coverage, and if one thought that certain noncovered services should in fact be covered, then one would want to measure the waits for those who cannot afford private coverage. Finally, even if services are covered, there may be other national factors that 47. For instance, both the Dutch and Swiss systems have rates of uninsurance of about 1%. See Leu et al., “The Swiss and Dutch Health Insurance Systems,” p.  vii; Westert et  al., “Dutch Health Care Performance Report 2008”; and Medecins Sans Frontieres, “Switzerland.”

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prevent the use of the services:  a lack of accessible providers, inability to take time off work, ignorance of when services should be sought. If one finds these obstacles problematic, then the waits that result should be counted when assessing a health system as well.

The Normative Significance of Standard Wait Times We’ve examined two ways to measure wait times, and we could devise others as well. Now we can ask whether the standard measure is morally relevant when deciding whether to adopt universal health insurance. On the face of things, it would seem not. Suppose low wait times are a means to some morally important outcome affected by health systems, either improved health, a reduction in the anxiety that comes from waiting to see a doctor, or something else. These are outcomes we want for the whole populace, not just some subset of it, and so the modified measure, not the standard one, will be the relevant one. This becomes clear if we imagine a situation in which a proposed universal health insurance system would increase wait times as they are standardly measured but decrease them overall, using the modified measure proposed above. If individual reductions in wait times are correlated with, say, improved health, then it would surely be a mistake to evaluate universal health insurance systems using the standard measure. It would, by hypothesis, point us toward a system which made the populace less healthy in aggregate. There is one important wrinkle here, though. Consider again the moral framework that we looked at during the discussion of personal cost. There we saw that when determining the level of the social minimum, our decision might be reasonably based (in part, at least) on whether the sacrifices made

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by those who fund the decent minimum are outweighed by the benefits produced by those contributions, as judged on a weighted scale that gives disproportionate weight to the individual sacrifices. If this way of setting the decent minimum could be justified, then the standard measures of wait times would be morally relevant in an interesting way. They would help inform us about the sacrifices that would be made by the insured population if we moved to a universal coverage system. Notice, though, that even if we granted that this way of setting the decent minimum is legitimate, and thus that the standard measures of wait times are not wholly irrelevant, it would still be inappropriate to rely only on standard measures when reasoning within this moral framework. This framework requires that we look at not only the sacrifices made by those who fund expanded coverage but also the benefits to those who receive the expanded coverage, including benefits in reduced wait times. And we cannot do that unless we use the kind of data that would be collected in the modified procedure I have proposed, because that is the procedure which looks at the waits of the uninsured before and after any health reform. So far, then, we’ve seen that one certainly can’t make a case against universal health insurance by a straightforward appeal to the standard measures of wait times. At best they could figure into an appeal to personal cost, and even then they would be only a part of the picture and would need to be supplemented by the alternative measure I have described. The previous chapter already discussed how we could assess an appeal to personal cost, so rather than reiterate that debate, let us leave behind arguments that appeal to wait times as a reason to reject universal health insurance altogether, turning instead to the idea that facts about wait times can help us choose between universal health insurance systems.

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Debating Alternative Methods of Achieving Universal Access When critics of health reforms appeal to wait times, they are not always challenging the idea that we should adopt universal health insurance. Instead they sometimes admit that the government should attempt to achieve universal coverage, but they cite wait times to show that one particular way of achieving universal coverage—​say, by adopting a single-​payer system—​is worse than an alternative that they favor. As an example, consider Goodman et al.’s argument in Lives at Risk. These authors write that “by U.S. standards, rationing by waiting is one of the cruelest aspects of government-​run health care systems.”48 They suggest that higher wait times are at least one drawback of single-​ payer to be weighed against its merits, and the end of their book proposes alternative health care reforms that the authors think are superior to single-​payer along many dimensions.49 Does this argument work? Goodman et al. seem to be assuming that waits under their system would be equivalent to America’s present wait times. Therefore, in order to compare waits in their system to waits in a single-​payer system like Canada’s, they cite standard wait-​list data that compares present U.S.  wait times to Canada’s. However, we know that the standard wait measures are really comparing wait times for the whole Canadian population to wait times for only a portion of the U.S. population. The authors’ arguments are therefore unsound and could only be improved by relying on (among other things)50 the alternative data described above, which measure 48. Goodman et al., Lives at Risk, p. 18. 49. Goodman et al., Lives at Risk, p. 38. Compare also Gratzer, The Cure, ch. 9. 50. Other data about wait times would also be relevant in a holistic argument that compared two universal-​coverage systems on their various merits. For

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waits for the whole population. Think of it this way: It would obviously be inappropriate for someone to argue that the Canadian system has superior wait times to the Dutch system by looking at data which compares the whole Dutch population to only the part of the Canadian population that waits the least. And yet that is precisely the sort of thing that these critics of universal health insurance are doing when they appeal to standard wait-​time surveys. Their arguments cannot get off the ground unless they use the alternative measure of wait times. Nor is this a problem restricted to the particular argument given by these authors. If we are engaging in a debate about which universal access system to adopt, then we have already granted that all deserving citizens have an entitlement to reasonable access to health care. In such cases it would, of course, be perfectly reasonable to prefer the system which has the lowest wait times, other things equal, and thus to treat short wait times as a pro tanto reason in favor of one particular system. However, since all citizens have the entitlement, one would have to look at wait times for the population in aggregate.51

Summary In this section I’ve considered another efficacy-​related objection to universal health insurance. The objection relies on the standard measures of wait times, but I’ve argued that a proper philosophical examination reveals that those measures are at instance, if one believed that patients with nonurgent conditions should wait longer than those with urgent ones, then one might want to look at which universal-​coverage system best triaged the patients in that way. 51. The only exception would be if we adopted the framework described at the end of the previous section, one in which the extent of the entitlement to health care is a function of the burdens placed on the presently insured population. But as I showed earlier, even in that case one would need to rely not only on the standard measure but on the alternative measure as well.

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best only a part of the picture and that the standard measures either need to be replaced by or at least supplemented by alternative measures. Measures of wait times might figure more plausibly into a decision about which universal access to adopt, but in that case it is the alternative measure that is relevant, and in no case could the argument show that we should adopt anything less than a universal access system.

CONCLUSIONS This chapter has examined issues of efficacy in health care, considering three of the most prominent efficacy-​related objections to universal health insurance. If we focus on the most obvious measure of effectiveness, the ability of a health system to improve health, then it seems that any objection from effectiveness can be refuted using some of the common empirical facts about health systems. I also considered two other objections grounded in concerns about efficacy. We saw that we must pay careful attention to the measures of effectiveness used in discussions of health systems, since data can be perfectly accurate and yet incomplete, normatively problematic, or even irrelevant. That was true for certain measures of innovation in a health system, which seemed normatively irrelevant, and with the standard measures of wait times, which seem to be at best a minimal part of a proper discussion of health systems. In sum, then, it does not seem like the most common worries about efficacy provide any reason to withhold our support from well-​ designed universal health insurance systems. The next chapter examines the fiscal effects of those systems.

Chapter Five

FISCAL ISSUES

IN CHAPTER TWO, WE SAW that some Americans cite fiscal

concerns as a reason to oppose extensions of the health care social minimum. For instance, two months before the ACA passed, 60% of Americans thought the legislation would increase the deficit, including 83% of Republicans.1 About 30 to 40% of respondents also reported that these costs meant that, in light of the financial situation of the U.S., “we cannot afford to take on health care reform right now.”2 These poll results and others like them don’t tell us how the people with fiscal concerns would expand those worries into a more robust argument. I’ll try to develop and examine such an argument on their behalf, first laying out some information on government debt and the fiscal risks it can create, then asking how considerations about fiscal risk could most plausibly figure into our moral assessments of universal health insurance. We’ll see that in some instances, there are legitimate fiscal objections to extensions of the health care social minimum, but that fiscal objections cannot ground opposition to well-​designed universal health insurance systems.3 1. Kaiser Family Foundation, “Kaiser Health Tracking Poll.” 2. See, e.g., Penn, Schoen, and Berland Associates, “Divided We Remain”; and also Kaiser Family Foundation, “Kaiser Health Tracking Poll.” 3.  The text that follows reprints and builds upon work from Rajczi, “Fiscal Objections to Expanded Health Coverage,” which was first printed in The

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GOVERNMENT DEBT AND FISCAL RISK Let’s begin with some factual information on government debt and the risks it can create. In 2008, before the 2008 financial collapse, the federal government had an annual budget of about $2.9 trillion. However, it took in only about $2.5 trillion.4 The difference between receipts and spending in a single year is called the “deficit.” The deficit for 2008 was about $450 million. Each year’s deficit becomes part of the national debt. In 2008, the national debt totaled $9.9 trillion. Deficits and debts are sometimes expressed as a percentage of GDP. Roughly, GDP is the total value of the products produced in a single year. The American GDP for 2008 was about $14.4 trillion, so the deficit was about 3% of GDP, and the total national debt was 69% of GDP. After the 2009 financial collapse, Congress and the Obama administration spent large amounts trying to jump-​start the economy. This increased the deficit and the rate at which debt was accumulating. The hope was that eventually the budget would return to normal. Whether that has or has not been achieved is a matter of opinion, but the raw numbers are that in 2016, the federal government spent about $3.9 trillion and took in about $3.3 trillion.5 The deficit was approximately $600 million. The total debt was about $19.5 trillion. The GDP in 2016 is estimated to have been about $18.5 trillion, so the deficit was still about 3% of GDP, though the national debt had grown to 105% of GDP. Affordable Care Act Decision. I thank Taylor and Francis Group LLC Books for permission to reuse that material. 4.  U.S. Office of Management and Budget, “Updated Summary Tables, May 2009.” 5. U.S. Congressional Budget Office, “The Federal Budget in 2016.”

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Economists don’t agree about how existing and future debt will affect our country. For simplicity’s sake, I’ll sort the possible effects, very artificially, into effects that are moderate or dire. On the moderate end, some economists think that high levels of debt can have some or all of these effects:6 (1) reduced public investment, since the government is spending on interest payments instead of public programs; (2)  reduced private investment, since federal borrowing creates more demand for borrowed funds, raising interest rates, which in turn reduces private borrowing; and (3)  reduced individual opportunities to buy homes, cars, and education, since typical Americans finance these through borrowing, which would be done at higher rates. There are other possible effects too. The dire effects would constitute a large-​scale fiscal crisis.7 Specifically, our creditors might decide that investing in our country’s debt is risky. Therefore, they won’t lend us more unless we pay higher interest rates. High government rates lead to higher commercial rates, and those affect the rest of the economy. As Bittle and Johnson put it, “Businesses can’t get loans. Their costs go up. When they get in a pinch, they start cutting jobs. When the economy goes into a tailspin, there are more layoffs, fewer raises, more cuts in benefits, more businesses failing, bigger consumer debt, people’s investments getting savaged, and more. Think ‘very, very bad recession.’ ”8 At the same time, the government couldn’t get the loans it needs to cover existing expenses. It could raise taxes and slash government spending. But higher taxes and slashed spending would cut into Americans’ lifestyle, leaving them with less money to

6. U.S. Congressional Budget Office, “The 2017 Long-​Term Budget Outlook.” 7.  See U.S. Congressional Budget Office, “The 2017 Long-​ Term Budget Outlook,” esp. pp. 6ff. 8. Bittle and Johnson, Where Does the Money Go?, p. 10.

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obtain housing, medical care, education, and so on.9 Worse yet, sudden tax hikes and high interest rates could push us farther into recession. The stock market might fall sharply. Investors might stop investing in America.10 We can’t know for sure whether these dire effects will ever occur. For instance, the CBO says that “it is impossible for anyone to accurately predict whether or when such a fiscal crisis might occur in the United States. In particular, the debt-​to-​GDP ratio has no identifiable tipping point to indicate that a crisis is likely or imminent. All else being equal, however, the larger a government’s debt, the greater the risk of a fiscal crisis.”11 Despite the uncertainty, many reputable economists think either moderate or dire risks are live, to some degree, in America at present.

FISCAL RISK AND ARGUMENTS A B OU T A S O C IA L M I N I M UM Suppose that the extension of a social minimum program creates additional fiscal risk, either moderate or dire. How could this fact fit into a larger, plausible argument against the extension? I see three possibilities worth considering. First, one could appeal to the moderate effects of debt, arguing that these moderate effects, together with others, have a large enough impact on the individuals who fund the social minimum program that it therefore imposes excessive personal costs. This is an interesting line of reasoning, but pursuing it

9. Walker, Comeback America, pp. 19–​20. 10. Bittle and Johnson, Where Does the Money Go?, p. 24. 11.  U.S. Congressional Budget Office, “The 2017 Long-​ Term Budget Outlook,” p. 7.

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would take us over ground already covered in the chapter on personal cost, so I’ll focus on other arguments. A second possibility is that either the moderate or dire effects of debt (or both) could play a role in a utilitarian or quasi-​ utilitarian argument against an extension of the health care social minimum. To see how that argument might go, let’s artificially divide the population into the uninsured and the insured and consider some hypothetical utility levels in several different scenarios:





• In the present situation, without any further extension of the health care social minimum, assume the uninsured have lower utility than the insured because of their lack of health insurance and because of other, covariant problems such as poverty. • If we do extend the health care social minimum and thereby increase government debt, there are different possible outcomes, given that the increased debt might or might not have substantial negative effects. If there are substantial negative effects, we will assume that people who were insured before the extension of the social minimum are worse off after it. However, those uninsured before the extension will still be better off with it, since despite the negative effects of increased debt, they have health coverage. (Later I will consider the possibility that the uninsured will be worse off, despite their increased coverage.) • If there are no substantial negative effects from debt, those insured before the extension of the social minimum will maintain their previous utility level after it, and the utility level of those uninsured before the extension will go up after it, given that they now have health coverage.

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Attaching some stipulated values to the outcomes, table 5.1 depicts this hypothetical. This table contains no sizes for the two population groups and assigns no likelihood that increased debt will create substantial negative effects. However, some assignments of those numerical factors would produce a situation where net expected utility is maximized by not extending the health care social minimum. My hunch—​though it’s only a hunch—​is that ordinary Americans have something like this argument in mind when they offer fiscal objections to extensions of the health care social minimum. Their perhaps-​inchoate idea is that increased debt brings moderate or dire risks borne by all, and these are somehow substantial enough that an extension of the health care social minimum is, expectationally, a net utility loss for society. The problem, though, is that this argument would require us to embrace some moral principle that says or entails that social minimum programs may be eliminated or not enacted when doing so maximizes utility, and a principle like that is intuitively very implausible for the reasons given in the previous

Table 5.1

HYPOTHETICAL EFFECTS OF DEBT ON POPULATION GROUPS No Extension of the Health Care Social Minimum

Extend Social Minimum, and Negative Effects of Debt Occur

Extend Social Minimum, and Negative Effects Don’t Occur

Pop. Group Avg. Utility

Pop. Group Avg. Utility

Pop. Group Avg. Utility

Uninsured Insured

Uninsured Insured

Uninsured 6 Insured 7

3 7

4 5

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chapter. As noted there, I  suspect ordinary Americans would be appalled by the idea that we should leave deserving citizens without reasonable access to food or shelter so long as doing so maximized utility overall, especially via gains to the better off. And while those considered judgments are only about specific issues, I suspect that the considered judgments are likely to be reinforced by any further theorizing. Suppose again we use the method of wide reflective equilibrium in order to formulate a theory that tells us whether our pro tanto obligation to provide reasonable access to a social minimum to deserving citizens takes precedence over any pro tanto obligation to maximize citizen welfare. Our considered judgments about prioritizing the social minimum are not immune from revision in that process, but they are firm enough that it would take substantial competing considerations to displace them. It is very hard to see what those additional, theoretical considerations might be, since abstract considerations about the equality of all citizens, the need to treat all people as individuals, and so on, either seem to favor the same policy or at least don’t point in one way rather than another.12 The weaknesses of this second argument point toward a third and more plausible reconstruction of an argument from fiscal risk. We saw earlier that among the dire effects of debt could be layoffs, fewer raises, cuts in federal benefits, failing businesses, and so on. Such effects would almost surely worsen the situation of the uninsured we hope to benefit with the extension of the health care social minimum. In fact those effects might hit the uninsured particularly hard, since the uninsured 12. Note that here I am again presuming that, for reasons given earlier, a wide reflective equilibrium process will not lead us to a crude form of utilitarianism that would tell us, under any remotely realistic circumstances, to leave a disadvantaged group of citizens without basic necessities. However, I leave open the possibility that we would be led to a subtle form of utilitarianism, perhaps even a form of act-​utilitarianism.

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tend to be among the least socioeconomically advantaged. It is possible, then, that the effects just described, if great enough, would make the presently uninsured population worse off than they would have been if we never enacted the extension of the social minimum in the first place. Now of course we cannot be sure that these negative effects of debt will occur. But if the chance is great enough and the effects are dire enough, then standard expected value calculation might yield the result that the uninsured are expectationally worse off with the extended social minimum than without it. And it’s highly plausible that if an extension of the social minimum is expectationally worse for the group you intend to benefit, and has no other, offsetting moral merits (such as helping yet another disadvantaged group), then it should not be enacted. This third version of the argument from fiscal risk would avoid some of the controversies surrounding utility maximization that dogged the second argument above. There it seemed objectionable to increase aggregate citizen welfare at the cost of not providing a social minimum to a particularly disadvantaged subgroup. Here we would not be doing that, since the argument focuses only on the subgroup itself. Granted, there could be subgroups within subgroups, and surely some members of the uninsured population would be better off with an extension of the health care social minimum, even if it resulted in fiscal crisis. Nonetheless, this third argument does at least focus on a single, fairly homogenous demographic group rather than aggregating across groups that might be affected very differently by fiscal collapse or an extension of the social minimum. Furthermore, anything finer-​grained might be impossible, practically speaking, since it is hard to predict the effects of policy on more narrowly defined demographic subgroups. Expected value calculation might therefore be defensible, because it tells us with the greatest precision that is practically possible whether particular people will be made better or worse off under a certain policy.

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In sum, we’ve seen that some members of the population criticize extensions of the health care social minimum on the ground that they create fiscal risk, and this critique might be reconstructed into a philosophically plausible argument in two ways. One is a variant of the earlier argument from personal cost, which I will not re-​examine here. The other argument—​ the one new to this chapter—​focuses on the possibility that if an extension of the social minimum creates certain levels of fiscal risk, it is expectationally bad for the very group we hope to benefit. Interestingly, the key ethical premise of this argument seems highly plausible: under conditions of uncertainty, there is pro tanto reason not to adopt extensions of the social minimum that are expectationally worse for the very people you intend to benefit. So if we want to know whether this argument against universal health insurance succeeds, we must focus on whether it’s rational to believe that extensions of the social minimum create fiscal risks of sufficient probability and magnitude that the extensions are expectationally worse for those we hope to benefit. Of course, if a universal health insurance system were very poorly designed, it obviously could create terrible risks, but in the remainder of this chapter I want to ask whether the extensions of the health care social minimum that we are likely to see could plausibly be viewed as carrying the high risks necessary to undergird this argument. I’ll begin by looking at the debate over the fiscal effects of the ACA and systems with similar funding mechanisms.

THE ACA AND SYSTEMS WITH SIMILAR FUNDING Before the ACA was enacted, the CBO predicted that the legislation would reduce the national debt over time rather than

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expanding it.13 It has updated those predictions since then, with updates still showing savings over time.14 It might seem as though predictions such as these eliminate any real possibility of a fiscal argument against the ACA, absent some exaggerated and unfounded skepticism about the objectivity or competence of the CBO and similar organizations. However, some skepticism is more rational than that and is not based on any general skepticism about the CBO’s competence or objectivity.15 Two criticisms in particular are worth noting. First, critics point out that the CBO is required to make projections in a specific way, with Congress feeding assumptions to the CBO, and the CBO calculating their implications without being allowed to alter those assumptions. For instance, the CBO calculated the effects of the ACA on the national debt assuming that certain changes would be made to Medicare and Medicaid spending, and critics thought that maintaining those changes might not be politically feasible. Second, critics point out that claims of debt neutrality can be true and yet misleading in an important respect. The ACA raises revenue through spending cuts and new taxes, but it then spends the revenue on an extended health care social minimum. The fact that the revenue is spent means it cannot be used on other things—​e.g., to alleviate the existing national debt. In the view of some, this means that even if the ACA legislation is

13. U.S. Congressional Budget Office, H.R. 4872. 14. U.S. Congressional Budget Office, “Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act”; and U.S. Congressional Budget Office, “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision.” 15. See, e.g., Holtz-​Eakin and Ramlet, “Health Care Reform Is Likely to Widen Federal Budget Deficits, Not Reduce Them”; and Bredesen, Fresh Medicine, ch. 2, esp. pp. 21ff.

