Column - Access, affordability and health care reform

On Thursday, in a 5-4 decision, the Supreme Court of the United States upheld key provisions of health care reform legislation enacted in 2010, the Patient Protection and Affordable Care Act (PPACA). The Court decision presents an apt occasion to consider the rationale of the PPACA (or, as it is sometime derisively called, "Obamacare").

The primary aims of the PPACA are twofold: 1) to reign in the spiraling cost of health care and 2) to expand access to health care with the ultimate goal of achieving universal access (i.e., access that is not dependent on a person’s ability to buy health insurance or pay for medical services).

The U.S. far outpaces other developed countries in health care spending. For example, in 2009 per capita health care spending in the U.S. was almost $8,000 per person. The next two countries were Norway ($5,352) and Switzerland ($5,144), the only nations in which per capita health care spending exceeded $5,000. In 2008, health care spending in the U.S. was approximately 16 percent of the GDP. The next highest country was France at 11.2 percent. Only two years later in 2010, health care spending in the U.S. had increased to 17.9 percent of the GDP. Nevertheless, on measures of health, the U.S. ranks low. Thus, other countries get a much bigger bang for their health care bucks.

The situation with respect to access is no less striking. In 2010 49.9 million Americans (16.3 percent of the population) lacked health insurance. Millions more had insufficient insurance, and studies indicate that significant differences in utilization of health care services are correlated with differences in income. Thus, tens of millions of Americans cannot count on being able to get affordable health care services if and when they should need them.

The reasons for controlling health care spending are well known and do not need to be repeated. However, the same cannot be said of the reasons for promoting universal access. After all, it might be claimed, the U.S. is a capitalist country with a free market economy. Americans who cannot afford to purchase iPods, Ferraris, McMansions or Caribbean cruises are not thought to have a moral entitlement to them. So why should people who can’t afford health care or health insurance receive it?

There are several reasons for providing universal access to health care.

First, universal access can be supported by a social benefit or utilitarian rationale. It can be claimed that universal access promotes the general welfare by helping to keep people productive and prevent them from being a drain on social resources. The social benefits of providing universal access to health care are thus said to exceed the costs. Like utilitarian arguments generally, this defense of universal access relies on factual claims and assumptions that are subject to confirmation or disconfirmation by empirical evidence.

Second, universal access can be supported by a social solidarity rationale. A commitment to universal access can be viewed as a "social bond" that promotes solidarity. There are two variants of this rationale. One is based on the assumption that social solidarity is an intrinsic value. That is, it is assumed that a sense of community and cohesiveness is a characteristic of a "good society." The second is a variant of the utilitarian rationale. Universal access allegedly promotes a sense of solidarity, which in turn promotes the general welfare by: a) discouraging undesirable character traits and behavior, such as greed, selfishness, and criminal acts, and b) promoting desirable character traits and behavior, such as generosity, empathy and altruism.

Third, universal access can be based on the ethical principal of beneficence, which requires us to help others when important needs are at stake. Insofar as health care can prevent death and substantial disability, it appears to be connected to important needs. Hence, it can be maintained that we have a beneficence-based obligation to help others receive health care when they lack the financial means to do so themselves. Assuring universal access can be seen as a means to satisfy this obligation.

Fourth, it can be claimed that universal access is a requirement of justice. There are two versions of this justice-based argument.

The first maintains that need is the only relevant principle of distributive justice in relation to health care. Consider the following principles of distributive justice: a) to each according to merit or achievement, b) to each according to ability, c) to each according to effort, d) to each according to ability to pay, and e) to each according to need. It is arguable that merit or achievement, but not ability, effort, need or ability to pay, is relevant when distributing grades to students or when distributing Nobel prizes. Similarly, it is arguable that need, but not achievement, ability, effort or ability to pay, is relevant when distributing health care.

The second justice-based defense maintains that universal access is a requirement of the principle of fair equality of opportunity. Defenders of this line of argument cite education as an analogue to health care. Just as fair equality of opportunity requires universal access to education, so, too, it requires universal access to health care. Preventing and treating illness, it can be claimed, is no less essential to promoting a "level playing field" than providing education.

For all these reasons, then, it can be maintained that Americans should have universal access to health care. Several features of the PPACA are designed to accomplish this objective. These include expanding Medicaid, the joint federal-state program for poor and disabled Americans (the Supreme Court limited the ability of the federal government to require states to participate); establishing insurance exchanges to make health care more affordable;enabling children to be covered by parents’ insurance plans through the age of 26; eliminating life-time limits on insurance benefits; and prohibiting insurance companies from risk-rating premiums, denying coverage due to pre-existing conditions and cancelling policies for people who develop serious illnesses.

Among the most controversial features of the law is the so-called "individual mandate," which the Supreme Court upheld. Americans who are not insured by employers or government programs (e.g., Medicare, Medicaid and the Department of Veterans Affairs) who also fail to purchase health insurance will have to pay a fee that the Court majority characterized as a tax. (Subsidies will be offered to anyone who cannot afford to purchase insurance).

Although unpopular, this provision has been defended on the grounds that it is the lynchpin for many of the other, more popular provisions. For example, supporters claim that without the individual mandate, healthy otherwise uninsured people are likely to wait until they become ill to buy health insurance. If, as the PPACA currently provides, insurance companies could not risk-rate premiums or deny coverage to people with preexisting conditions, insurance companies can be expected to significantly raise everyone’s premiums. Thus, defenders of the individual mandate claim that without it, affordable universal access will be unattainable.

It remains to be seen whether the PPACA will succeed in significantly expanding access and controlling costs. If it doesn’t accomplish these objectives, there is no lack of alternative plans, including socialized medicine on the model of the National Health Service in the UK, single payer or "Medicare for all" on the Canadian model, private insurance together with a public option, and a free market system with health care vouchers.

Mark Wicclair is a professor of philosophy and an adjunct professor of community medicine at WVU. He is also an adjunct professor of medicine at the University of Pittsburgh.