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itself debt neutral, it still makes it harder for us to relieve our existing debt burden and thus increases fiscal risk. Given that there is a debate about the fiscal effects of the ACA, it might seem logical to try to resolve it by examining the underlying evidence. Of course, that evidence would not be definitive, given the inevitable uncertainty surrounding predictions about the future. The hope would be that the evidence is robust enough to indicate whether the ACA creates the kinds of fiscal risks that could underpin a fiscal objection to the program. However, in cases where the evidence is imperfect, there is another possibility. It could be that after examining all the available evidence, we would conclude that reasonable people can draw different, justifiable conclusions from it. We run into situations like that in philosophy, I think. For instance, in a previous chapter I pointed out that even if two reasonable people are well informed about the current state of political theory, they may each draw different conclusions about which political theory is best supported by the evidence. In that situation, disagreement persists because evaluating the evidence requires judgment calls about issues that reasonable people can disagree about, such as whether a problem for a theory seems potentially correctable, and so on. So when discussing the argument from fiscal risk, we must at least consider the possibility that there are multiple reasonable assessments of the fiscal risks associated with a program like the ACA. I will assume here that it is reasonable to believe the ACA won’t create substantial fiscal risk, given that that assessment is backed by the work by the CBO and other reputable economic forecasters. The question is whether the opposite conclusion is also reasonable.16 16. And note that the point is not the obvious one that people can have different reasonable levels of risk aversion. Instead the point is that people reasonably disagree about other issues, such as the possible upshots of a policy, their likelihoods, and so on.

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Is There Reasonable Disagreement about the ACA? I’ll assume that it’s reasonable for critics of the ACA to believe that the ACA carries substantial fiscal risk when:

1. the critics have enough evidence for their view that, absent any contrary reasons provided by the other side, their view would be reasonable, and 2. defenders of the ACA don’t have an argument which should change the minds of the critics, even if the critics were to react rationally to all the evidence. This is an extension of the framework offered in chapter three when we were discussing other-​oriented political philosophy. Two things suggest that the disagreement about the fiscal risks of the ACA is reasonable in the sense just defined. The first is that top experts come down on both sides of the issue despite full knowledge of the same facts. For instance, although top economists defend the CBO projections and the fiscal soundness of the ACA,17 other top economists—​including two former heads of the CBO itself—​have criticized the CBO projections and endorsed fiscal objections to the ACA.18 This piece of evidence alone is not dispositive. The mere existence of disagreement among experts does not show that the disagreement is reasonable, since there will always be at least some unreasonable dissenting voices. Many think the debate over climate change is an example. The vast majority of climatologists and other experts agree that the earth is experiencing 17. See, e.g., Gruber, “The Impacts of the Affordable Care Act.” 18. See, e.g., Holtz-​Eakin et al., “Letter to the Honorable John Boehner, the Honorable Harry Reid, the Honorable Nancy Pelosi, and the Honorable Mitch McConnell.”

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anthropogenic warming, and though a few experts disagree, the mere fact of disagreement does not show that the disagreement is reasonable. The few dissenting experts may simply be reacting irrationally to the evidence. However, the debate over the fiscal risks of the ACA does not take that shape, and that is the second piece of evidence that suggests the disagreement is reasonable. When economists and policy experts discuss the fiscal risks of the ACA or debt more generally, we do not find consensus statements from 90+% of the experts, as we do with climate change. Instead the disagreements are more pervasive and less polarized. (Moreover, since most of us are not economists or analysts, there are additional reasons why we can reasonably disagree with each other. Faced with experts who disagree, we must decide which experts to trust. One option is to withhold belief on the factual issues altogether, which would not lead to reasonable disagreement as defined here but would nonetheless require us to become agnostic about the validity of the fiscal argument against the ACA. Another option is to try to pick between the competing experts by assessing their claims. I  doubt that nonexperts can intelligently do that, so another alternative—​ the one most of us actually adopt—​is to put our trust in experts who share our ideological views. Even if choosing in that way is defensible—​and it is probably more defensible than it first appears—​note that it would entail that nonexperts can reasonably put their trust in different experts. We can reasonably disagree about which political theory is correct, and so we can also reasonably disagree about our choice of experts.) The existence of a debate among experts seems even more suggestive of reasonable disagreement once we note that reasonable disagreement could easily arise in this context for multiple, legitimate reasons. One is the technical fact that economists disagree about many economic matters. Another is the familiar fact that predictions about the ACA are predictions about the

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future, and reasonable people can make such predictions differently. The latter is particularly noteworthy in this context and deserves further comment. In order to estimate the likely impact of the ACA, we have to make a variety of projections about the behavior of various parties. For instance, when we estimate whether investors will demand higher interest rates once our debt-​to-​GDP ratio hits a certain level, or whether congressional representatives will reduce payments to Medicare and Medicaid, we are making projections about future human action. We might try to do so with quasi-​mathematical models or with implicit evidence such as the evidence of markets in treasury bonds or other financial instruments, but such evidence is of limited value, and so inevitably we must turn to a different method. Roughly, we take our best guesses about the future situations that people will face, then we imaginatively take on board the others’ psychology and try to determine how we would react to the choices they face, if we were them. Even when informed by empirical research on politicians and markets, this imaginative process involves substantial guesswork. We can look at past behavior of members of Congress, for instance, and try to infer their psychology from it, but this is far from an exact science. Likewise, even when we have a very good grasp of people’s psychologies, we can only take educated guesses about how they will react to a very specific set of choices and influences. All these uncertainties multiply as we try to sketch out an extended chain of future action and reaction. We are not sure what Congress will do, which means we are not certain what situation foreign investors will face, and so on. My point is not that we can never make demonstrably bad guesses about these things. Instead the point is that two people who make different guesses will not always have an argument they can present which should change the other’s mind, even

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if the other reacts rationally to the evidence. For instance, the policy analysts Alice and Ben might both try to imagine how Congress will react when the time comes to make or maintain changes to Medicare and Medicaid payments,19 and when they imagine themselves in Congress’s shoes, things might (for lack a better term) “seem” different to them. Alice imagines that members of Congress will be reluctant to make or maintain the changes, and Ben thinks they will be willing. At that point Alice and Ben can articulate their reasons for why they imagine things as they do. Perhaps one will even decide that he or she is mistaken. But it is also possible that even after both give the best arguments they have, each will still arrive at different results from their imaginative exercises. Notice that in saying that neither has an argument that should convince the other, we do not commit ourselves to the view that there is no such argument and that Alice and Ben’s disagreement is unresolvable in principle. Perhaps if they talked long enough and thought of enough new arguments, one could always prove the other wrong. That is a separate issue, though, because reasonable disagreement exists when they have exhausted the arguments they have, and my contention is that that can and often does happen during policy debates. Once Alice and Ben have exhausted their arguments, it can be granted—​if only for the sake of argument20—​that each of them can still reasonably maintain their own view, even in the face of intractable disagreement. Still, their disagreement is now reasonable in the sense defined earlier: neither has an argument that should convince the other, even if he or she were to react reasonably to all the evidence presented. 19. For a summary of the changes put in place fairly recently, see Blumenthal, Abrams, and Nuzum, “The Affordable Care Act at 5 Years.” 20. Here I’ve made a large assumption in what is known as the “peer disagreement debate.” For an overview, see Christensen, “Disagreement as Evidence.”

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The Implications of Reasonable Disagreement So far I have argued that experts can reasonably disagree about whether the fiscal effects of the ACA are likely to be dire or not. For the same reasons, experts might reasonably disagree about the fiscal effects of any extension of the health care social minimum that is funded in a similar way. What are the implications of this reasonable disagreement? First, we have found evidence that a reasonable person could believe the moral and factual premises of the fiscal argument against the ACA (or similarly funded program—​I will omit this qualification hereafter), and so a reasonable person could oppose the ACA on fiscal grounds. That alone is a significant conclusion. However, this is not as big a “win” as it might seem for those opposed to extensions of the health care social minimum. Even if some critics might reasonably oppose the ACA on fiscal grounds, that argument requires a rather extreme factual claim that even most critics of the ACA do not embrace. This becomes clear when we remember that the factual premise does not merely say that the ACA will expand debt and bring about some negative effects on the economy and the population, including its least advantaged members. Instead it says that the ACA will make its proposed beneficiaries expectationally worse off because it sufficiently increases the risk of massive fiscal crisis. And while some critics of the ACA do connect its spending to the possibility of fiscal crisis and deleterious effects for the least advantaged,21 most critics do not posit such effects, suggesting

21.  Cf. Holtz-​ Eakin, “Opposing View”; Tanner, “2010 Health Care Legislation”; Holtz-​Eakin et al., “Letter to the Honorable John Boehner, the Honorable Harry Reid, the Honorable Nancy Pelosi, and the Honorable Mitch McConnell”; and Boccia, “How the United States’ High Debt Will Weaken the Economy and Hurt America.”

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that they do not believe the factual premise of the fiscal argument at all.22 Third, our examination of the factual premise of this argument has shown us that, even if some critics could reasonably accept it, parallel reasoning would show that supporters of the ACA can reasonably reject the factual premise. Reasonable disagreement cuts both ways. Supporters need not give up their position merely because of the fiscal objection. Fourth, notice the fiscal argument is easy to misuse. Even if it justifies opposition to extensions of the health care social minimum that are funded in certain ways, it cannot justify opposition to all attempts to extend the health care social minimum. To the contrary, if people’s concerns about the social minimum are honestly fiscal, then they should support an alternative funding mechanism that they regard as fiscally responsible. (I will discuss those in detail below.) The only exception would be for those who have concluded that any additional spending on the health care social minimum created too much risk. That is completely implausible, but note that even if 22. These critics might think that the ACA is likely to increase debt but not lead to crisis for several reasons. They might think that a fiscal crisis will not suddenly spring on us, and that if a crisis looms, we will be able to avert it—​ e.g., by deflating our currency. They might believe that the ACA and related programs will not significantly increase the debt-​to-​GDP ratio at all, or that if they did, there are means available to mitigate the problem. There are other possibilities as well. (Cf. U.S. Congressional Budget Office, “The Budget and Economic Outlook.”) Those critics who predict much more direct effects might reply that fiscal crises could occur quickly, without much advance notice. In addition, they might say that we should not count on our ability to react rationally to fiscal risk once an entitlement program is in place. After a program has been enacted, it is hard for politicians to cut back, even if that is the rational thing to do, since one is attacked for “cutting off benefits to the poor” and such. Likewise, it’s hard to correct the problem by raising revenue through increased taxation, since that opens one up to the attack that one is “raising taxes.” These ideas have not been explored here, but they are at least plausible reasons why some reasonable people could think that enacting the ACA can create unacceptable risk of a fiscal crisis.

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it were true, it would not get advocates of the fiscal critique off the hook. If they do not want to increase government spending at all, they would still be obligated to examine present government spending—​including spending on defense, on corporate welfare, on transfer payments that disproportionately benefit the privileged, like the tax deduction for employer-​sponsored health insurance and home mortgage interest—​and evaluate whether that spending is the best way to further our social ideals. Depending on how those social ideals are spelled out, it might easily turn out that even if the government cannot spend more to guarantee access to health insurance, it must at least shift spending so as to prioritize health care above other current programs. Finally, even if shifting spending were impossible and we could not spend more on health, this would still not justify our current health system. For if we agree that all citizens deserve reasonable access to health insurance, then as we’ve seen in previous chapters, we cannot defend the present system, which guarantees very good health insurance to some (e.g., seniors through Medicare, and some low-​income people through Medicaid) while providing no guarantee to others. The only defensible policy would be to take the money which we believe we can justifiably spend on health care and reallocate the money in a way that respects all citizens’ entitlement to reasonable access. In the end, then, it seems as though, at the very most, the fiscal objection can ground opposition to certain particular extensions of the health care social minimum, but cannot justify opposition to universal health insurance in general. This becomes even clearer if we set aside plans with funding mechanisms like the ACA and consider those with superior funding systems.

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F I S C A L R I S K I N   N AT I O N A L S Y S T E M S W I T H   D E D I C AT E D   F U N D I N G Proponents of universal health insurance systems often highlight the fact that countries with such systems spend less per capita on health care than the U.S., and that even if we could never spend as little as they do, the more robustly funded proposals for American universal health insurance don’t increase total spending. And though it is controversial, these same proponents sometimes also contend that universal health insurance systems will do a better job of controlling the growth of health care costs over time than non-​national plans.23 Those two factors together might seem to suggest that universal health insurance systems will do a better job at reducing health care–​ related national debt, since the total amount spent over time will be lower. Note, though, that even if these two things were true, a universal health insurance system could still increase government debt. The reason is that even if universal health insurance systems reduce total health care spending, systems like those described earlier in this book still route more of that spending through the government. And if the government paid for that spending by accumulating more debt, then debt could still increase, even if aggregate health spending were lower. As an example, consider Emanuel’s voucher system, described in chapter one. At the time when he proposed his plan, Emanuel estimated that the total cost of the voucher system for the non-​Medicare population would be about $995 billion 23. For instance, advocates of national plans often say that national coordination will make it easier to move away from fee-​for-​service payment, though in Canada, for instance, this has not been the case.

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annually. Added to the $325 billion spent on Medicare that year, this means that in 2006 the voucher system would have run $1.32 trillion through the government. The actual 2006 spending on Medicare, Medicaid, SCHIP, and veterans’ health benefits was about $540 billion. Thus the voucher system would increase government spending by $780 billion. If the government didn’t offset that spending with tax increases, the voucher system would add $780 billion annually to the national debt. In other words, even in the case of a single-​ payer or regulated-​market system, we must still ask whether it will increase debt or not, and the answer will depend on the funding mechanism that accompanies the system. The funding mechanism could be roughly similar to that behind the ACA, and in that case, our assessment of its fiscal effects would follow roughly the same pattern as the one described previously. In contrast, though, several major proposals for universal health insurance—​including the proposals from Emanuel and Relman that we looked at earlier—​explicitly try to reduce or eliminate even the fiscal risks we see in a system like the ACA. They do this by proposing that the universal health insurance system should be funded through specific taxes which are used for health care and nothing else. These dedicated taxes guarantee that the health system itself doesn’t add to debt because, according to the enabling legislation, the system’s budget may not exceed the tax revenue. In Emanuel’s phrase, the tax functions as a health care “rheostat.” If people want more health care, they must encourage Congress to raise the tax. And if they want the tax lowered, they have to agree to cuts in health care. Strictly speaking, a dedicated tax doesn’t guarantee that enactment of the universal health insurance system won’t result in a net increase in government debt. One can imagine, for instance, that the new health care tax so aggravates a portion of the populace that politicians react by greatly cutting taxes on other things—​cutting them so severely that the net result

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is more debt than would have existed absent universal health insurance. Or, to give another hypothetical example, one can imagine that without universal health insurance, fiscally responsible politicians would have increased taxes in order to pay down the debt, but they find themselves unable to pass those provisions once the populace is already paying higher taxes for universal health insurance. And of course there are other possibilities as well. However, these scenarios are striking in two respects. One is that they seem more like mere possibilities than the scenarios we considered when discussing the ACA. For instance, if we claim that Congress might not have the stomach to maintain the Medicare spending controls that were part of the original ACA, then that projection can be grounded in evidence about Congress’s past behavior. In contrast, it seems like we are citing mere possibilities if we claim that heath care taxes might one day irritate the populace and result in calls for even larger tax cuts. And since the citation of mere possibilities does not justify a prediction about what will happen in the future, it is harder to see how a reasonable person could conclude that a universal health insurance system with dedicated funding is expectationally worse for the people it aims to help. Second, part of the reason I concluded that reasonable people could disagree about the fiscal effects of the ACA was that actual, reasonable people seem to do so. And yet here we do not have that same evidence, because critics of universal health insurance systems do not in fact take up the position that even a system with dedicated funding would create excessive fiscal risk. And it is easy to see why they don’t. Anyone who maintained that universal health insurance systems with dedicated funding created excessive fiscal risk is on the verge of taking up the view that no legislation involving substantial new spending, no matter how well crafted, can ever be justifiably enacted in our present situation. After all, a universal health insurance system would do a

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vast good involving, among other things, saving thousands and thousands of lives annually, and it has the strongest guarantee of not adding to the debt that is practically possible. If that kind of spending cannot be justified, what can? In sum, then, it seems that even if some reasonable people can mount fiscal objections to extensions of the health care social minimum that are funded in the way the ACA was, those same objections cannot be leveled against systems with dedicated funding.

GENERAL CONCLUSIONS ABOUT FISCAL RISK Americans sometimes oppose extensions of the health care social minimum on grounds of fiscal risk. In this chapter I’ve tried to take that idea, develop it into the most promising philosophical arguments possible, and then evaluate the merits of those arguments. We’ve seen that considerations of fiscal risk could form a part of an argument from personal cost. We also considered two new ways that fiscal considerations could enter into our evaluation of extensions of the health care social minimum. The most plausible is the argument that we should oppose extensions of the health care social minimum when they create enough risk that they are expectationally worse for the very people we are trying to benefit. That moral idea is sound, so the argument’s force depends on whether a given extension of the health care social minimum does create the very serious fiscal risks just posited. I argued that for systems funded in the way the ACA is, it’s reasonable for many of us to believe that the fiscal risks are not that serious, though it’s possible that some small number of reasonable critics will decide that they are. Such critics have no ground for opposing universal health systems in general, though, since fiscal concerns should simply

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lead critics to support systems with better funding mechanisms or systems which take our existing government spending and use it to provide universal access to some level of health care. This chapter concludes our examination of three objections to universal health care—​objections that are both philosophically rich and seem to motivate some real-​world resistance to extensions of the health care social minimum. In the next chapter, I’ll draw together the different strands of argumentation and ask how they can combine to form part of a single, unified case for universal health insurance.

Chapter Six

THE CASE FOR UNIVERSAL HEALTH INSURANCE

WE’VE NOW EXAMINED THREE PHILOSOPHICAL issues that

are part of the debate about universal health insurance. In this chapter I’ll synthesize those separate discussions. This requires not only connecting the arguments from the previous chapters but also thinking further about the exact force of those arguments, given that many were not completely definitive. We will see that the ACA is problematic—​deserving of support only in the face of inferior alternatives. In contrast, there are no similar problems with well-​designed single-​payer or regulated-​market systems. The chapter concludes with some reflections on the next steps in a complete case for universal health insurance.

T H E A F F O R DA B L E C A R E   AC T Let’s begin by synthesizing our arguments about the ACA. Efficacy turned out to be the least significant moral concern. The efficacy-​related charges that are often leveled at true universal health insurance systems are rarely mentioned in debates about the ACA, and in fact I know of no serious scholar or policy analyst who has offered concrete projections showing that the ACA will decrease aggregate health, since in fact the ACA increases insurance coverage and thereby benefits aggregate

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health.1 Likewise, the objection that universal health insurance will reduce innovation is usually leveled against systems that try to reduce aggregate health care spending,2 which the ACA has not done, and so objections related to innovation are rare as well. The one notable efficacy-​related concern is that the ACA might have increased wait times for some,3 though we saw that one cannot plausibly argue against the ACA (or any other extension of the health care social minimum) by appeal to increased wait times alone. Instead, increased wait times can at best be part of a larger appeal to personal cost, and that might or might not succeed, depending on the total personal costs and benefits. I’ll return to personal cost in a moment, but first let’s recall our results about fiscal risk. We saw that if the ACA creates either moderate or dire fiscal risks, this could properly affect our moral evaluation in two ways. The fiscal risks might make individuals worse off, and those losses of well-​being could again be part of an appeal to personal cost—​the success of which would turn on the total personal costs and benefits. More significantly, if the ACA’s risks are so dire that it is expectationally bad for the very people it aims to help, with no compensating moral benefits or counterconsiderations, then the legislation seems not only problematic but wholly unjustified. Since fiscal risk of this severity would be morally significant, the key question is whether the ACA creates that kind

1. See, e.g., Sommers, Blendon, and Orav, “Changes in Utilization and Health Among Low-​Income Adults After Medicaid Expansion or Expanded Private Insurance.” 2. For instance, U.S. Council of Economic Advisers, “Economic Report of the President,” pp. 190ff. 3.  Merritt Hawkins, “2017 Survey of Physician Appointment Wait Times.” I hedge and say “seems” because, interestingly, a very large number of reports about increased wait times appear to be based on this single Merritt Hawkins survey.

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of fiscal risk. Here we saw that the debate is not purely factual but extends into interesting questions about the limits of our (present) argumentative powers. We have estimates from reputable organizations such as the CBO indicating that the ACA is on the whole a debt-​reducing measure compared to a pre-​ACA baseline, and I’ve argued that it’s reasonable to believe these projections. Even most critics who disagree with the projections do not posit fiscal risks that are serious enough to ground a fiscal argument against the ACA. However, some small number of critics do posit severe fiscal risks, and I argued that their beliefs are reasonable in the following sense:  they have evidence that warrants their belief, absent any competing evidence to the contrary, and the hard evidence that we can give them right now would not rationally require them to change their minds. This is a significant result in the debate over the ACA, one that its defenders are usually reluctant to admit. But recognizing it is important for many reasons. One is that it can push the relevant experts toward further factual research. In particular, I argued that one key source of reasonable disagreement about those predictions is that they are predictions about future human action, which are often grounded in our own imaginative exercises about how we would react in other people’s places. However, it’s possible that this subjective technique might be supplemented by others that are more objective. For instance, future research might uncover at least somewhat better ways to model the behavior of members of Congress or the reactions of financial markets to certain debt levels. That kind of research could, in turn, undercut the more dire predictions about the fiscal risks of the ACA. Recognizing this reasonable disagreement also has important philosophical upshots. One is that it would establish a link between some very concrete issues in health care ethics and the larger “peer disagreement” debate in epistemology.

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(Since I’m not an epistemologist, I’ve largely set aside that debate and simply made the assumption that even if two reasonable people can seemingly examine the same evidence and reach different conclusions about fiscal risks, it can nonetheless be rational for each to maintain their own position.) Another philosophical upshot is that we are required to reflect on whether and in what sense we can claim to have an “argument” that the ACA has acceptable fiscal risks, given reasonable disagreement over their extent. In one sense we clearly do have such an argument: chapter five pointed out that even if we concede that some critics can reasonably believe that the ACA creates high fiscal risk, reasonable disagreement cuts both ways, and those of us who find the standard CBO projections trustworthy can continue to believe them and thus believe that the ACA does not create problematic fiscal risk. But in another sense the answer seems to be that our argument has limitations. We’ve seen that some people reasonably believe that the ACA creates dire and morally problematic fiscal risks, and we’ve also found that we have no evidence to offer them that must change their minds, even if they react to it in a fully rational way. However, here I think we should not hesitate to say, without any real qualification, that we have an argument showing that the fiscal risks of the ACA are perfectly reasonable. The only reason to hesitate is that we cannot produce an argument that we feel should be compelling to 100% of people, but that is an unreasonable standard, one that seems plausible—​if it does at all—​ only because of some peculiar and misleading habits that are common in philosophical discourse. Philosophical arguments tend to be presented as though they are absolutely definitive. Authors say that they have “refuted” this or that position, “established” another, and so on. In fact, I myself have published an article with the subtitle “A Refutation of Act-​Consequentialism,” as if I thought that was what I’d actually accomplished. And yet

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as Robert Nozick wrote in the introduction to his great work of political philosophy, Anarchy, State, and Utopia: The usual manner of presenting philosophical work puzzles me. Works of philosophy are written as though their authors believe them to be the absolutely final word on their subject. But it’s not, surely, that each philosopher thinks that he finally, thank God, has found the truth and built an impregnable fortress around it. We are all actually more modest than that. For good reason. Having thought long and hard about the view he proposes, a philosopher has a reasonably good idea about its weak points; the places where great intellectual weight is placed upon something perhaps too fragile to bear it, the places where the unravelling of the view might begin, the unprobed assumptions he feels uneasy about.4

Nozick is right. Take even the most highly regarded arguments in political philosophy, normative ethics, or applied ethics—​ arguments like Rawls’s case for Justice as Fairness, Judith Thomson’s arguments for the morality of some abortions, or Scanlon’s arguments for contractualist ethics. Surely almost no philosophers really believe that the arguments presented by these or other authors, even together with supplemental work from others, should convince all rational people. Nor is this something particular to philosophy. Surely almost no one really believes that arguments about, say, the causes of human violence or the effects of the minimum wage on hiring are so complete and compelling that they should convince all rational people. The only thing Nozick underestimates, I think, is the extent to which unrealistic ideals truly infect our thinking. He makes it sound as though philosophers merely write as though their arguments were definitive, knowing deep down that they are 4. Nozick, Anarchy, State, and Utopia, p. xii.

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not. But he underestimates, I think, the extent to which we use unrealistically high standards when judging the success of arguments. The fact that we cannot definitively refute all fiscal objections to the ACA feels like a defeat, even though it leaves the fiscal case for the ACA no less complete than the case for any other interesting proposition, either in philosophy or in many other disciplines. So considerations of fiscal risk do not present major problems for the ACA, and this brings us to our third factor, personal cost. Although the ACA might impose a variety of personal costs on individuals, I argued that the most serious is the possibility that the ACA has made insurance unobtainable to people who otherwise would have justly had it. Defenders of the ACA might argue that it is still less unjust than the pre-​ACA system and morally preferable to it, but I  think they should not take much consolation in that result, even if true. Lack of insurance produces suffering and sometimes death, and so the injustices created by the ACA are very, very serious. Any believer in a social minimum should strongly support replacing the ACA with something better. The discussion of personal cost also raised some interesting metaphilosophical issues. I didn’t try to convince readers that they should believe the personal cost principle, and I  suspect many will not, since some political philosophies set the social minimum in other ways. For instance, Rawls’s difference principle requires us to maximize the index position of the least advantaged citizens, a standard that seems at odds with the personal cost principle, and we noted earlier that other egalitarian philosophies, such as Dworkin’s, are at odds with the personal cost principle as well. However, even though some readers will reject the personal cost principle, we found several reasons to consider its implications. One is that the personal cost principle is a part of larger, plausible theories of political justice—​theories that many people might reasonably believe and which cannot

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always be dislodged by arguments available to us right now. So if we want to do other-​oriented political philosophy, which aims to offer evidence that should convince rational interlocutors, then we must argue from the inside, taking on the personal cost principle and showing that the ACA does not have excessive personal costs. It might seem that this focus on what we can prove to others is inconsistent with my earlier position that we should not be terribly bothered by our inability to convince some people that the ACA has acceptable fiscal risks. It seems that we are focusing on proof to others in one case but not in the other. And yet the two positions are not really in tension at all. We can develop philosophical arguments for many purposes, and in other-​oriented political philosophy, we aim to give arguments which would convince our audience, were they to react rationally to the evidence presented. Aim is the key word. We strive to rationally persuade others, and I’ve argued that in the case of debates over personal cost, the best way to achieve that aim is by taking on board the personal cost principle and exploring its implications. But this aim is perfectly compatible with the idea that, having aimed at convincing others, as we did in our discussion of fiscal risk, we will find that we cannot produce arguments that are compelling to every single person. We’ve completed our task as best we can. So that is one reason to take seriously issues of personal cost, even if one’s own political philosophy does not involve the personal cost principle: doing so is part of other-​oriented political philosophy. But there is another reason as well. When we examined the possible personal costs of the ACA, the most significant seemed to be the possibility that the ACA had made insurance unobtainable to people who otherwise would have justly had it. Essentially, the law cost them their insurance. This is a cost that should concern us whether we believe the personal cost principle or not, because the fact that some people

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lack insurance under the ACA is a severe injustice in any political theory that requires a social minimum in health care. For instance, Rawls’s political philosophy might not countenance the personal cost principle, but it still requires universal access to health insurance, so the fact that the ACA costs some people their insurance and leaves them uninsured is still a good reason to think that the ACA does not establish justice in health care. Having now seen how our discussions of efficacy, fiscal risk, and personal cost fit together, what can we say about the case for or against the ACA? The system is deeply unjust, and there is certainly no case for it if the alternative were a true universal health insurance system. At most there might be a contingent case for preferring the ACA to the pre-​ACA system, if those are the only options.

S I N G L E -​PAY E R A N D R E G U L AT E D -​M A R K E T   S Y S T E M S Let’s turn to the true universal health insurance systems that the U.S.  might adopt, such as a single-​payer or regulated-​market system. Critics raise several concerns about efficacy. The most common is that universal health insurance systems hurt aggregate health, but as we’ve seen, that is incorrect. Concerns about innovation seemed misguided too, partly because projections about reduced innovation lack a solid foundation, but more importantly because we should not deprive some of a decent minimum just to produce future innovation for others. The objections related to wait lists were problematic for a variety of reasons. If we assume, as critics do, that an American system would mimic those in other countries, then a regulated-​ market system would have no waiting lists to speak of. A single-​ payer system might produce longer wait times, though we’ve seen that that’s the case only when wait times are measured

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in a problematic way that excludes the wait times suffered by America’s uninsured. Even if a particular individual’s wait times increased under a single-​payer system, that will in all likelihood be a comparatively small burden to be factored into an overall appeal to personal cost. To evaluate our second factor, the fiscal effects of a universal health insurance system, we would have to know how the system is funded. One possibility is a system of nondedicated funding like the ACA’s, but we also saw that if a true national system were funded with dedicated taxes, there would be no fiscal objection to it. The system would be as fiscally responsible as any system could practically be, and no one could credibly claim that it carries so much fiscal risk that it hurts, expectationally, the very people we aim to benefit. Turning to personal cost, I won’t repeat the theoretical discussion from above about why we should take considerations of personal cost seriously and engage with them on their own terms. When doing so, we saw that true universal health insurance systems eliminate the largest personal costs created by the ACA, since they ensure that no one will be unjustly denied access to health insurance. That mitigates objections from personal cost, but it doesn’t totally eliminate them. Critics might still try to push the objection that the personal costs, especially increased taxes on upper-​income Americans, are overly burdensome. I didn’t offer an algorithmic formula for weighing these costs and benefits, aiming instead at what I termed “compelling explanation.” The goal was to lay out the costs and benefits of universal health insurance, discuss their significance, and reveal that the two are unbalanced enough that all or almost all reasonable people will agree that the benefits of a universal system outweigh the costs, even when judged on a weighted scale. That conclusion would be of a piece with conclusions that almost all Americans seem to have already embraced about other social minimum programs with similar costs and benefits.

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Of course, there is no guarantee that our “compelling explanation” will seem compelling to all people, but chapter three pointed out that even if this attempt at compelling explanation failed to convince someone when it was focused on very robust single-​payer and regulated-​market systems, the objection from personal cost would still not undercut the case for universal health insurance. We should simply seek a system that provides universal coverage at a lower benefit level. If necessary, we could use only the money we already spend on health programs.

THE ARGUMENT FOR UNIVERSAL H E A LT H   I N S U R A N C E I have just drawn together the arguments of this book, showing that universal health insurance should not be rejected on grounds of fiscal risk, efficacy, or personal cost. These are some of the ethical objections that are both philosophically substantial and that find a place in ordinary discourse, so refuting them advances the case for universal health insurance. Still, to build an absolutely complete case for universal health insurance, we would need to cover further ground. Here are some of the most important components that would be part of that discussion. First, although I  have addressed what I  believe to be the three major concerns that people express about universal health insurance, they are not the only ones. For instance, as noted earlier, appeals to individual liberty are common in the discourse of those opposed to certain extensions of the social minimum, and other concerns play a role in that discourse as well. I have not addressed those concerns here, arguing earlier that objections grounded in individual liberty are either relatively easy to undercut or that they are not the principal drivers of opposition during health care debates. But of course if we wanted

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an absolutely complete case for universal health insurance, we would want to address those objections more fully. Second, at the beginning of the book, I  presupposed that an ideally just society would extend a social minimum in health care to at least all deserving citizens. I did so because other philosophers have given extensive arguments for that conclusion, and the additions I might make to that discussion would contribute fine detail only. Resting this presupposition on existing work seems unproblematic in one way, since it’s quite common for philosophical arguments to presuppose ethical starting points that their authors believe are both true and well-​defended elsewhere. Still, a more thorough case for universal health insurance would need to identify which theory of justice is the correct one. Doing so is a very large task, of course. I see no way to complete it other than through an extensive examination of the major theories of justice—​a massive undertaking in its own right. Third, even if we presuppose or establish that deserving citizens should have a social minimum, this leaves open the question of whether any undeserving citizens should also enjoy that social minimum in health care, as well as the question of whether the social minimum should extend to noncitizens, deserving or not. In the next chapter I will describe some promising argumentative strategies for the view that some social minimum should be available to everyone, and I  won’t anticipate the details of that material now. Here it is enough to note that such issues would need to be resolved in any complete, overarching argument for universal health insurance.5 5. A wrinkle: If “universal health insurance” requires only universal access to health insurance, then a system that doesn’t provide the undeserving with coverage may nonetheless still be universal, since they could presumably change the behaviors that render them undeserving (such as not working when they could), and therefore still have reasonable access to health insurance. On the other hand, if a “universal” system is one that provides coverage to all, regardless of whether they are deserving or not, then a system that excludes the undeserving from coverage might not be universal.

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Otherwise the argument would be theoretically incomplete, since we would not know the proper extension of the social minimum, and it would also be pragmatically less useful, since it would not help us adjudicate difficult real-​world questions about who should be protected by the social minimum. Fourth, merely knowing that there should be some social minimum of health care doesn’t tell us where to set the exact level of the social minimum. With some notable exceptions,6 it is surprising how little philosophers and bioethicists have written about this question. Here are a few ways in which we might move that debate forward. To begin, notice that from a societal perspective, the proper method for setting the level of the social minimum might be fairly clear. Liberal democratic theory tells us that most government policies, including the level of the social minimum, should be set through the democratic process, broadly construed.7 This does not mean that the details of the social minimum will be set by direct vote but that it will be determined within a political structure which is under democratic control. Philosophers have even offered fairly developed accounts of how such processes should play out when applied to health care in particular. For instance, in Setting Limits Fairly, Daniels and Sabin suggest that procedural systems for adjudicating benefit levels should meet four criteria:

• Publicity:  decisions on benefit levels, as well as their rationales, must be publicly accessible.

6. See, e.g., Fleck’s Just Caring or Menzel’s “The Cultural Moral Right to a Basic Minimum of Accessible Health Care.” 7. There might be some government policies and requirements which should be enshrined in a set of citizen rights and enforced judicially. Here I assume that the level of the social minimum is not determined in that way.

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• Relevance: rationales for decisions must be based on evidence, reasons, and principles that fair-​ minded persons would affirm. • Possibility of Appeal:  there must be mechanisms for challenging allocation decisions and, more generally, for revision and improvement of policies in the light of new information. • Regulation: public procedures must ensure the fulfillment of the previous three conditions.

But while procedural solutions like these might help whole societies determine the proper level of the social minimum, they do not explain how an individual should develop a morally grounded position on where to set it. The procedural solutions amalgamate multiple individual viewpoints into a social policy, and they presuppose that those individual viewpoints are justified in other ways. When we turn to the question of how each of us should formulate a viewpoint on the proper content of the health care social minimum, I do not see any way around complex theory. The major theories are likely to set the social minimum at different levels, so to know what the correct one is, we must determine which theory is best. Obviously that is very difficult work. Some people may have sufficient confidence in one of the major theories that they can justifiably use it to determine the level of the social minimum. However, others will not yet have enough confidence in any single theory to feel justified in basing a specific policy about the health care social minimum on this or that theory in particular. I find myself in this situation, which is why I have not staked out an exact position on the level of the social minimum in this book. I do not believe I could fully justify a claim that one of the major political theories is superior to all others, and thus I  could not in good conscience claim to tell readers the exact level of the social minimum.

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But for those in my position—​or even for those who just want to avoid complex debates about foundational political philosophy—​there is hope of a partial work-​around. First, although there has not been a great deal of work on the level of the health care minimum, there has been some, and the arguments sometimes identify a bottom floor for the social minimum while only using principles that comport with a wide variety of political theories. For instance, in “The Cultural Moral Right to a Basic Minimum of Accessible Health Care,” Menzel appeals to commonsense precepts about fairness and free-​riding in order to establish some basic parameters of a social minimum. Work like this can guide us even in the absence of deeper theory. Moreover, those of us who haven’t settled on one political theory can nonetheless commit to a level required by all the political theories we regard as live candidates. For instance, suppose we believe that Waldron’s theory, discussed earlier, sets the lowest level to the social minimum of health care of any plausible political theory, requiring only a level which does not produce excessive strains of commitment within the political community. We might then ask what social minimum is required by that theory and embrace that minimum while we wait on further theoretical developments. While this may sound morally risky, since Waldron’s theory (or any other) might set the minimum lower than it should be, this approach could be functionally sound. I suspect the social minimum required by even the weakest theory will be quite robust—​higher than the social minimum provided to Americans now, and probably higher than we can realistically expect to achieve in our contemporary political climate. If so, this method would provide us with a fully justified goal to strive for, and we would not have to worry that, from a practical point of view, we had set our sights too low. These are just a few examples of important issues in the health care debate that are not settled by the arguments of the

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previous chapters. Notably, all are issues in what we might call the “ideal” part of the debate, about the proper level of the social minimum in an ideally just society not subject to problems of fiscal risk, inefficacy, or excessive personal costs. The arguments of this book are intended to complement that discussion of ideal justice by examining the objections made by even those people who agree to a social minimum in principle. By replying to those objections, we help make a complete case for universal health insurance.

Chapter Seven

BEYOND HEALTH CARE

BY SHOWING THAT WELL-​ DESIGNED UNIVERSAL health

insurance systems have acceptable personal costs, are efficacious, and are fiscally sound, we help make the case for expanding health coverage in the U.S. More importantly, perhaps, this examination of the ethics of universal health insurance has revealed larger lessons. Latent in our discussion is a whole new approach to debates about the social minimum. It can prove useful during inquiries into any part of the social minimum, not just health care, and it can be applied to debates in any country, not just the U.S. To see what’s distinctive about the approach we’ve taken, consider typical debates about distributive justice. Those debates usually focus on whether society should have a social minimum at all. On one side are those who think an ideally just society would have some form of social minimum, such as Rawls and Dworkin, and on the other are those who are against the social minimum in principle, such as Nozick. Naturally this debate has been enormously valuable and philosophers should continue to focus on it. I have no criticisms of it at all. However, our exploration of the ethics of health care has revealed that in the world as we find it, there is a second, separate debate about the social minimum. In that debate, all parties support a social minimum in principle, including those people who oppose specific programs such as

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the ACA. The parties to the debate disagree because of their diverging assessments of whether social minimum programs are or will be, to a problematic extent, inefficacious, fiscally risky, excessively costly, or—​in the case of many non-​health-​ related programs—​subject to abuse by able-​bodied people who are leeching off the system rather than working to support themselves. Notice that this debate cannot be mapped onto the standard framework of Rawlsian egalitarianism versus Nozickian libertarianism. If forced into that paradigm, all parties to the real-​ world debate would show up as Rawlsian egalitarians, since they all support a social minimum in principle. And yet surely something has gone wrong if even self-​professed conservatives are being placed, without qualification, into the Rawlsian egalitarian camp. So to properly represent debates over the social minimum, we need a more nuanced description of the progressive and conservative viewpoints about distributive justice. Both viewpoints affirm that society should in principle have a social minimum. But our descriptions of the two positions must identify the principles and presuppositions that distinguish these two viewpoints from each other and explain why conservatives are often skeptical about many social minimum programs and progressives are not. I’ll begin this chapter with the conservative point of view, describing it and saying why it is philosophically interesting and plausible. After that I’ll identify the parts of the conservative view that progressives might challenge, thereby building up a picture of the progressive view itself. I’ll close by explaining why it’s valuable to frame debates over the social minimum in this new way.1 1.  Some material and ideas in this chapter were first published in Rajczi, “What is the Conservative Point of View about Distributive Justice?”

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T H E C O N S E R VAT I V E P O I N T O F   V I E W My first aim is to lay out a set of principles about distributive justice that can be rightfully described as “conservative” and that explain why conservatives are often more skeptical of social minimum programs than are progressives. Before proceeding, let me make a few methodological notes. First, there is surely no single set of principles that all ordinary conservatives would agree to, even after thorough reflection. To avoid awkward writing, though, I will sometimes refer to “the” conservative point of view, meaning only the particular version of a conservative viewpoint that I develop in this chapter. As a later section will make clear, I  suspect that this point of view would be amenable to large numbers of conservatives, even if not to all of them. Second, my goal is to develop a point of view that would be amenable to ordinary citizens who call themselves conservatives and who are more skeptical of redistributive programs than are their left-​leaning counterparts. I suspect that the views of those ordinary conservatives differ in important ways from the views of some of the more important conservative theorists and some of the more prominent conservative politicians. I  don’t have the space to argue that point here,2 so for simplicity’s sake I will merely focus on ordinary conservatives, leaving aside any examination of prominent theorists and politicians. If the theorists and politicians would also embrace the view I develop, then so much the better, but since I want to ensure that I describe a

2. There is reason to think that party activists hold more extreme views than average voters within their parties. See, e.g., Fiorina, Abrams, and Pope, Culture War?, pp. 16ff. There is some evidence that party leaders may be even more extreme than their fellow party members; see, e.g., Grofman, Koetzle, and McGann, “Congressional Leadership 1965–​96.” This debate is complicated, though, and other evidence points in a contrary direction.

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view amenable to ordinary conservatives, I use their views as my fulcrum.3 Third, although my description of the conservative point of view is inspired by the poll data we examined in chapter two, my goal here—​as it has been throughout—​is not to merely codify those views into general principles. Instead, my goal is to develop a more sophisticated conservative point of view, one that would be accepted by ordinary conservatives upon reflection. Roughly speaking, one can think of the project this way. Suppose that ordinary conservatives engaged in extensive philosophical reasoning and examination. That reasoning would surely lead them to revise or abandon some of their existing beliefs, just as philosophical reflection leads all of us to revise or abandon certain beliefs. However, at the end of this process the conservatives would arrive at certain principles of distributive justice that are likely to continue to reflect the conservatives’ main concerns and values, and it is in that sense that it is still their view, and a conservative view, about distributive justice. Here is an example of how my project diverges from mere codification of actual conservative beliefs. As I will detail later, many conservatives believe that able-​ bodied adults should make a productive contribution to society, and that if they don’t, there is some reason to cut them off from the social minimum. However, some empirical research suggests that conservatives—​ and, indeed, centrists and progressives too—​apply this standard implausibly or inconsistently. For instance, people object strongly when the poor don’t make productive contributions, 3. Useful theoretical works include Mead, Beyond Entitlement and The New Politics of Poverty; Murray, Losing Ground; Gilder, Wealth and Poverty; and Kekes, A Case for Conservatism. Useful historical works, particularly about the importance of private virtue to conservative thought, are Jones, An End to Poverty?; Himmelfarb, The Idea of Poverty; Allitt, The Conservatives; and Robin, The Reactionary Mind.

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but they seem unconcerned with the noncontribution of the idle rich. Or to give another example, many people seem to count paid labor as a suitable “contribution,” but they do not count care work of children, infirm relatives, and so on, especially when the care work is performed by the poor. If we were merely codifying what ordinary conservatives believe, we would make these implausible or inconsistent principles part of our “conservative view.” But I assume that such principles could not survive rational reflection,4 and that upon reflection, conservatives could only endorse a principle requiring productive contributions of various sorts from all able citizens. More generally, I will always focus on conservative principles that I believe could survive philosophical scrutiny, and I rely on readers to make these sorts of “corrections” to the conservative point of view on their own. For instance, although conservatives (and nonconservatives) often rail about fiscal risk when talking about programs they don’t like, they often conveniently ignore fiscal risk when discussing programs they do like. Readers don’t need me to point out the inconsistency in that, so I will often move past these inconsistencies without further comment and focus on the most plausible versions of conservative principles. It is worth noting that my method is not the only “right” way to examine conservative beliefs. It is equally interesting and valuable to look at the political principles that actual conservatives (or centrists or progressives) employ in life, before reflection, and then subject them to examination and criticism—​a task that other writers have undertaken with much success.5 The two projects are simply different. 4. For critiques of some of these positions, see Young, “Mothers, Citizenship, and Independence”; Kittay, “What (Welfare) Justice Owes Care”; and Anderson, “Welfare, Work Requirements, and Dependent-​Care.” 5.  See, e.g., Kittay, “What (Welfare) Justice Owes Care”; Smiley, “ ‘Welfare Dependence’ ”; Fraser and Gordon, “A Genealogy of Dependency”; Young,

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The Conservative Point of View about Distributive Justice So what is the conservative point of view about distributive justice? In my view, it partly consists in some principles which we’ve already run across, including these: 1. Hard-​working Americans and other deserving individuals (such as children, those unable to work, and the elderly) have a pro tanto entitlement to reasonable access to the things needed for a minimally decent life, such as food, housing, security, and medical care. If private markets don’t provide access, the government has pro tanto reason to enact social minimum policies that guarantee access. 2. The level of the social minimum is at least partly determined by comparing the costs and benefits of programs, and programs which impose excessive personal costs are not part of the social minimum. 3. If social minimum programs are less efficacious than alternatives at achieving some important goal, then there is pro tanto reason to discontinue them and replace them with the alternatives. 4. If social minimum programs are counterproductive or unnecessary, then that is a pro tanto reason to end them or not enact them in the first place. 5. If social minimum programs create such serious fiscal risks that they make things expectationally worse for the individuals they intend to benefit, then there is pro tanto reason to end or not enact them.

“Mothers, Citizenship, and Independence”; and Anderson, “Welfare, Work Requirements, and Dependent-​Care.”

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I have phrased these as pro tanto principles since, as we saw in earlier chapters, they must be balanced against any other pro tanto principles that pull in contrary directions. For instance, the fact that universal health insurance might slow innovation is perhaps a pro tanto reason against it, but if the alternative is a system that has more innovation and yet leaves many without any social minimum, then even for conservatives, this is at least a pro tanto consideration in favor of the universal system that we must incorporate into our decision-​making. In the chapter on polling data, we also saw that many Americans, including conservatives, object to social minimum programs that they feel are abused by able-​bodied individuals who could be working to support themselves. This suggests that conservatives believe something like this principle: 6. If social minimum programs admit of abuse by the undeserving, then that is a pro tanto reason against them. This is once again stated only as a pro tanto principle because, as we discussed in chapter two, many conservatives seem to believe that some social minimum programs, including at least some health programs, should be available to all. Moreover, even if we focused on those programs which should be restricted to deserving individuals, surely just any abuse is not a decisive ground for discontinuing the program. For instance, if only a handful of people are wrongly collecting Food Stamps, that seems like a cost we must bear rather than a decisive reason to discontinue otherwise effective food support. I’ll call this collection of principles Decent Minimum Theory, or DMT, and let me make two notes on it. First, one could think that DMT’s principles are the ultimate principles of distributive justice, but one might also think of DMT as a set of intermediate-​ level principles that are grounded in further, foundational

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principles. This in turn opens up the possibility that the widespread consensus on DMT (to be discussed more below) is the result of what Rawls called an overlapping consensus—​perhaps an overlapping consensus among people with otherwise very different views about the foundational principles of justice. Second, note that DMT itself is not a conservative theory, nor can it alone motivate conservatives’ often-​skeptical attitudes toward social minimum programs. Partly that is a purely logical point. Apart from principle (1), which says that we should strive for a social minimum, all the other principles are conditional, and so nothing follows from them—​including a conservative attitude toward social minimum policies—​without further information about whether the antecedents are true. But the point is also partly sociological. The polling data reviewed in chapter two gave us reason to think that large numbers of progressives agree with most if not all of the principles of DMT, so of course embracing DMT cannot make one a conservative. And in fact it’s not surprising that many progressives believe the principles of DMT, since some of the principles seem obviously right. For instance, who wouldn’t be skeptical of a program that was completely counterproductive? Since the principles of DMT are not inherently conservative and cannot on their own motivate conservative skepticism toward some social minimum policies, the conservative point of view must comprise additional components. The next one is the empirical assumption that social minimum programs often face problems of fiscal risk, abuse, inefficacy, or excessive personal cost. For instance, conservatives typically believe that at least some social minimum programs, such as Food Stamps and “welfare,” are often abused by undeserving individuals who could support themselves. Earlier we also saw that many conservatives believed that the ACA would be ineffective and lead to untenable increases in federal debt. And yet DMT, even together with these empirical assumptions, does not imply a conservative stance on social minimum

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programs. For instance, even if we granted that the Food Stamps program was widely abused, and thus (according to DMT) that there is pro tanto reason to oppose it, this would not imply that we should oppose or alter the program all-​things-​considered. To reach that conclusion we must add the third component of the conservative point of view:  the assumption that, with respect to at least some social minimum programs (perhaps Food Stamps or the ACA), the pro tanto reasons against them outweigh the reasons to keep such programs in place. Note one wrinkle. The second principle of DMT says that the right level of the social minimum is partly a function of its costs and benefits. This principle does not express a moral consideration which can compete with the pro tanto obligation to provide a social minimum. Rather it helps define the level of that social minimum. So when conservatives appeal to excessive personal cost as part of their argument against a particular social minimum program, they are not arguing that excessive personal costs generate pro tanto reasons against the program that outweigh the pro tanto reasons in favor of it. Rather they are arguing that the personal costs of a given program are excessive and so the program’s benefits should not be part of the social minimum at all. So that, in sum, is my definition of the conservative point of view about distributive justice. It is made up of several kinds of beliefs, each of which is itself somewhat complex. If correct, together they would justify a typical conservative attitude toward social minimum policies.

Is This a Complete Representation of Conservative Beliefs? My description of the conservative point of view is inspired by and comports with the polling data from chapter two, and that is the main evidence that it is a plausible representation of ordinary conservative concerns. Still, someone might wonder

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whether conservatives would explain their attitudes toward the social minimum by appealing to additional principles that I  have not discussed. For instance, I’ve previously noted that it might seem as though appeals to individual liberty are common in conservative discourse, and that conservatives might explain their opposition to some social minimum policies by claiming that they somehow intrude too greatly on individual liberty. There is certainly a grain of truth here. My description of the conservative point of view is not intended as an exhaustive description of all the principles conservatives would adhere to upon reflection, and I would certainly acknowledge that conservatives believe in a pro tanto right to individual liberty, as well as other pro tanto rights and obligations. However, my goal here is to describe the principles that guide conservative thinking about the majority of social minimum policies, and I think that pro tanto claims to individual liberty are less important than they might appear, since the empirical data in chapter two suggest that conservatives do not in fact explain their opposition to most social minimum policies by appealing to individual liberty. There are also certain other conservative concerns which, while at least verbally distinct from the ones I’ve listed in DMT, can nonetheless be seen as instances of them. For instance, conservatism has traditionally been associated with the viewpoint that we should be more favorably disposed to something the longer it exists. One form of this doctrine would have us value tradition for tradition’s sake. Another form would have us treat a program’s long-​standing, traditional nature as evidence that it functions well and/​or that its removal might produce unforeseen and destabilizing effects. Though I think the former is difficult to defend and probably not what ordinary conservatives believe, I suspect conservatives could mount plausible defenses for the latter position, suitably qualified. When the

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presumption in favor of traditional programs is seen in the latter way, the presumption is a form of the concern about efficacy, and I would treat it as a defensible part of the third principle of DMT.6 Likewise, some significant number of conservatives believe that social policy can mitigate poverty and its effects only to some extent, and that the only real solution would come from the poor themselves—​through hard work, changes in attitudes toward work, and so on.7 In fact, as noted in the discussion of polling above, some significant number of conservatives seem to believe that most poverty-​relief programs make the problems of poverty worse. I count these worries as concerns about inefficacy and counterproductivity that fall under the scope of the third and fourth principles.

ARE THE PHILOSOPHICAL ASPECTS O F   T H E C O N S E R VAT I V E V I E W P L AU S I B L E ? Having described the conservative view, I’ll argue that its philosophical aspects—​the subparts I called DMT—​are philosophically defensible. Part of that work has already been done in previous chapters. There I assumed that the first principle was 6. On this, see Brennan and Hamlin, “Analytic Conservatism.” 7.  For defenses or explorations of this point of view, see, e.g., Mead, “The Logic of Workfare”; Mead, “Social Programs and Social Obligations”; Mead, Beyond Entitlement; Mead, The New Politics of Poverty; Gilder, Wealth and Poverty; Murray, Losing Ground; Jones, An End to Poverty?; Himmelfarb, The Idea of Poverty; and Robin, The Reactionary Mind. For critiques of the ethical and factual issues in this debate, see Smiley, “ ‘Welfare Dependence’ ”; Gilens, Why Americans Hate Welfare, esp. ch. 3; Fraser and Gordon, “A Genealogy of Dependency”; Kittay, “What (Welfare) Justice Owes Care”; Young, “Mothers, Citizenship, and Independence”; and Anderson, “Welfare, Work Requirements, and Dependent-​Care.”

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defensible for reasons given by others in the standard debate over the social minimum:8 1. Hard-​working Americans and other deserving individuals (such as children, those unable to work, and the elderly) have a pro tanto entitlement to reasonable access to the things needed for a minimally decent life, such as food, housing, security, and medical care. If private markets don’t provide access, the government has pro tanto reason to enact social minimum policies that guarantee access. The trickier part was the related principle, which said: 2. The level of the social minimum is at least partly determined by comparing the costs and benefits of programs, and programs which impose excessive personal costs are not part of the social minimum. I did not attempt to convince readers that this principle was true, but I  did show that it fits into several larger theories of justice which are themselves plausible, and I  gave additional

8.  Here it might be worth noting that some of those existing rationales for the social minimum seem not only compatible with the principles professed by many conservatives but specifically conservative in nature. For instance, Menzel and Light have argued that two common conservative beliefs are that individuals should take care of themselves and that they should not free-​ride on the work of others. Menzel and Light then argue that both of these beliefs can underlie a case for universal access to health care, both because ill health compromises the ability for individuals to take care of themselves and because when citizens are allowed to go uninsured but then seek care in emergency rooms and via other public problems, they shift the costs of their health care onto others (“A Conservative Case for Universal Access to Health Care”). It is unclear to me, though, whether the rationale offered by Menzel and Light is compatible with the personal cost principle, labeled (2) in the text.

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reasons for thinking that those viewpoints are not something we should always expect to dislodge with the arguments presently available to us. In other words, (2) is a perfectly reasonable view to hold, though we will later return to the question of whether progressives might ultimately reject it. The earlier chapters also defended these aspects of the conservative view: 3. If social minimum programs are less efficacious than alternatives at achieving some important goal, then there is pro tanto reason to discontinue them and replace them with the alternatives. 4. If social minimum programs are counterproductive or unnecessary, then that is a pro tanto reason to end them or not enact them in the first place. 5. If social minimum programs create such serious fiscal risks that they make things expectationally worse for the individuals they intend to benefit, then there is pro tanto reason to end or not enact them. These are close to truisms, and it’s hard to see why there would be any real controversy over them at all. The one idea we have not yet assessed concerns individuals who are able to make a social contribution but do not, and whether their abuse of a social minimum program warrants favoring an alternative instead. I’ll use the term deserving for anyone who performs a “significant service for, or on behalf of, the wider community,” as Stuart White put it,9 or for anyone who should not be expected to, such as children. Almost everyone agrees that a sufficient amount of paid labor would count as a significant service, most would probably count care work (of

9. White, The Civic Minimum, p. 98.

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children, infirm relatives, and so on), and other forms of contribution might count too. Naturally it would take much more work to decide what counts as a proper social contribution and what does not, and my quick discussion isn’t meant to downplay the importance or difficulty of that project. Instead, I set aside these vexed issues because I think that even if we haven’t decided what counts as a proper social contribution, we can still make out a general rationale for excluding the undeserving from some or all social minimum programs. The most obvious rationale would go as follows:  People come together in societies because, among other things, society provides us with better lives than we would have in a state of nature. Once societies are established, anyone inside them receives the society’s benefits, and anyone receiving benefits owes a proper contribution in return, if they are reasonably able to make one. In political philosophy, this is often referred to as the “principle of fair play,” and though it’s not uncontroversial, it is a plausible moral norm. It appears, for instance, in the work of H. L. A. Hart and in Rawls’s work before Political Liberalism. White offers a similar rationale by appealing to commonsense notions of reciprocity and exploitation: Any member of the community who is a willing beneficiary of cooperative industry . . . must make a reasonable effort, given his or her endowment of productive capacities, to ensure that other members of the community are not burdened by his or her membership in the scheme. As a matter of their dignity, other citizens have the right to expect you to make this effort. Failure to do so treats them in an offensively instrumental way; or, as we more usually say, it exploits them.10

10. White, The Civic Minimum, p. 62, italics in original.

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These ideas about reciprocity and exclusion of the undeserving are, I suspect, part of the reason why people so naturally embrace the idea of a “social contract.” Philosophers use the notion of a “social contract” in two main ways. Some use it to explain why government has authority; the government may rule over us because we have, in some way or other, agreed to government rule. Other philosophers, such as Rawls, use the social contract to determine the structure of a just society; society must conform to the principles that would have been chosen under certain conditions. However, the commonsense notion of a social contract is slightly different from both of these, I think. One important feature of most contracts is mutual dependence. For instance, A agrees to pay money to B, and B agrees to deliver steel to A. Because the duties are mutual, either party’s failure nullifies the contract. If A doesn’t pay, B doesn’t owe the steel, and if B doesn’t deliver the steel, then A doesn’t have to pay. Society can also be viewed as this sort of compact with mutual duties. We guarantee each other minimally decent lives, and in exchange, all people must do their part to maintain our society. Moreover, note that this particular use of the principle of fair play is not subject to many of the standard objections that are made when that principle is used in discussions of political obligation generally. In those discussions, philosophers appeal to the principle to explain why citizens have a duty to obey the law or why we have a duty to support the state with our efforts and resources. When the principle is used that way, as it was by Rawls in his early work, it can seem dubious. One famous objection is Nozick’s, who argued that one acquired a duty of fair play only if the benefits are voluntarily received. To back this up, he gave an example in which a group of townspeople build a PA system which will broadcast public entertainment to the whole town. Each person in the

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town is supposed to take a turn playing music, reading news, and such. Now Nozick asks: Your day arrives. Are you obligated to take your turn? You have benefitted from it, occasionally opening your window to listen, enjoying some music or chuckling at someone’s funny story. The other people have put themselves out. But must you answer the call when it is your turn to do so? As it stands, surely not. Though you benefit from the arrangement, you may know all along that . . . [the] entertainment supplied by others will not be worth your giving up one day. You would rather not have any of it and not give up a day than have it all and spend one of your days on it.11

Some philosophers believe this criticism dooms a general principle of fair play, and that the principle is plausible only when a person voluntarily opts to receive the benefits. Thus, they think, it cannot ground a general political obligation, since most benefits provided by the state, such as police protection and national defense, cannot be avoided by anyone living within the state’s boundaries. But whether that is right or not,12 economic transfers via the social minimum are voluntarily received, for in real-​ world cases individuals must request them. Thus the objection does not apply in this case, and we can plausibly appeal to a more narrow principle of fair play—​one that ranges only over 11. Nozick, Anarchy, State, and Utopia, p. 93. 12. Menzel argues for a narrowed principle of fair play that might overcome the problem presented by Nozick, one that would require individuals to pay their share of a collective enterprise, even if they do not explicitly consent to the payment, in cases where (1) they cannot be excluded from the benefits of that enterprise, and (2) they prefer receiving the benefits and paying their fair share of the costs to losing all of the benefits and being free from the costs, and (3) it would be impossible or prohibitively costly to seek actual consent. See Menzel, “How Compatible Are Liberty and Equality in Structuring a Health Care System?,” pp. 290ff; as well as his book Strong Medicine, pp. 29–​31.

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benefits that are voluntarily received—​in order to explain why the undeserving are not entitled (as a matter of justice) to help from the social minimum programs. Furthermore, a related though slightly different rationale for excluding the undeserving from the social minimum is suggested by some writings on egalitarianism. For instance in Luck, Health, and Justice, Segall applies a luck-​egalitarian framework to questions of health distribution. Segall notes that “within justice, fairness . . . is the focus of attention for luck-​egalitarians.”13 We might add that fairness is a key concern not only for luck-​ egalitarians but also for most people’s thinking about justice. Segall then notes that luck-​egalitarians believe that fairness requires that people “should not end up worse off than others due to reasons that are beyond their control.”14 This notion grounds luck-​egalitarian arguments for helping the deserving, but a related thought, which also accords with commonsense, is that the intuitive notion of fairness does not require us to help the undeserving, and in fact plausibly offers a reason to not help the undeserving, for in so doing you are offering them the rewards earned by contributors, even though the undeserving have by hypothesis not earned those rewards.15 Such appeals to fairness can offer some theoretical backing for the exclusion of the undeserving, at least if our focus is (for the moment) on the requirements of justice rather than beneficence, mercy, or charity. So far I’ve laid out several theoretical rationales for excluding the undeserving from social minimum programs, rationales that conservatives or others might appeal to when defending the idea that, other things equal, we should prefer 13. Segall, Health, Luck, and Justice, p. 64. 14. Segall, Health, Luck, and Justice, p. 64. 15. Though that is not Segall’s position. See Segall, Health, Luck, and Justice, pp. 64ff.

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social minimum programs that are less open to abuse by undeserving noncontributors. However, these rationales would need further qualification in at least two ways. One is that these arguments would not justify excluding the undeserving from social minimum programs unless certain other conditions are met.16 For instance, as White points out, if we exclude the undeserving from the social minimum on the ground that they have failed to make a proper social contribution, then there must be jobs or other contributory avenues open to them. In the real world this is an important qualification, especially when unemployment exceeds job availability. Additionally, it’s arguable (although more controversial) that if the undeserving are expected to work, often in low-​paying and unpleasant jobs, then society must provide a reasonably fair chance for them to compete in the marketplace by having, among other things, an adequate level of fair equality of opportunity. This too would matter a great deal in the actual world, since, in America at least, the educational system often does not provide fair equality of opportunity. Even more importantly, these rationales for excluding the undeserving would need to be qualified or supplemented if we wanted them to accord with ordinary Americans’ considered judgments. As we saw earlier, there are whole categories of social benefits which we never consider taking away from the undeserving, including the right to vote or even citizenship itself. In addition, even if we restrict ourselves to social minimum programs, it seems that people do not support cutting off the undeserving from all such programs. For instance, American law requires that emergency rooms treat all patients for serious acute conditions, regardless of their immediate ability to pay, and this law is widely supported. And though I don’t know of polling data on this subject, it is surely plausible that Americans 16.  The best discussion of this is White, The Civic Minimum, from whom I borrow in the following text.

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would favor providing the undeserving with other basic goods, such as food and shelter, when absolutely necessary. For while people express hostility to “welfare” programs that (allegedly) provide benefits to undeserving noncontributors, it seems implausible that the American populace would be comfortable watching the undeserving die in the streets from lack of food. I don’t know of any empirical research that explains why people sometimes reject social minimum policies that they believe are abused by the undeserving and yet countenance others. However, we can at least speculate about several sensible reasons for these views, all of which are compatible with the overall normative framework that we are attributing to conservatives. First, we can borrow another point from Segall. Segall points out that on the face of things, luck-​egalitarianism cannot justify universal health care but instead seems to imply that we should guarantee health care only to those whose lack of health insurance results from factors beyond their control. But he says that we don’t have to construe luck-​egalitarianism as a complete account of justice, but rather as an account of fairness or distributive justice in particular. He then appeals to other important aspects of justice, such as the value of meeting people’s basic needs, to explain why we should have a universal social minimum in health care. Whether Segall’s particular arguments succeed or not, he provides a valuable general lesson. The principles of DMT are surely not the sum total of people’s thoughts about justice or morality. They could, like Segall, believe that some minimum level of health care—​such as rescue care in emergency rooms—​might be required by other aspects of justice, or that even if no aspect of justice requires E.R. access, some other aspect of morality, such as an obligation of charity or mercy, requires provision of minimal health care. Second, Americans might support universal provision of some social minimum benefits, including universal health care provision, on various pragmatic grounds. For instance, in

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chapter two I briefly mentioned that the populace might have thoughts similar to those offered by Menzel and Light, or by Daniels, all of whom highlight the fact that health is a precondition for work: if we cut off undeserving noncontributors from health care, then when they get sick, they won’t be able to change their ways and return to the workforce.17 If we want to incentivize such changes, then, we cannot cut off the undeserving from minimal health care. In this respect, some people might view minimal health care provision in the way that they view job retraining programs. Chapter two revealed that those programs receive near-​universal support, even though they might be used by people who are undeserving. So why do Americans support these programs? The obvious explanation is that the programs are part of a path out of noncontribution. Third, we should not overlook the fact that Americans might support minimal medical care and some other social minimum programs for the undeserving simply because they cannot bear to see people dying from lack of basic medical services. While generally set aside during ethical analysis, personal calculations like these play a significant role in actual social policy. Overall, then, it seems that there are several substantial rationales for thinking that the undeserving are not, as a matter of justice, owed the benefits of a social minimum, but that there are various moral and pragmatic rationales for providing some social minimum benefits to all citizens, regardless of social contribution. This overall outlook can then make sense of the final principle of DMT, outlined above: 6. If social minimum programs admit of abuse by the undeserving, then that is a pro tanto reason against them. 17. Menzel and Light, “A Conservative Case for Universal Access to Health Care”; Daniels, Just Health Care.

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T H E P R O G R E S S I V E   A LT E R N AT I V E We’ve now developed a reasonable conservative viewpoint about distributive justice, one that comprises the normative principles of DMT, the empirical assumption that at least some social minimum policies suffer from certain problems, and the additional philosophical claim that some pro tanto reasons against these policies are decisive. Now let us develop a progressive alternative to this viewpoint. There are obviously three ways to distinguish the progressive viewpoint from the conservative one:  progressives can challenge the principles of DMT, the empirical assumption that social minimum programs suffer certain problems, or the way conflicts between pro tanto principles are resolved by conservatives. Let’s start with DMT’s principles.

Challenging the Principles of DMT Some principles of DMT seem so obviously plausible that it’s hard to imagine a progressive view denying them. These include the principles about efficacy and fiscal risk: 3. If social minimum programs are less efficacious than alternatives at achieving some important goal, then there is pro tanto reason to discontinue them and replace them with the alternatives. 4. If social minimum programs are counterproductive or unnecessary, then that is a pro tanto reason to end them or not enact them in the first place. 5. If social minimum programs create such serious fiscal risks that they make things expectationally worse for the individuals they intend to benefit, then there is pro tanto reason to end or not enact them.

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Progressives probably have a more complicated attitude toward the initial principle of DMT: 1. Hard-​working Americans and other deserving individuals (such as children, those unable to work, and the elderly) have a pro tanto entitlement to reasonable access to the things needed for a minimally decent life, such as food, housing, security, and medical care. If private markets don’t provide access, the government has pro tanto reason to enact social minimum policies that guarantee access. Progressives don’t disagree with this principle, even if they might have a different theoretical foundation for it than conservatives do. On the other hand, progressives might feel that this principle should either be broadened to include the undeserving or resident noncitizens, or that some other principle ought to be added to our moral outlook which ensures that the social minimum covers some or all of those additional groups. This seems like one plausible way to distinguish the progressive view from the conservative one, and I’ll return to it later. First let’s consider the other two principles of DMT.

Personal Cost The principle of DMT that is related to personal cost says that: 2. The level of the social minimum is at least partly determined by comparing the costs and benefits of programs, and programs which impose excessive personal costs are not part of the social minimum.

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Should progressives accept this principle? In chapter three, I argued that challenging the core idea behind (2) is not a promising strategy for anyone engaged in a specific kind of other-​oriented political philosophy, the kind where the goal is to provide opponents of national health insurance with evidence that should convince them, were they to react rationally to that evidence. If that is the goal, then attempting to disprove (2) will fail in many cases, since the principle comports with several highly plausible political frameworks. But at the moment our aims are different. We are trying to fully develop and understand two poles of the debate about the social minimum, conservative and progressive. So, leaving aside questions of who can convince whom, we can ask whether progressives should accept or reject (2). Either option seems plausible. For instance, we’ve already seen that certain plausible political frameworks reject (2), including what is probably the most popular egalitarian political theory at present, Rawls’s Justice as Fairness. Rawls’s difference principle requires us to maximize the index position of the least advantaged members of society, and that directive does not make the level of the social minimum a function of whether the benefits outweigh the costs when judged on a weighted scale. However, though progressives might plausibly reject (2), I should also offer the cautionary note that, as progressives reason more about their theories of justice with an eye to issues of personal cost, they might discover that their own presuppositions do indeed lead to principle (2), or at least leave it open that (2) is true. As an illustration, let me continue the discussion of Rawls, showing how certain chains of reasoning might lead to a Rawlsian philosophy that accepts (2) rather than rejects it. As we noted in chapter three, during our discussion of Waldron, Rawls’s most famous argument from A Theory of Justice aims to show that contractors in the original position would prefer Justice as Fairness to utilitarianism. But as Rawls

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notes,18 this merely rules out a single alternative. He must also show that contractors would prefer Justice as Fairness to other plausible theories, including the theory Rawls refers to as the mixed conception.19 Like Justice as Fairness, the mixed conception has a principle of equal basic liberty (EBL) and a principle of fair equality of opportunity (FEO). But in place of the difference principle, the mixed conception contains a restricted utility principle that guarantees a basic social minimum and then maximizes wealth thereafter. Rawls gave one objection to the mixed conception in Theory, but the argument didn’t work, and Rawls offered a different argument in the Restatement. To understand it, let’s begin by imagining a society governed by the mixed conception, called Mixed. Perhaps the social minimum in Mixed guarantees the least advantaged a minimum income of $12,000. This minimum is lower than it would be in a society governed by the difference principle, Difference. (Here I  have spoken of minimum annual incomes, but readers of Rawls will know that he thought of his theory as one of pure procedural justice rather than allocational justice, with the difference principle arranging institutions so that they maximize the expectation of the least advantaged group rather than specifying some guaranteed income. For simplicity’s sake, though, I will continue to compare mixed conceptions and the difference principle with respect to annual income minimums, 18. Rawls, Justice as Fairness, pp. 119–​120. 19. Many readers of Rawls don’t even notice that Rawls needs to address the mixed conception. They think his argument is finished after he argues against utilitarianism. Rawls blamed himself for misleading readers in that way. In Justice as Fairness he emphasizes that the argument against the mixed conception is as important as the argument against utilitarianism. They are described as the two “fundamental comparisons,” and Rawls even suggests that the argument against the mixed conception is the more important of the two. See Justice as Fairness, p. 120.

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and readers may take this as only a convenient shorthand for more complex discussions of the lifetime expectations of representative people from the least advantaged group. This simplification does no real harm, I think.)20 So the social minimum is lower in Mixed than in Difference, but what is Rawls’s argument against mixed conceptions? Rawls’s remarks in the Restatement are difficult, but here is one reconstruction.21 Rawls rejects the mixed conception because it doesn’t satisfy a requirement of strict reciprocity. Strict reciprocity exists when “those who are better off at any point are not better off to the detriment of those who are worse off at that point.”22 But we know that because the social minimum in Mixed requires less redistribution than in Difference, the most advantaged in Mixed enjoy 20.  Rawls thought his theory placed restrictions on how we arrange, as Freeman says, the “basic institutions that make economic production, trade, and consumption of wealth possible:  the legal institution of property; the structure of markets; the relations between capital and labor including the role and powers of labor unions within firms; the law of contracts, sales, securities, negotiable instruments, corporations, partnerships, and so on. All these background institutions are to be designed so that, when their rules are complied with and people’s legitimate expectations are met, the final outcome is one that maximally benefits the least advantaged” (Rawls, p. 126). Commentators rightly emphasize that, because Rawls’s theory is not allocational, the difference principle does not specify an annual income which is the “right” one for each member of the least advantaged. Instead the difference principle only arranges institutions so that they maximize the expectation of the least advantaged group. In the text I point out that we can take the figures about annual income minimums as a shorthand for more complex discussions of the lifetime expectations of representative people from the least advantaged group, but we should also note that, even though Rawls’s theory is clearly not allocational, Rawls did believe that while implementing the difference principle, we would set up a system of monetary transfers which maximized the expectations of the least advantaged group, transfers that might take the form, Rawls says, of a graded income supplement or a negative income tax. Both of those would set up an income floor, so it is not totally artificial to speak of the minimum annual income under the difference principle. 21. This draws on Samuel Freeman’s reconstruction of the argument in Rawls. 22. Rawls, Justice as Fairness, p. 124.

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higher incomes than they would in Difference. The most advantaged in Mixed are thus better off to the detriment of the least advantaged. We don’t have strict reciprocity. So far so good, but the key question is why should we think that a theory of justice must satisfy this particular definition of “strict reciprocity”? More to the point, the contractors in the original position pursue only their own good, so why should they care whether a theory of justice expresses strict reciprocity? Samuel Freeman points out that Rawls doesn’t allow contractors to choose any conception of justice that is in their self-​interest. Instead they must choose a conception they can affirm in “good faith”—​that is, a conception they can support no matter how rich or poor they turn out to be.23 But Freeman thinks that if society lacks strict reciprocity, people can’t support the conception of justice. Instead they suffer what Rawls called the strains of commitment: they “grow distant from political society and retreat into [their] social world. [They] feel left out; and, withdrawn and cynical, [they] cannot affirm the principles of justice in [their] thought and conduct over a complete life.”24 One obvious problem with this argument is that we have no good reason to think that in a society governed by the mixed conception, the least advantaged would suffer the strains of commitment. Freeman tries to offer evidence. He points out that in current societies, the “less advantaged are likely to withdraw from active participation in politics and public life,” and cites as evidence the “striking lack of political participation by the poorest members of society.”25 However, America shouldn’t be taken as a model of a society governed by the mixed conception. 23. Rawls, A Theory of Justice, p. 153. 24. Rawls, Justice as Fairness, p. 128. 25. Freeman, Rawls, p. 193.

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Our least advantaged may suffer the strains of commitment because our social minimum provides fewer benefits than an appropriate mixed conception would. For instance, our system doesn’t guarantee basic medical care, ensure that people can find useful work, guarantee that they won’t go hungry once they work, and so on. These problems might not exist in a society governed by the mixed conception, which could set the social minimum higher and thus avoid the strains of commitment. Rawls saw this response coming; he explicitly considers Jeremy Waldron’s suggestion that the social minimum should be set at precisely the point where the strains of commitment are not excessive.26 (This is the view we looked at briefly in chapter three.) In response, Rawls said that to avoid the strains of commitment, we would have to set the social minimum at the level required by the difference principle. In other words, Rawls thought that if we design the mixed conception to avoid the strains of commitment, it collapses into Justice as Fairness. The lingering problem, though, is that Rawls’s claims seem unjustified. It’s very hard to believe that we can prevent disaffection among the worst-​off only by making them as well-​ off as possible. Even America’s poor don’t all withdraw from public life. Rawls admitted that this and other problems were very serious. He wrote, “From the preceding account of the [argument against mixed conceptions] it is evident that, while I view the balance of reasons as favoring the difference principle, the outcome is certainly less clear and decisive than in the [argument against utilitarianism].”27 Rawls saw the balance of reasons in one way, but he concedes that the argument is far from definitive and that some might think that the difference principle 26. Rawls, Justice as Fairness, pp. 128ff. 27. Rawls, Justice as Fairness, p. 133.

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should be replaced with some alternative, such as Waldron’s principle. All of this matters because, as we saw in chapter three, Waldron’s framework would seem to include a version of DMT’s principle (2). Specifically, it would be a version of principle (2) in which the social minimum is lifted just to the level where, as a matter of empirical fact, a knowledge of the comparative costs and benefits of social minimum policies no longer leads the less advantaged to the conclusion that others care very little about their welfare and thus to problematic levels of political disaffection. And if the best development of Rawlsian political philosophy might lead us, not to Justice as Fairness and the difference principle, but rather to a mixed conception and its accompanying social minimum principle, then it is entirely possible that even the political frameworks favored by many progressives will in fact include a version of principle (2). Now of course Rawls’s philosophy is far from the only political philosophy that progressives might build upon. But our examination of Rawls’s philosophy is a cautionary tale: the most plausible political philosophies that comport with a progressive outlook might well include principle (2).

Exclusion of Undeserving Citizens Finally, let’s ask whether a plausible progressive viewpoint would accept or reject principle (6), which said: 6. If social minimum programs admit of abuse by the undeserving, then that is a pro tanto reason against them. Note that the issue is not whether the undeserving should be excluded from the social minimum, all things considered. That is a topic we’ll come to later on. At the moment the only

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question is whether progressives should accept that there is some pro tanto reason against programs that fail to exclude noncontributors. I certainly can’t rule out that progressives will adopt a more general political theory that rejects (6). However, there are also good reasons to think they would end up accepting (6). Let me illustrate why using Rawls’s political philosophy once again. I think many people familiar with Rawls’s theory might say at first that it does not include anything like principle (6). The difference principle, for instance, has no explicit clause excluding undeserving noncontributors from the scope of the principle. But that appearance is misleading. In some of Rawls’s few remarks about the problem of noncontribution, he reminded us that the principles of Justice as Fairness are principles of ideal theory and are not intended to cover certain nonideal situations: In elaborating Justice as Fairness we assume that all citizens are normal and fully cooperating members of society over a complete life. We do this because for us the question of fair terms of cooperation between citizens so regarded is fundamental and to be examined first. Now this assumption implies that all are willing to work and to do their part in sharing the burdens of social life, provided of course the terms of cooperation are seen as fair.28

Essentially, Rawls admits that his theory abstracts away any problems about undeserving noncontributors. And yet we do get hints of his opinion about the problem of noncontribution, since in the continuation of the passage above, he writes: But how is this assumption [that all citizens are fully cooperating members of society] to be expressed in the difference 28. Rawls, Justice as Fairness, p. 179.

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principle? The index of primary goods, as discussed so far, makes no mention of work, and the least advantaged are those with the lowest index. Are the least advantaged, then, those who live on welfare and surf all day off Malibu? . . . This question can be handled in two ways: one is to assume that everyone works a standard working day; the other is to include in the index of primary goods a certain amount of leisure time, say sixteen hours per day if the standard working day is eight hours. Those who do no work have eight extra hours of leisure and we count those extra eight hours as equivalent to the index of the least advantaged who do work a standard day. Surfers must somehow support themselves.29

This isn’t clear, and Samuel Freeman interprets this passage so that Rawls is actually endorsing social support of surfers, just at a lower level than for nonsurfers.30 That seems wrong to me (“Surfers must somehow support themselves”), and the passage can also be read so that Rawls is proposing the more radical idea that surfers should receive nothing at all. (Let us define the index of the least advantaged as $X, which includes the value of all benefits they receive through government action. Rawls says that the surfers’ extra eight hours of leisure are all by themselves equivalent to this $X.) Either way, it is clear that Rawls sympathizes with the notion that the undeserving lack the same claim to social benefits that others do. In fact he seems to think this is so obvious that he relies on the notion without argument. Why might he have felt the point was obvious? Rawls was thoroughly committed to reflective equilibrium. And although

29.  Rawls, Justice as Fairness, p.  179. Note as well that his discussion of a negative income tax in A Theory of Justice hints at awareness of the issue of noncontribution, since one of its merits is that it always provides incentives to work. 30. Freeman, Rawls, pp. 229–​230.

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no considered judgments are immune from revision during the reflective equilibrium process, some of our considered judgments seem so secure that it’s hard to see how they will be displaced, given both their strength and how they seem to comport with the other general considerations that will enter into a reflective equilibrium process. Consider a simple example like “Slavery is wrong.” Although the method of reflective equilibrium does not make this considered judgment immune from revision by fiat, it still seems impossible that any reasonable, modern individual could end up abandoning it during a proper reflective equilibrium process. That is an extreme example, of course, but I suspect that Rawls thought our considered judgments about noncontribution were secure enough that they too would almost surely survive a proper reflective equilibrium process. The idea that individuals should not exploit each other seems like a fundamental ethical idea, as is the related consequence that we have at least some reason to exclude the undeserving from the benefits of collective projects. (Not many things are more intuitive than that your coworker should have to do his fair share of the work in your department, and that if he refuses to work, he shouldn’t get paid!) Moreover, if we accept the ethical idea that the undeserving are not entitled to benefit from the social minimum as a matter of justice, we can then see why principle (6) is plausible. If a social minimum program taxes some people to provide a social minimum to the undeserving, then it taxes and transfers those people’s earnings (to which they have a presumptive right) for no justice-​related reason. It thus moves us in one respect farther from our ideal of justice, and so there is always some reason against the policy. Of course, these quick arguments do not prove that plausible progressive political philosophies must incorporate something like principle (6). However, since they might well do so, we do have reason to examine the other ways in which

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progressives might distinguish their political philosophy from a conservative one. Let’s turn to the second main element of the conservative point of view, its empirical assumptions about social minimum programs.

Empirical Assumptions The progressive viewpoint might be distinguished from the conservative one by an empirical assumption that social minimum policies do not suffer as many problems as conservatives think they do—​problems of inefficacy, abuse, or fiscal risk. Whether that is a plausible way to develop the progressive viewpoint depends, obviously, on the facts, and so I will not try to adjudicate the point philosophically. Instead I will merely note that, in my experience, progressives often feel that their viewpoint can be proven right, and the conservative viewpoint wrong, largely or even wholly with factual information. However, even if conservatives might be wrong on some factual matters (as are progressives, no doubt), a progressive philosophy surely can’t be distinguished from a conservative one solely by their factual claims. The reason is simple:  progressives and conservatives sometimes disagree about the merits of a social minimum program even though the empirical assumptions underlying the conservatives’ objections are either correct or, if the matter is uncertain, perfectly plausible. For example, in chapter four we looked at the contention by some conservatives that universal health insurance would reduce innovation. Although there was no definitive proof that this was correct, it was certainly plausible. To know whether it’s a good idea to invest money in research projects, entrepreneurs must know the odds of developing something new as well as the return on investment if the product gets to market. If universal health insurance lowered profit margins, it would reduce the expected return on investment and disincentivize some entrepreneurship.

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Moreover, even though advocates of universal health insurance often propose to fund their systems at levels comparable to current spending, equal spending doesn’t automatically translate into equal profits, because universal health insurance systems could partly pay for expanded coverage by reducing profits. As a second example, consider the assumptions some conservatives make about the fiscal risks of universal health insurance. In chapter five we saw that, even though an American universal health insurance system could almost surely be funded without increasing total health care spending as a percentage of GDP, it is nonetheless true that such a system would increase the percentage of that spending which is routed through the federal government. Rather than pay for that spending, the government might just increase the national debt, as it often does, and increasing the debt puts the economy at risk. Judging the extent of that risk is very difficult, but we saw that some dire predictions are not wholly unreasonable. It’s easy to produce further examples in which the conservative factual assumptions are correct or at least reasonable—​some social minimum programs are at least to some extent abused, and so on. In light of this, progressives cannot rely solely on empirical information to distinguish their position from the conservative one. However, having noted this, we should also note that at least some conservative positions can probably be effectively rebutted only by drawing on complex empirical data. Take as an example the charge that universal health insurance would drastically reduce aggregate health, even for those who currently lack health insurance. If that were true, then it would be a strong consideration against universal health insurance, and progressives will have to reply to this objection by disputing its underlying factual claim. For this reason we can be confident that the progressive position is at least partly distinguished by its factual stance.

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Weighing Moral Considerations Conservatives sometimes believe that the pro tanto reasons against a particular social minimum program outweigh the reasons in favor of it. How might progressives respond? To answer that question, we must first lay out this conservative line of argument more thoroughly. When discussing social minimum policies, conservatives often highlight problems of efficacy, fiscal risk, excessive personal cost, and abuse by the undeserving. Now suppose for the moment that conservatives cite these issues, not as reasons to oppose social minimum programs altogether, but only as reasons for getting rid of our (by hypothesis) problematic programs and replacing them with ones that are more efficacious, less risky, and so on. In that case, progressives might or might not agree with the factual claim that the alternatives are better, but they and the conservatives would have no fundamental disagreement over the moral need for a social minimum. This is not the interesting case. Instead, the interesting case is one where conservatives claim that social minimum programs suffer problems, that there are no better options, and that the programs should be eliminated even though there aren’t better alternatives. Essentially, these conservatives are claiming that the problems are so severe that they warrant eliminating the social minimum policies entirely. Whether this conservative line of argument is plausible depends in part on how severe the problems are. And though that issue can’t be settled a priori, we have good reasons to think that the problems cannot be both extremely severe and intractable. For instance, it’s implausible that all universal health insurance programs or food support programs carry such massive fiscal risks that they are expectationally bad for everyone involved, since programs can be accompanied with reliable funding mechanisms, or even dedicated ones. Likewise, it’s implausible that social minimum policies are completely and inevitably counterproductive or

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subject to high levels of abuse, since programs can be cleverly designed, have work requirements, and so on. Instead, insofar as programs suffer from abuse, inefficacy, fiscal risk, or high personal costs, these problems are likely to be moderate rather than unavoidably severe, and their real-​ world upshot is likely to be that the costs of the programs go up. For instance, the realistic consequence of inefficiency is likely to be that some fraction of the money we spend on a program is wasted, and therefore that provision of the social minimum imposes greater costs on certain taxpayers than it would in an ideal situation where more waste could be eliminated. Similar things might be said about abuse, since the main problem with abuse is that it’s a kind of inefficiency: some people collect benefits who do not deserve them, and because others must pay for those benefits,31 the abusers introduce costs into the system that ideally should not be there. Fiscal risk introduces distinct kinds of costs, but not totally dissimilar ones. We saw in chapter five that moderate fiscal risk produces problems like reduced public investment, reduced private investment, and higher interest rates for private loans. Essentially, then, the reason there would be pro tanto reasons against these programs is that they have negative effects on the welfare of those who pay for them, and perhaps others as well. Why are these increased costs morally problematic? When answering that question, one option is for conservatives to rely on the idea that society has a pro tanto obligation to promote the welfare of its members. If so, then there is a stronger reason against any program that is wasteful, inefficient, and so on, since 31. The payors might also have to make up for the fact that the noncontributing could work less than they otherwise would and deprive society of additional productivity. In addition, theorists worried about abuse of the social minimum often allege that providing a social minimum to the undeserving can result in other social problems that also produce costs, including out-​of-​ wedlock births, juvenile delinquency, and adult crime.

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those programs cost more and therefore have a greater net negative effect on the welfare of those who fund them. To complete this line of argument, conservatives must also maintain that this pro tanto reason against the programs is strong enough to outweigh the reasons in favor of the social minimum policies. This line of argument is problematic, though. In response, progressives might point out the internal inconsistency of the conservative position. If, by hypothesis, all social minimum programs have problems of efficacy, fiscal risk, and abuse, then that must also be true of the social minimum programs that conservatives support. Now of course proving that conservatives have been inconsistent is not the same as proving they’re wrong or that progressives are right. Therefore, the next step would be to examine why both progressives and conservatives seem to have considered judgments favoring provision of a social minimum, even in the face of various intractable problems. The hope would be to develop a theoretical framework that vindicates those considered judgments. Theory can be of various “depths,” and some progressives might develop and defend a set of fundamental political principles that would explain the priority of the social minimum. However, in this case it seems unnecessary to explore deep theory. Even if progressives remain at the level of intermediate political principles—​principles about pro tanto reasons for various policies—​they can make a plausible case for why the reasons in favor of social minimum programs often take precedence over others. One way to do so is by appealing to arguments like those produced in chapter four, regarding innovation. There I argued that we should provide a social minimum even if aggregate welfare could be maximized by not doing so. Bringing that argument to bear here would have the advantage that, if it works at all, it can succeed even if we think that enacting a somewhat wasteful social minimum imposes welfare costs on others.

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However, arguments like that one, which appeal to the moral priority of the social minimum, might also be unnecessary. Instead progressives might point out that, even if problematic programs create welfare costs to those who fund them, as conservatives maintain, it’s also true that not having the programs produces a great cost to human welfare, since people will suffer and die without social minimum programs. Society’s obligation to promote the welfare of its members therefore speaks both for and against a social minimum, and the question is whether the best way to respect that obligation is by having a social minimum or not. The most obvious way to resolve that conflict is by adopting the policy that maximizes overall welfare, which progressives can plausibly argue is that policy containing a social minimum. Importantly, the reason to adopt the welfare-​maximizing policy is not that conflicts between reasons or obligations should always be resolved in favor of the obligations which, when fulfilled, result in the highest aggregate welfare. That general claim is wrong. Instead the key here is that for argument’s sake, we have set aside almost all social obligations, including any obligations to prioritize the social minimum, and the only obligation at play is, by hypothesis, society’s obligation to promote the welfare of its members. Society has that obligation equally to all citizens,32 and the most reasonable way to adjudicate conflicts created by this single, welfare-​focused obligation is by choosing the policy which maximizes aggregate welfare.33 32.  Society might not always have symmetrical obligations to promote the welfare of its citizens, but apart from the exceptions noted in the text, the asymmetries don’t seem relevant to our debate here. For instance, perhaps the state has a stronger pro tanto obligation to promote the welfare of its veterans than others, given the veterans’ sacrifices, but that is not something that would affect the argument under consideration. 33. One wrinkle here is that there sometimes seem to be cases where one’s obligations are perfectly symmetrical and yet one should not adopt the policy

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So far we have been sketching ways to refute a possible conservative argument grounded in the pro tanto obligation to promote citizen welfare. We should also note that conservatives might take their argument in a different direction. Within the DMT framework, personal cost functions as a partial determiner of the proper level of the social minimum, and so when conservatives object to social minimum programs on the ground that they are inefficient, fiscally risky, and so on—​and therefore impose higher-​than-​ideal personal costs—​they might be claiming that the costs of the programs are so high that the programs are not part of a proper social minimum at all. If conservatives gave that argument, progressives would need to follow the route laid out in chapter three, where I argued that there are often compelling explanations for why expanding certain social minimum programs is not excessively costly. Naturally that argument schema will not always work—​ some programs could indeed impose excessive personal costs. But as we saw during our earlier discussion, it does seem like that leads to the highest aggregate welfare. For instance, consider the much-​ discussed hypothetical case where you can kill one innocent person, take out his or her organs, and save five people who need organ transplants. It seems wrong to maximize the aggregate good by killing, and yet someone might object that one’s obligations to all parties seem symmetrical, since none of them is a spouse, sister, and so on. However, the key to that case is that the obligations are not in fact symmetrical, since we have a pro tanto obligation not to kill the potential donor, but only a pro tanto obligation to promote the welfare of the sick patients in need of transplants. Thus even though I have no special relationship with any of the people involved—​none of them is my brother or father, for instance—​I do not have symmetrical obligations to them. In fact, the only way one could use this case as an analogy with the decision about the social minimum would be if the state had some obligation that was analogous to the pro tanto obligation not to kill the potential donor. The most plausible candidate would be a pro tanto obligation for the state not to take its citizens’ money, even in order to fulfill its other proper goals. That line of argumentation could be pursued further, but I will leave it aside here since it clearly takes us beyond the scope of a dispute between progressives and conservatives. Conservatives are not right-​libertarians who oppose taxation.

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the kinds of appeals to personal cost that are seen in real-​world debates can often be undercut by arguments like the one given in chapter three.

Summary We’ve now looked at various ways in which the progressive viewpoint does and does not differ from the conservative one. Perhaps surprisingly, it is similar in many of its fundamental moral assumptions. A plausible progressive view might therefore contrast with the conservative one, and involve greater acceptance of social minimum programs, for some or all of the following reasons. First, according to DMT’s sixth principle, we have pro tanto reason to exclude the undeserving from a social minimum. Although that principle is controversial and some progressives might reject it, I argued that this principle is plausible and should find a place in progressive theory. However, accepting it does not entail believing that undeserving citizens should be cut off from social minimum programs all-​things-​considered, and so one plausible way for progressives to distinguish their position is by making the case that this pro tanto reason is outweighed by competing reasons to extend social minimum programs to all citizens or residents. I  briefly reviewed some arguments of that sort above. Second, according to DMT’s second principle, the proper level of the social minimum is a function of personal cost. I’ve argued that this principle might easily find a home in many arguments for a social minimum, but I do not see a case that it will find a home in all. Therefore, if conservatives object that certain social minimum programs are excessively burdensome, progressives can respond in two distinct ways. One is by arguing that personal cost is irrelevant, as it would be in certain egalitarian philosophies. Another is by arguing that particular

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extensions of the social minimum are not excessively burdensome. Naturally there is no fully general argument for that conclusion—​some extensions might indeed be overly burdensome. But in actual political discourse most extensions are no more burdensome than the kinds of extensions discussed in this book, so the argument of chapter three provides a template for how to argue that such extensions are not overly burdensome. Third, in some cases the progressive viewpoint will be distinguished by its factual assumptions that social minimum programs do not face severe problems of certain kinds, including problems of inefficacy, fiscal risk, or abuse. It would be foolish to dictate which empirical assumptions are “progressive,” since progressives, like everyone else, should accept whatever empirical assumptions are true. But it does seem like progressive thought is sometimes characterized by the view that conservatives are simply wrong about the facts—​e.g., about the efficacy of universal health insurance. Fourth, we’ve seen that, in principle at least, conservatives could try to maintain that various noncalamitous problems of fiscal risk, abuse, and inefficacy are so serious and ineliminable that they justify not having certain social minimum programs. There are various ways to reply to this position, and perhaps the most plausible progressive view would be that this argument fails because it does not properly prioritize the provision of a social minimum to all citizens.

THE SIGNIFICANCE OF DEVELOPING LIBERAL AND C O N S E R VAT I V E   V I E W P O I N T S We’ve noted that when philosophers discuss the social minimum, they typically focus on disagreements between those who support a social minimum in principle and those who,

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like right-​libertarians, oppose it in principle. That discussion is fascinating, and the philosophical work on these subjects has shed much light onto the foundational question of whether we should have a social minimum at all. However, as the discussion in this book revealed, people of different ideologies are not necessarily divided on the question of whether society should, in principle, have a social minimum. Their disagreements about social minimum programs can persist for other reasons, and in this chapter I’ve tried to develop and articulate a general picture of those reasons. We’ve looked at a set of principles and assumptions that I  called the conservative point of view, one that would explain why conservatives are often skeptical of specific social minimum programs despite agreeing on the general need for a social minimum. And we’ve also looked at a set of principles and assumptions that I called the progressive point of view, which would lead to greater support for social minimum programs. In the remainder of this chapter, I  want to explain why incorporating these frameworks into our philosophical thinking aids our understanding and points us toward important areas of philosophical inquiry.

Understanding Understanding the details of the progressive-​conservative debate leads to further clarity in several ways. Consider first how progressive and conservative thought is usually represented, intentionally or not, in typical philosophical research and teaching. I don’t know of any empirical data on what is typically taught in philosophy classes, but one good proxy comes from textbooks. These are designed to reflect the important philosophical positions on any subject, and they are regularly used by philosophy teachers around the country. The sections on distributive justice in these textbooks typically include two things. First, we find excerpts from egalitarian philosophers such as Rawls and

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Dworkin, philosophers whose theories are (rightly or wrongly) taken to reflect the progressive point of view which favors a robust social minimum. Second, we find that the major opposing point of view is almost always represented with excerpts from right-​libertarian philosophers such as Nozick. Similar things might be said about contemporary philosophical research. Progressive philosophers who defend social minimum policies often ground their positions in egalitarian philosophies like Rawls’s or Dworkin’s, and they assume that their conservative opponents are those who oppose such policies entirely. We’ve seen that this way of portraying things is misguided on two counts. Rawls, Dworkin, and others make the case for a social minimum in principle, but that alone doesn’t make one’s position progressive, since many conservatives support a social minimum in principle as well. Moreover, most conservatives aren’t right-​libertarians, so it’s wrong to represent their position as akin to Nozick’s. These points aren’t hard to see, so why does this way of misrepresenting things persist? Any answer is speculation, but several possibilities suggest themselves. Focusing for the moment on the misrepresentation of the conservative position in particular, some might allege that academics are predominantly liberal and thus ignore the real conservative position because of alleged “liberal bias.” I don’t think so. In fact, over the past 40  years, professional philosophers have shown a near-​obsession with right-​wing libertarianism. They certainly aren’t averse to considering points of view that are not progressive. Another possibility is simply that progressive philosophers have misperceived conservative attitudes. When any of us read the news and hear that progressives support certain social minimum policies such as the ACA and conservatives oppose them, one can jump too easily to the conclusion that conservatives oppose social minimum policies in principle. This

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makes conservatives look akin to right-​libertarians, and so perhaps philosophers genuinely believed that by discussing right-​ libertarian writings, they were discussing something quite close to the conservative point of view. This misunderstanding could be compounded by the fact that some conservative leaders seem more sympathetic to right-​libertarianism than the average conservative voter does. I think that there is some truth in this explanation, but I suspect at least one other factor is at play as well. Some philosophers might understand that conservative objections often arise from a complex combination of moral principles and empirical assumptions, but they might feel that the empirical claims are obviously false and so not worth taking seriously. For instance, in my work on health policy debates, I have been surprised at the number of philosophers who will say—​in my view, too blithely—​that there is simply no question that a universal health insurance system can be made to function in an efficient and fiscally sound way. If one makes that assumption, then one will tend to think that the only live right-​wing position is the libertarian one. Moreover, this same set of attitudes would explain why people assimilate the egalitarian position and the progressive one. Egalitarians such as Rawls and Dworkin make the case for the social minimum in principle, and if (hidden assumption) there aren’t any practical problems with the social minimum either, then these egalitarian theories should lead us to support a social minimum. Regardless of why the categorizations take hold, we can see that they’re mistaken. But just recognizing this error is not enough. If we continue to use only the categories from the standard debate about distributive justice, then even after correcting the errors in our thought, we will place most progressives and conservatives into the same category—​namely, those who agree that an ideal society would have a social minimum. That categorization will now be correct, which is an

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improvement, but obviously it fails to recognize differences between the progressive and conservative positions. What we need is the conservative-​progressive framework that I’ve described above. Employing that framework allows us to see how and why actual progressives and conservatives disagree despite their common acceptance of a social minimum in principle. An improved general understanding of the progressive-​ conservative debate also helps us understand certain specific aspects of it. For instance, I suspect many progressive readers of this book reacted to chapter two, on poll data, with a bit of disbelief. They might have felt that conservatives just couldn’t support a social minimum in principle—​and often in practice. Likewise it might have been hard to believe that progressives and conservatives have so many bedrock moral principles in common. After all, both ideas fly in the face of the common notion that Americans are deeply divided. However, a better understanding of the progressive-​conservative debate helps us see how the two sides can share so many moral principles and also deeply disagree about specific policies. Or consider another example of how this general understanding produces specific insights. Above I  pointed out that we often mistakenly identify positions like Rawls’s or Dworkin’s with progressivism. As a consequence, it’s easy to start thinking, as a progressive, that one’s views on the social minimum can be vindicated by Rawls’s or Dworkin’s arguments alone. But a better understanding of the progressive-​conservative debate, and of the conservative position in particular, corrects this misimpression. Egalitarian arguments aim to show that we should have a social minimum in principle, but they do not settle the issue of whether any particular program is so abused, fiscally risky, or inefficacious that it ought to be opposed. Typical egalitarian arguments therefore leave most conservative objections untouched, and it takes further work to figure out whether those objections succeed.

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Future Research I’ve laid out some of the ways in which understanding the true nature of the progressive-​conservative debate leads to further philosophical insights. It can also help guide us toward important areas for philosophical research. First, we make progress in our research and writings about philosophy merely by ceasing to misrepresent parts of the debate over the social minimum, especially the conservative point of view. As we’ve seen, that point of view is not well-​represented in contemporary philosophical discussions, which tacitly suggest—​incorrectly—​t hat the conservative view is a right-​libertarian position opposed to all social minimum programs. It is not. Instead it supports some programs but finds others problematic, and it is best understood as being motivated by a combination of moral principles, empirical assumptions, and further ideas about how the reasons against social minimum programs should weigh against the reasons in favor. To my knowledge, very few philosophers have ever attempted to discuss a view with these motivations or implications, but we could. Second, once we understand both the progressive and conservative points of view, including the points each side most needs to establish, philosophers can begin exploring the merits of each side’s arguments. This book has been an attempt to explore those arguments as they apply to health care, defending the progressive point of view, but also highlighting the strengths of certain conservative objections, especially when applied to a very imperfect health care system like the ACA. Similar work can be done concerning other parts of the social minimum, and those further debates would surely raise issues that were not discussed here. For instance, I largely bypassed debates about abuse of social minimum programs, since those don’t appear to be highly salient to health care disagreements. But they are more important

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elsewhere, and although philosophers have written on such debates, they could choose to focus more attention on the subject, including the specific issue of whether abuse of social minimum programs, if it occurs, would be a sufficient reason to override the pro tanto obligation to provide a social minimum. Exploring these debates could open up interesting lines of thought that are presently overlooked. For instance, once we break out of the grip of thinking that arguments favoring a social minimum, such as Rawls’s or Dworkin’s, are necessarily progressive, then we can ask the intriguing question of whether conservatives might embrace those arguments or modified versions of them.34 For instance, earlier we looked at Waldron’s proposal for a modified Rawlsianism that does not require us to maximize the index position of the least advantaged but rather to offer a guaranteed minimum. Conservatives could embrace that form of Rawlsian argument for an in-​principle social minimum without thereby relinquishing their skeptical attitude toward particular social minimum policies, a skepticism driven by the further commitments outlined above. Third, understanding the progressive-​conservative debate opens up research projects that relate to all other countries with social minimum programs. In this book I’ve largely focused on the ongoing health care debate in the U.S., asking whether certain concerns about fiscal risk, efficacy, and personal cost justify leaving some people without reasonable access to health insurance. Other countries have similar debates about whether to extend their social minimum policies more widely, and even in countries where it is already agreed that there should be a social minimum for all, there are often debates about whether a particular program is superior to alternatives. In those debates

34. The possibility of a conservative Rawlsian was first called to my attention by Laura Sucheski.

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concerns are often raised about efficacy, abuse, personal cost, and fiscal risk. The progressive and conservative viewpoints developed here help frame those debates philosophically and can point us toward the specific questions we must take up if we want to contribute to those debates. Fourth, understanding the progressive-​conservative framework raises the question of whether philosophers can or should undertake certain interdisciplinary projects that, at the moment, they largely avoid. Earlier we saw that certain parts of the social minimum debate can probably be resolved only by appeal to empirical data, perhaps in combination with further philosophical argumentation. Political philosophers must therefore ask themselves whether they would prefer to seek out the complex factual information or, alternatively, eschew it and simply leave some actual political debates unaddressed, including important debates about the social minimum. My view is that this is a personal preference, and philosophers might opt for either course. One problem with writing about complex factual issues is that it is simply far from the core definition of what philosophers do and thus, in one sense, “unphilosophical.” Another problem is that when nonexperts try to draw on complicated work from other disciplines, they often misunderstand the information. However, there are also important reasons for philosophers to make use of more complex empirical information and to attempt to integrate it into their philosophical writings. The most important is that, unless we do, we will not be able to fully engage in the sort of applied political philosophy that many of us aspire to do. Political philosophers such as myself do not just aim to show that America should have universal access to health insurance if we can solve certain (as yet uninvestigated) problems about fiscal risk, abuse, efficacy, and personal cost. Instead we aim to show that we should have universal health insurance period. We can do that only by combining complex empirical research with our philosophical analysis.

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Fifth, once we begin to engage in interdisciplinary inquiry, we might find that philosophers have something to contribute even to the empirical discussions. Jonathan Wolff pointed out that philosophers can make important contributions to policy debates if they simply do what philosophers do. Make distinctions. Work out what follows from what. Ask awkward questions.  .  .  . As philosophers our life’s work is to develop skills of analysis and argument, informed by a study of the history of the subject and the best contemporary work. We know about patterns of argument, with standard objections, and thoughtful replies. We are used to challenging and being challenged. We know how to depersonalize arguments and consider them on their merits rather than on the authority of the person who uttered them. There is work for us to do, but not necessarily the work we thought. Public policy needs philosophers more than it needs philosophy.35

Wolff ’s point should not be underestimated. Even without breaking new theoretical ground, philosophers can do “good philosophy” just by applying the fundamental tools of our discipline with great care and precision. Finally, notice that when we rely on the progressive-​ conservative framework described here, we have the hope of producing arguments that appeal to shared principles rather than principles that are somehow specifically “conservative” or “progressive.” After all, our investigation has shown that the two camps agree on the moral ideas codified in the principles of DMT. The question is where those principles should lead us, and in particular whether they should lead us to support

35. Wolff, Ethics and Public Policy, p. 202.

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particular social minimum policies. If we can argue that they should, then that argument is not a conservative or progressive argument, it is an argument from shared values—​one that in principle all sides can accept. My hope is that this book has exemplified that kind of argumentation. Pundits and political commentators like to divide Americans into two camps: Republicans versus Democrats, red states versus blue states, conservatives versus progressives. But I side with President Eisenhower. “It is only commonsense,” he said, “that the great bulk of Americans, whether Republican or Democrat, face many common problems and agree on a number of basic objectives.” Exactly right. Universal health insurance need not divide us. Instead it can express our shared values.

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gezondheidszorgbalans.nl/ ​ o bject_ ​ b inary/​ o 6118_​ D utch%20 Healthcare%20Performance%20Report%202008.pdf. White, Stuart. The Civic Minimum: On the Rights and Obligations of Economic Citizenship. Oxford: Oxford University Press, 2003. Wilper, Andrew, et al. “Health Insurance and Mortality in US Adults.” American Journal of Public Health 99, no. 12 (2009): 1–​7. Wolfe, Alan. One Nation, After All: What Americans Really Think about God, Country, Family, Racism, Welfare, Immigration, Homosexuality, Work, The Right, The Left and Each Other. New York: Penguin, 1998. Wolff, Jonathan. Ethics and Public Policy:  A Philosophical Inquiry. Oxford: Routledge, 2011. Woolhandler, Steffie, Terry Campbell, and David Himmelstein. “Costs of Health Care Administration in the United States and Canada.” New England Journal of Medicine 349 (2003): 768–​775. Woolhandler, Stephanie, et al. “Proposal of the Physicians’ Working Group for Single-​Payer National Health Insurance.” Journal of the American Medical Association 290, no. 6 (2003): 798–​805. World Health Organization. “Disease and Injury Country Estimates.” 2012. http://​www.who.int/​healthinfo/​global_​burden_​disease/​estimates_​country/​en/​index.html. World Health Organization. The Global Burden of Disease:  2004 Update. Geneva: WHO Press, 2008. http://​www.who.int/​ healthinfo/​global_​burden_​disease/​2004_​report_​update/​en/​index. html. Young, Iris Marion. “Mothers, Citizenship, and Independence:  A Critique of Pure Family Values.” Ethics 105, no. 3 (1995): 535–​556.

INDEX

Tables are indicated by “t” following page numbers. abortion, philosophical methodology and debate over,  103–​4 abuse of social minimum programs conservative views on, 254, 255 DMT principle about, 267 as inefficiency, 282 need for philosophical attention to,  292–​93 progressive views on, 275–​78 public opinion on, 64–​66 social contributions and, 260–​61 by the undeserving, 282n31 act-​utilitarian theories,  194–​96 affordability of health insurance, 9n7, 14–​15, 18–​19, 25–​26, 63 Affordable Care Act (ACA, 2010), 17–​21,  240 arguments supporting, 233–​40 debates over, 77 fiscal effects of, 218–​27, 234–​38 health insurance choice under, 132

impact of, 1, 121 individual mandate under, 24–​25,  136–​37 loss of insurance under, 138,  146–​47 public opinion on, 1–​2, 70–​72n46 wait times and, 198–​99 aggregate health and efficacy, 166–​81, 228, 233–​34, 240–​41, 280 health outcomes, data on,  167–​68 introduction to, 166–​67 particular medical issues, 176–​78 self-​reports,  178–​81 standard measures, 168–​74 summary of, 181 aggregate welfare, maximization of, 284 AHCA (American Health Care Act, proposed), 137 Aid for Families with Dependent Children (AFDC), 64–​65n23

3 2 4   |    I ndex alternative health care systems, 27–​46. See also regulated-​ market systems; single payer systems budgetary issues, 41–​46 regulated-​market systems, American,  37–​40 regulated-​market systems, Netherlands and Switzerland,  30–​33 single-​payer, American, 33–​37 single-​payer, Canadian, 27–​30 American Health Care Act (AHCA, proposed), 137 Anderson, Elizabeth, 68–​69 ANH (artificial nutrition and hydration),  190–​92 Anscombe, G. E. M., 87 artificial nutrition and hydration (ANH),  190–​92 associative obligations, 76–​77, 92–​102, 110–​11 Barrett, Edith, 64–​65n23 baselines, for evaluating costs of universal health insurance, 138–​43 basic goods, 87 basic institutions, 84–​85, 140–​41 Beauchamp, Tom L., 190–​92 benefits. See costs and benefits; universal health insurance, benefits of biases, influence on public policy,  79–​80 Bittle, Scott, 212–​13 Blendon, Robert, 55–​56 Buchanan, Allan, 4 Bush, George W., 184–​85

Canada. See also single-​payer systems access to health care services in, 134, 135 comparison with United States,  177–​78 self-​reported health care systems assessments in, 179–​80 single-​payer system in, 27–​30 wait times for health care in, 199–​200,  207–​8 CBO. See Congressional Budget Office CDHC (consumer-​driven health care), 46–​52. See also regulated-​ market systems Census Bureau, data on uninsurance, 13, 14 Center for Studying Health System Change (HSC), 11–​12 Centers for Disease Control (CDC), data on uninsurance, 13, 14 CHAMPUS (health insurance program for veterans), 11 children child care for poor working mothers,  66–​67 uninsured, 12–​16, 119, 163–​64 Childress, James, 190–​92 choice in universal health insurance systems, 124–​25, 132–​34, 149 civic obligations, 92 Clinton, Bill, 69–​70, 74–​75 COBRA (Consolidated Omnibus Budget Reconciliation Act),  123–​24 coinsurance in Swiss and Dutch systems,  31–​32 Commonwealth Fund health care systems self-​reported assessments, poll on, 180, 180t International Health Surveys, 201–​3,  204

I ndex    |   3 2 5

wait times, survey on, 199–​200,  199t community rating of insurance, 22–​24,  25 conationals, duties and relationships with, 83, 92, 97, 98–​102, 107 Congress, health care plan for, 38 Congressional Budget Office (CBO) on ACA, 74–​75, 218–​19, 234–​36 on CPS study, 13 on government debt, impact of, 213 individual mandate repeal and, 24 on single-​payer system costs, 45 uninsurance data, report on, 13 conservative view of social minimum, 250–​67. See also progressive view of social minimum completeness of representation of,  256–​58 conservative Rawlsianism, 293 on distributive justice, 253–​56 empirical assumptions of, 279–​80 factual claims of, 279–​80 introduction to, 250–​52 misrepresentations of, 288–​91,  292 plausibility of philosophical aspects of, 258–​67 right-​libertarianism, confusion with, 289–​90, 292 Consolidated Omnibus Budget Reconciliation Act (COBRA),  123–​24 consumer-​driven health care (CDHC), 46–​52. See also regulated-​market systems Cook, Fay Lomax, 64–​65n1 copayments, 33–​34, 38, 45

costs and benefits of health systems, 117–​50. See also personal cost; universal health insurance, benefits of; universal health insurance, costs of; weighing costs and benefits comparison of costs by country, 41–​44, 41t, 42t costs of social minimum programs, fears of, 70 Cottingham, John, 96n1, 97, 98, 100 Council of Economic Advisors, on medical innovation, 184–​85 counterproductive social minimum programs, 73, 253, 260, 268 culture war, evidence of, 56–​57n2 Current Population Survey (CPS), 13,  19–​20 DALYs (disability-​adjusted life years), 170–​72, 173t Daniels, Norman, 244–​45, 266–​67 data. See also polls under individual polling organizations; public opinion author’s treatment of, 5 importance of, 4–​5 on social minimum, 56–​80 (see also social minimum and social minimum programs) timeliness of, 5 underestimation in polling data,  61–​63 on universal health insurance and health outcomes, 167–​68 deaths associated with uninsurance,  20–​21 death spiral of insurance costs, 23–​25 debt, fiscal risk and government debt,  211–​13

3 2 6   |    I ndex Decent Minimum Theory (DMT),  254–​56 conservative-​progressive agreements on, 295–​96 defensibility of, 258–​59 personal cost and, 269–​75, 285 progressive challenge to principles of,  268–​69 on proper level of social minimum,  286–​87 on the undeserving, 286 dedicated funding, fiscal risk in national health insurance systems with, 228–​31 deductibles in Swiss and Dutch systems, 31–​32. See also high-​ deductible insurance plans deficits, description of, 211 Democrats on government services, 58t on single-​payer systems, 166 on welfare programs and recipients, 65–​66, 73 Department of Health and Human Services (DHHS, U.S.), 35 deserving individuals, 260–​61. See also the undeserving difference principle, 196, 271–​72, 274,  276–​77 disability-​adjusted life years (DALYs), 170–​72, 173t distributive justice, 248–​49, 251, 253–​56, 266, 288–​89. See also conservative view of social minimum; Decent Minimum Theory; progressive view of social minimum; social minimum DMT. See Decent Minimum Theory dualism of practical reason, 155 Dworkin, Ronald

egalitarian philosophies of, 4, 196,  238–​39 on ideally just society, 54 incongruence with progressivism, 293 personal cost principle, views on,  105–​6 in philosophy textbooks, 288–​89 progressives’ reliance on, 291 on social minimum, 248, 290 EBL (equal basic liberty) principle,  270–​71 economic climate, impact on attitude to social minimum programs, 66 efficacy, 166–​209 concerns over, in health care debate,  70–​72 conclusions on, 209 conservative views on, 255,  281–​83 increasing aggregate health and, 166–​81, 169t, 171t, 173t, 175t, 179t, 180t innovation, effect on, 181–​98, 189t, 197t introduction to, 3, 166 as moral concern over ACA,  233–​34 philosophical question of, 55 social minimum and, 69–​73, 253, 260, 268 wait times and, 198–​209, 199t (see also wait times and waiting lists) efficiency. See efficacy. egalitarianism, on social minimum, 291 egoism, 154–​55,  157–​58 Eisenhower, Dwight D., vi, 296

I ndex    |   3 2 7

Emanuel, Ezekiel, and Victor Fuchs, regulated-​market system of, 30,  37–​40 congressional-​quality health care, proposal for, 44–​45, 123 mandate in, 137 national health board under  38–​39 spending proposal for, 44 vouchers in, 51, 129–​30, 228–​29 Emergency Medical Treatment and Labor Act (EMTALA, 1986), 26–​27, 67–​68,  265–​66 emergency rooms, primary care for uninsured in, 117–​18 employment-​based health insurance ACA and, 17–​18 costs of, 186 description of, 11–​12 impact of move to universal health insurance on, 130–​31 job lock and, 133–​34 loss of, 123–​24, 125 pre-​ACA,  16 problems of, 47–​48 in regulated-​market system, 40 subsidies for, 142–​43 EMTALA (Emergency Medical Treatment and Labor Act, 1986), 26–​27, 67–​68, 265–​66 England, single-​payer systemin, 28 equal basic liberty (EBL) principle,  270–​71 Equality and Partiality (Nagel),  82–​84 ethical issues. See also morality explanations for decisions on,  112–​16 in health care debates, 54–​56

experts, agreement and disagreement among, 221–​22 exploitation, 261–​62 fair equality of opportunity (FEO) principle,  270–​71 fair play principle, 261–​64 familial obligations, 88–​89, 110–​11, 138–​39, 143–​44, 183. See also personal relationships federal poverty line (FPL), 9, 18 fee-​for-​service payments,  228n23 FEO (fair equality of opportunity) principle,  270–​71 fiscal risk, 210–​32 of ACA and similar systems, 218–​ 27, 234–​35,  237–​38 conclusions on, 231–​32 conservative views on, 280 evaluation of, 241 fears of, 1 of government debt, 211–​13 introduction to, 3, 210 in national systems with dedicated funding, 228–​31 philosophical question of, 55 of social minimum, 74–​75, 213–​ 18, 215t, 253, 260, 268, 282 Food Stamps (now SNAP), 57–​59, 64,  255–​56 FPL (federal poverty line), 9, 18 Freeman, Samuel, 273–​74, 277 friendships, nature of, 92–​93, 94–​95 Fuchs, Victor. See Emanuel, Ezekiel, and Victor Fuchs, regulated-​ market system of Gallup poll on ACA, 70–​72 GBD (Global Burden of Disease) project (WHO), 170–​74, 173t General Social Survey, 64

3 2 8   |    I ndex Gilens, Martin, 55–​56, 60–​61, 65–​66n1,  79–​80 Global Burden of Disease (GBD) project (WHO), 170–​74, 173t Goodman, John, 207–​8 Government Accounting Office, on single-​payer system costs, 45 guaranteed issue of insurance, 22–​24 Haislmaier, Edmund, 46 Harris Poll on government services, 57, 58t, 62, 64 on health care decision making, 70–​72n1 on health care system self-​ reported assessments, 178, 179t Hart, H. L. A., 261 health care debates efficacy and, 69–​73 ethical issues in, 54–​56 fiscal responsibility and, 74–​75 personal cost principle and, 75–​80 possible factors influencing,  78–​80 social minimum, background data on, 56–​80 (see also social minimum and social minimum programs) the undeserving and, 64–​69 wait times and debate over alternative methods of achieving universal access,  207–​8 health care systems, 6–​53. See also regulated-​market systems; single-​payer systems ACA and, 17–​21 alternative systems, 27–​46 assessments,  176–​81

consumer-​driven health care,  46–​52 insurance markets, logic of, 21–​27 introduction to, 6–​7 particular medical issues, assessments for, 176–​78 pre-​ACA, 7–​16,  7t self-​reports, 178–​81, 179t, 180t standard measures, 168–​74, 169t, 171t, 173t, 175t summary on, 53 health expenditures. See also costs and benefits; health care systems national health spending levels 186 per capita spending on, 42t statistics on, 41, 41t, 42t health insurance. See also individual mandates; uninsurance and the uninsured; universal health insurance affordability of, 9n1, 14–​15, 18–​ 19, 25–​26, 63 impact of lack of, 1 loss of, health insurance mandates and, 138 sources of (2006), 7t health maintenance organizations (HMOs) in Switzerland, 32 health outcomes data on, 167–​68 standard measures of, 168–​74 health reform, 17. See also specific types of proposals health savings accounts (HSAs), 50 Health Security Act (proposed, 1993),  69–​70 Herzlinger, Regina, 46, 47–​49, 52 high-​deductible insurance plans (HDP), 46–​47n1, 50, 51 homelessness, 89–​90, 89–​90n15

I ndex    |   3 2 9

Howard, Christopher, 56–​57n2 HSC (Center for Studying Health System Change), 11–​12 ideally just societies, social minimum and, 4, 54, 56, 61–​62, 243, 246–​47, 248 illegal residents, uninsured, 33 immigrants, uninsured, 15 individual mandates in ACA, 17, 77 as cost of universal health system,  136–​37 free-​riding and,  26–​27 impact on health insurance costs, 23–25 rationale for, 78–​79 in regulated-​market systems, 30–​31,  39–​40 individuals. See also uninsurance and the uninsured familial obligations, 88–​89, 110–​ 11, 138–​39, 143–​44, 183 healthy individuals, health insurance premiums for, 25n43 individuality, personal cost and,  109–​10 individual liberty, 242–​43, 256–​57 personal relationships, 92–​95, 97,  101–​2 personal standpoints, 82–​83 specific personal projects, 146 viewpoint on level of health care social minimum, question of formulation of, 245–​46 ineffectiveness. See also efficacy ACA, concern about, 1–​2 of social minimum programs,  69–​73 infant mortality, 168–​70, 169t innovation. See medical innovation

Institute of Medicine, study on the uninsured, 20–​21, 118n1, 120 insurance markets, 18–​20, 21–​27 insurance companies in regulated-​market systems,  30–​31 intuitive balancing model, 190–​92 Italy, self-​reported health care systems assessments in, 179–​80 Jacobs, Lawrence, 73 job lock, 133–​34, 149–​50 job retraining programs, 66, 266–​67 Johnson, Jean, 212–​13 justice standards of, 82–​83 theories of, 82–​83, 84–​85, 101–​2n37,  104–​6 Justice as Fairness: A Restatement (Rawls), 270–​71n18,  272–​73 Justice as Fairness (Rawls’s principles), 84–​85, 105–​6, 237, 270–​75,  276 justified balancing model, 190–​92 Kaiser Family Foundation surveys on ACA, 70–​72n46, 72 on the uninsured, 14–​15, 118–​20 Kulinski, James, 74 Lazar, Seth, 92–​93, 97n31 liberalism innovation-​maximization policies and,  189–​90 liberal democratic theory on social minimum, 244 liberal political societies, features of, 84 pro tanto public welfare obligation, supposition of, 190 theories of, 196

3 3 0   |    I ndex life expectancy, measurements of, 170, 171t, 172–​74, 175t Light, Donald, 68–​69, 120–​21, 258–​59n1,  266–​67 Lives at Risk (Goodman), 207–​8 long-​term care, 28–​29, 32 Los Angeles Times poll on public attitudes on welfare, 64–​65 Luck, Health, and Justice (Segall), 264 luck-​egalitarianism, 264, 266 malpractice, 39, 41–​43 mandates. See individual mandates markets, efficiency of, 46–​47n87, 48–​52. See also insurance markets marriage, impact on uninsurance, 16 Mason, Andrew, 97n31 Medicaid under ACA, 18, 19–​20 elimination of, under regulated-​ market system, 40 pre-​ACA,  9–​10 problems with, 29 public support for, 66 medical bankruptcy, 21, 122 medical innovation, 181–​98 concerns over, 240–​41 consumer-​driven,  46 current system of, 186–​88 innovation and access, comparison of, 188–​97, 189t, 197t introduction to, 181–​83 plausibility of reduction in,  279–​80 reduction of, as concern over ACA,  233–​34 summary of, 197–​98 in universal health insurance system,  183–​85

medical research, funding sources for, 184 Medicare as component of social minimum policies, 57n1 elimination of, under regulated-​ market system, 40 Medicare-​For-​All and,  33–​34 pre-​ACA, 8–​9,  10–​11 single-​payer systems, similarity to, 28 Medicare Advantage Plans, 8–​9, 46–​47n87 “Medicare for All” (MFA) proposal (H.R. 676, United States National Health Insurance Act or Expanded and Improved Medicare for All Act), 33–​35,  123 Menzel, Paul, 4, 68–​69, 120–​21, 246, 258–​59n8, 263–​64n12,  266–​67 Miller, David, 94, 98, 100 mixed conception principle, 84–​86,  270–​74 morality associative obligations and, 93–​96 costs of universal health insurance, moral significance of, 147–​50,  205–​6 dualism of practical reason and,  155–​56 on elimination of social minimum programs, utility maximization and,  215–​16 fair play principle, 261–​64 moral assessments, 160–​61 moral considerations, conservatives’ vs. progressives’ weighing of, 281–85 moral insight, 127–​28 morally inappropriate baselines,  141–​42

I ndex    |   3 3 1

partiality relationships and, 93–​94,  95–​96 pro tanto obligation for social minimum and, 256 protected zone of, 153–​54 Murphy, Liam, 139–​41 mutual dependence, in contracts, 262 The Myth of Ownership (Murphy and Nagel), 139–​40 Nagel, Thomas, 4, 82–​84, 105–​6, 107,  139–​41 National Board of Universal Quality and Access (under MFA), 35 National Election Study (2000) on ideology about government,  59–​60 National Federation of Independent Business v. Sebelius (2012), 18 national medical care agency, under Relman’s proposed single-​payer system,  36–​37 national relationships. See conationals NBC/​Wall Street Journal polls on health care system, 73 on welfare, 64–​65 need personal relationships and,  88–​89 social policies and, 89–​90 Waldron on, 87 Netherlands comparison with United States,  177–​78 health insurance benefits in, 123 regulated-​market systems in, 30–​33,  39–​40 self-​reported health care systems assessments in, 179–​80 uninsurance rates in, 204–​5n47

wait times for health care in, 199–​200 Nozick, Robert, 54, 236–​38, 248, 262–​63,  288–​89 Nussbaum, Martha, 145 On What Matters (Parfit), 155 Organization for Economic Cooperation and Development (OECD) “Health at a Glance” reports, 176 health expenditures, statistics on, 41, 41t, 42t health systems assessments, 168, 169t, 171t, 173t, 175t others other-​oriented political philosophy, 103–​6,  238–​40 underestimations of suffering of, 125–​29 Page, Benjamin, 67 parent-​child relationships, nature of, 92–​93, 95–​96,  96n1 Parfit, Derek, 155–​56 partiality, 93–​94, 95–​96, 97, 99 patient care, weighing costs and benefits of, 112–​13 Patient Protection and Affordable Care Act. See Affordable Care Act peer disagreement debate, 224n20,  235–​36 personal cost, 81–​165. See also personal cost principle as concern over ACA, 238–​40 conclusions on, 165 conservative views on, 253, 256 DMT and, 269–​75, 285 explanations and, 112–​16, 150–​65 fear of, 1 introduction to, 3, 81–​82

3 3 2   |    I ndex personal cost (cont.) personal cost principle, 82–​102 in philosophical debates, 102–​16 philosophical question of, 55 progressive acceptance of conservative views on, 269–​75 of social minimum, 75–​77, 259 summary of, 241–​42 universal health insurance system, benefits of, 116–​29 (see also universal health insurance, benefits of) universal health insurance system, costs of, 129–​50 (see also universal health insurance, costs of) personal cost principle, 82–​116 associative obligations, teleological welfarist account of,  92–​102 description of, 153 egoist interpretation of, 154–​55 introduction to, 82 just baselines and, 143–​44 Nagel and, 82–​84 other-​oriented political philosophy and, 103–​6 in philosophical debates, 102–​16 precise version of, 108 social minimum, Waldron and Rawls and, 84–​92 validity of, 238–​39 personal liberty, as factor in health insurance debates, 78–​79 personal relationships, 92–​95, 97, 101–​2. See also familial obligations Pew Poll, on aid to poor, 64 philosophy future research needs in, 292–​95 other-​oriented political philosophy,  103–​6

philosophical debates, 54–​56, 102–​16,  236–​38 philosophical reflection, results of, 251 philosophical teaching, progressive and conservative thought in, 288–​89 political philosophy, role of, 294 Physicians for a National Health Program (PNHP), 35–​36, 44 politics. See also Democrats; Republicans party activists, extreme views of, 250–​51n2 political disaffection, 86, 88–​90,  107–​8 political theories, problems with,  105–​6 polling data. See data; public opinion. the poor. See also poverty aid to, Republicans’ attitudes on, 64 poor working mothers, child care for,  66–​67 public opinion of health care access by, 73 portability, of health insurance, 123 poverty. See also the poor blame of government for, 70–​72 conservatives’ attitudes toward, 258 pre-​ACA health insurance system benefits distribution under,  163–​64 predictions about, 196–​97 uninsured under, 12–​16, 163–​64 predictions of ACA impact, 222–​24,  235 preexisting conditions, impact on health insurance costs, 21–​22 private insurance, 29, 37–​38

I ndex    |   3 3 3

profit margins, possible effects of universal health insurance systems on, 184–​85 progressive view of social minimum, 268–​87. See also conservative view of social minimum DMT, agreement with, 255 DMT, challenge to principles of,  268–​69 on DMT and personal cost, 269–​75 empirical assumptions of, 279–​80 factual claims of, 279–​80 introduction to, 268 summary of, 286–​87 on undeserving citizens, exclusion of,  275–​79 weighing moral considerations and,  281–​86 pro tanto principles, conflicts among,  190–​96 public opinion on ACA, 70–​72n46, 74–​75 on foreign aid, 72–​73n53 on health care access by the poor, 73 on health systems, 178–​81, 179t, 180t on SNAP benefits, 57–​59 on social minimum and safety net programs, 54, 57–​61, 58t, 60t on welfare programs, 72–​73, 265–​66 quasi-​universal health insurance, 7,  116–​17 Quinnipiac Poll on health insurance affordability, 63 race impact on welfare debate, 65–​66n1 uninsured among nonwhites, 16,  163–​64

RAND study on health insurance enrollment, 138 Rawls, John difference principle, 238–​39 egalitarian viewpoint of, 4 fair play principle, 261, 262–​63 on ideally just society, 54 incongruence with progressivism, 293 Justice as Fairness principles, 84–​85, 105–​6, 237, 270–​75 liberal theory of, 196 on overlapping consensus, 254–​55 personal cost principle and,  239–​40 in philosophy textbooks, 288–​89 progressives’ reliance on, 291 on relative deprivation, 90 on social contract, 262 on social minimum, 54, 248, 275–​78,  290 Waldron and, 84–​86, 293 on wide reflective equilibrium,  105–​6 Raz, Joseph, 94–​95 reciprocity, 261–​62,  272–​73 reflective equilibrium processes, 192–​96,  277–​78 regulated-​market systems benefits of, 123 case for, 240–​42 debt impact of, 229 health plan choice under, 133 individual mandates in, 78–​79 in Netherlands and Switzerland,  30–​33 uninsurance and, 116–​17 in United States (proposed), 37–​40,  44–​45 wait times and waiting lists under, 135,  240–​41

3 3 4   |    I ndex The Rejection of Consequentialism (Scheffler),  153–​54 relative deprivation, 88–​91, 89–​90n15 relatives, responsibility toward. See familial obligations Relman, Arnold, 36–​37, 229 Republicans on ACA and deficits, 74–​75, 210 on aid to the poor, 64 American Health Care Act and, 137 on crime-​fighting and prevention, 62 on Food Stamps, 64 on government services, 57–​59, 57–​59n5,  58t on health insurance affordability, 63 on regulated-​market systems, 166 on social minimum programs,  65–​66 on universal access, 52n1 on welfare programs and recipients, 65–​66, 73 Research Institute in Social Welfare poll on social minimum programs, 63 restricted utility principle, 270–​71 Richardson, Henry, 190–​92, 192–​93n34 right-​libertarianism, 101–​2n37, 287–​88,  289–​90 risk equalization, 31n51 Royce, Josiah, 127–​28 Sabin, James, 244–​45 safety net programs. See social minimum and social minimum programs salaries, impact of universal health insurance on, 130–​31

Scanlon, Thomas, 237 Scheffler, Samuel, 153–​54 SCHIP (State Children’s Health Insurance Program), 10 Segall, Shlomi, 264, 266 self-​esteem, 89–​90n15,  90–​91 self-​interest, 155–​56. See also personal cost self-​reports, as health system assessment measures, 178–​81, 179t, 180t Setting Limits Fairly (Daniels and Sabin),  244–​45 Shapiro, Robert, 67 Sidgwick, Henry, 155–​56 single-​payer systems in Canada, 27–​30 case for, 240–​42 costs for, 45 debt impact of, 229 deductible levels in, 51 loss of choice under, 132–​33 uninsurance and, 116–​17 United States, proposals for, 33–​37 wait times under, 240–​41 small businesses, 16, 163–​64 SNAP (Food Stamps), 57–​59, 64,  255–​56 social contract, 262 social minimum and social minimum programs (social safety net). See also conservative view of social minimum; distributive justice; progressive view of social minimum abuse of (see abuse of social minimum programs) asymmetrical interpretation of weighing and, 156 baselines for evaluating costs of,  138–​44

I ndex    |   3 3 5

belief in, 56–​57, 61–​62 conational relationships and,  99–​102 conservative rationales for, 258–​59n1 conservative viewpoint, 250–​67 current health insurance system, indefensibility of, 227 data on attitudes toward, limitations of, 77–​80 debates over, 248–​96 efficacy and, 69–​73 egoist personal cost objectors’ support for, 157–​58 fiscal responsibility and, data on,  74–​75 fiscal risk and arguments on, 213–​18,  215t in health care, presupposition of, 4 human welfare and, 101–​2n1 ideally just societies and, 4, 54, 56, 61–​62, 243, 246–​47, 248 introduction to, 248–​49 just baselines for, 138–​39, 143–​44 justifiability of, 160–​62 level of, 86n9, 91n17 opposition to, ethical vs. practical,  61–​63 personal cost and, 75–​80, 147n86 presumption of, 54 progressive alternative viewpoint,  268–​87 progressive and conservative viewpoints, significance of developing,  287–​96 publicity for setting minimum levels, 244 regulations for setting minimum levels, 245 setting level of, 244–​46 support for, data on, 56–​63, 58t, 60t the undeserving and, 64–​69

Waldron and Rawls and, 84–​92 social safety net. See social minimum. Social Security, as component of social minimum policies, 57n1 society benefits of, 261 ideally just, social minimum and, 54, 56, 61–​62, 243, 246–​47 legitimacy of, 88, 91 modern democratic, foundational principles of, 86 mutual duties in, 262 participation in, 98 productive contributions to, conservative views of, 251–​52 social contract, 262 social contributions, 260–​61 welfare of members of, promotion of, 284 SSI (Supplemental Security Income) program, 10 standard measures of health, 168–​ 74, 169t, 171t, 173t, 175t Starr, Paul, 137 states insurance mandates and, 23–​24 Medicaid programs, 9, 10–​11, 18 status quo bias, 79 strains of commitment concept, 85–​ 86, 91–​92,  273–​74 strict reciprocity, 272–​73 subsidies under ACA, 18–​19 for employment-​based health insurance, 11–​12, 40, 52, 142–​43 for health insurance, 11n1, 11–​12 Herzlinger on, 52 for Medicare recipients, 8 overuse caused by, 49 in regulated-​market systems, 31–​32, 33,  39–​40 uninsurance problem and, 25–​26

3 3 6   |    I ndex supplemental insurance, 29–​30, 32, 132 Supplemental Security Income (SSI) program, 10 Switzerland comparison with United States,  177–​78 health insurance market behavior in, 46–​47n87 health plan choices in, 133 regulated-​market system in, 30–​33,  39–​40 uninsurance rates in, 204–​5n47 wait times for health care in, 199–​200 Tanner, Michael, 183–​84 taxes dedicated, for health care, 229–​31,  241 fears of increases in, 1 supporting Emanuel and Fuchs voucher system, 39, 129–​30 supporting proposed Medicare-​For-​All,  34 supporting Relman’s single-​payer system, 36 tax breaks for employer-​based insurance, 40 tax credits vs. subsidies, 142–​43n82 tax subsidies for health insurance, 11n10,  11–​12 technology assessment boards, 187 teleological welfarist account (TWA), of associative obligations, 92–​102, 106, 107–​8 A Theory of Justice (Rawls), 84–​86,  270–​73 Thomson, Judith, 104, 237 trust in government, lack of, 70–​72n46

underinsurance, 21, 121–​22 the undeserving abuse of social minimum by, 282n31 under DMT, 286 exclusion from social minimum, rationales, 261, 263–​66 inclusion in social minimum, rationales,  266–​67 progressive view on exclusion of,  275–​79 social minimum and, 64–​69,  243–​44 unemployment benefits, 66–​67 uninsurance and the uninsured under ACA, 19 factors affecting, 163–​64 health care for uninsured, 26,  117–​20 in market-​regulated systems, 33 pre-​ACA,  12–​16 reducing number of, 117–​21 wait times for uninsured, problems with data on, 202–​3 United States comparison to mixed conception society not valid for, 273–​74 Congress, health care plan for, 38 deficits, ACA and public opinion on,  74–​75 distrust of government in, 70–​72n46 government debt, fiscal risk and,  211–​13 government involvement in health care, fears of, 70–​73 government services, Harris Poll on, 57–​59, 58t health care system, pre-​ACA, 7–​16,  7t health insurance system, 1 health system costs, 41–​46

I ndex    |   3 3 7

national health spending levels 186 single-​payer systems, proposals for,  33–​37 voucher system, government’s role in, 39 universal health insurance, 6–​53. See also efficacy; fiscal risk; personal cost ACA, arguments for, 233–​40 case for, 233–​47 data on social minimum, 56–​80 description of, 1 ethical issues in health care debates,  54–​56 fiscal risks, 210–​32 objections to, 1–​2 personal cost, 81–​165 public support for, 67–​68n36 single-​payer and regulated-​ market systems, 240–​42 (see also regulated-​market systems; single-​payer systems) skepticism about, 1 summary of arguments supporting,  242–​47 universal health insurance, benefits of,  116–​29 examples of, 149–​50 for the insured, 123–​25 introduction to, 116–​17 significance of, 125–​29 underinsurance, reducing, 121–​22 uninsurance, reducing, 117–​21 universal health insurance, costs of,  129–​50 baselines for, 138–​43 choice,  132–​34 costs of moving to universal health insurance, 129–​32 health insurance mandates, 136–​37 introduction to, 129

loss of insurance, 138 significance of, 144–​50 waiting lists, 134–​35 University of Maryland survey on public opinion on SNAP benefits,  57–​59 utilitarian theories, 194–​96, 214–​16,  215t VAT, supporting Emanuel and Fuchs voucher system, 39,  129–​30 veterans health insurance program for, 11 promotion of welfare of, 284n1 Veterans Administration system, 11 voucher system. See Emanuel, Ezekiel, and Victor Fuchs, regulated-​market system of wait times and waiting lists, 198–​209 concerns over, 233–​34, 240–​41 as cost of universal health system,  134–​35 counting wait times, 200–​5 debate over alternative methods of achieving universal access,  207–​8 introduction to, 198–​200, 199t standard wait times, normative significance of, 205–​6 summary of, 208–​9 Waldron, Jeremy, 4, 84–​92, 106, 107–​8, 274–​75,  293 waste in government programs, fears of, 72–​73, 72–​73n1, 72–​73n53 wealth, impact on support for social minimum programs, 66

3 3 8   |    I ndex weighing costs and benefits. 150–​65. See also costs and benefits of health systems; personal cost; universal health insurance, benefits of; universal health insurance, costs of asymmetry interpretation of,  156–​57 comparison of benefits and costs,  160–​65 example of, 112–​16 multiplier interpretation of, 153–​58 outweighing, limits on, 158–​60 overview, 150–​53,  241–​42 personal cost and, 106–​12, 143–​44,  152–​53 philosophical debates, 106–​8, 109–​12,  143–​44 tipping point for, 161–​63 welfare and welfare programs. see also specific welfare programs administrative overhead of, 72–​73 attitudes toward, 64–​65, 65–​ 66n28, 66–​67, 72–​73,  265–​66 welfare-​maximizing policies, 284

well-​being of conationals, 100 factors affecting, 145–​46 increased taxes and, 147–​49 insurance loss and, 147 measures of, 153 partiality relationships and, 92–​93,  99 personal cost objections and, 159 personal cost principle and,  91–​92 relative deprivation and, 88–​90 requirements for, 98 universal health insurance’s impact on, 125 utilitarianism on, 194–​96 White, Stuart, 260–​61, 264–​65 wide reflective equilibrium, 105–​6, 192–​93,  215–​16 Wolff, Jonathan, 295 World Health Organization, Global Burden of Disease project, 170–​74, 173t