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The Clinton plan: with malice toward none and health security for all.

President Clinton's health reform proposal brings together the means generally associated with conservatives--market competition--to achieve the ends advocated by liberals--health security for all Americans. Exactly how the White House, Congress, and the American public reach consensus is open to negotiation and compromise. But certain fundamental principles such as universal coverage and cost control are not.

Cost Control↗
PubMed1997

Managed care: how economic incentive reforms went wrong.

In its response to pressures to rationalize health care resource allocation, the American health care system has embraced managed care without concurrent comprehensive health care reform, either in the form of the centralized tax-based systems found in Europe and Canada or that of the Clinton reform plan. What survives is managed care without managed competition, employer mandates, or universal access. Two problems inherent in the incentive structure of managed care plans developed in the absence of comprehensive health care reform work against the public interest. First, sacrifices in terms of medical innovation and quality of care may not be offset by greater equity in the distribution of health care. Second, such managed care plans fail to address the need for long-term accountability.

Biomedical Technology↗
PubMed1994

Health care reform and abortion: a Catholic moral perspective.

The Catholic Church in the United States provides extensive health care service through its more than 600 health facilities. The Church, on the basis of its moral teaching, sees health care as a basic human right and supports universal coverage. At the same time, the Church considers abortion morally wrong and opposes coverage of abortion as a health service in a national health plan. Mandated coverage of abortion would violate the moral commitments of Catholic hospitals and the consciences of Catholics who would be required to financially support provision of abortion services.

Abortion, Legal↗
PubMed1994

Personal freedom and responsibility: the ethical foundations of a market-based health care reform.

The current health care system is not operating with a properly functioning market. Health care costs are hidden and often shifted, consumers and providers are insulated from the economic consequences of their decisions, and costs therefore go up dramatically. Instead of attacking both the structural deficiencies and the consequent inequities of the current employer based insurance system, the Clinton Plan simply expands them, and adds a heavier level of government regulation. The ultimate choice for the public is between a health care system based on consumer choice or a government controlled system. In pursuing a market based health care reform that enhances personal freedom and responsibility, two ethical principles are served. First, American consumers will be made aware of the true costs of health care services, and market forces will thus introduce incentives on the part of providers to control costs. Second, justice will be served; for not only will providers of medial services receive their due, but public policy makers can target relief more effectively to those who need it most.

Ethics↗
PubMed1994

Rationing and the Clinton health plan.

President Clinton, already facing formidable obstacles in reforming the health care system, denies that it will involve any rationing. This is politically understandable, but wrong. Infinite needs are rapidly overtaking finite resources. Most health providers recognize that the genius of modern medicine has outpaced our ability to pay. But the public still has unlimited expectations and a blind faith that everything can be provided to everyone by simply eliminating "waste, fraud, and abuse." Rationing is inherent in any health care system. As government undertakes to define what is "medically necessary or appropriate," it will unavoidably undertake a series of rationing decisions. Health care is being transformed from a private good to a public good. Government, when it reforms the health care system, must inevitably ask: How do we buy the most health for the public?

Delivery of Health Care↗
PubMed1994

Health care reform: a study in moral malfeasance.

Instead of benefitting from open meetings and public discussions, the Clintons drafted their health care plan in private and asked that it be accepted in haste. They advance an ideology that claims we can receive the best care for all without any increase in cost or rationing, and then they use "ethicists" to justify this ideology through a supposedly common morality. However, there is no such common morality. In the context of American pluralism, one must look to the actual consent of the governed and recognize the limits on state authority. The result will be a two tiered system of health care, with a basic tier focusing on cost-effective care for the poor that eliminates suffering rather than equalizing inputs, and a space for collateral private insurance.

Advisory Committees↗
PubMed1994

Strategic compromise: real world ethics.

In this essay the Co-chair of Ethics Working Group 17 of the Health Care Task Force discusses the formation, organization processes and activities of the group, and provides an analysis and critique of the experience. It is suggested that the creation of the group and its inclusion in the process made a social statement which legitimized ethics as a significant part of public policy deliberations. At the same time, major questions are raised about the role of ethics in public policy arenas in which strategic compromise becomes the order of the day. Balanced and objective involvement may be illusory. Ethics, like informed consent, is a process, not an event and is ever evolving. Those who attempt to bring ethical considerations to the world of public policy have an obligation to think carefully about what should constitute an appropriate theoretical framework, make efforts to determine what is unique about ethics, and consider mechanisms for the various ethics disciplines to work effectively together. From this experience, the author developed a personal commitment to focus upon the critical importance of universal coverage for all Americans.

Advisory Committees↗
PubMed1994

Ethicists and health care reform: an indecent proposal?

The Clinton Administration stated that the list of values and moral principles generated by the Ethics group reflects "fundamental national beliefs about community, equality, and liberty" and that "these convictions anchor health reform in shared moral traditions." However, these statements are difficult to justify. There is not a moral consensus in America that would justify through-going health care reform. In such a context of pluralism, ethicists should seek to move society in the direction of solidarity. The participation of ethicists on the Clinton Task Force was valuable because it showed that health reform is an exercise in social ethics, disseminated the work of ethicists to the entire Task Force, and expanded the experience of the ethicists involved. It may also have accelerated the moral transformation of Americans, which is needed before radical reform can take place.

Advisory Committees↗
PubMed1994

The articulation of values and principles involved in health care reform.

The Ethics Working Group of Clinton's Health Care Task Force developed a list of principles and values that should govern health care reform. These principles and values are compatible with central moral and political traditions, as well as with more rigorous theoretical accounts of justice and health care, but they are "freestanding" points of agreement, not presupposing any particular theoretical background. Though imprecise and not ranked by priorities, the principles guide thinking about the fairness of alternative reform proposals. Their use is illustrated by comparing alternatives on universality of access, phase-in period, the creation of unequal tiers, and the provision for wise allocation and rationing.

Advisory Committees↗
PubMed1994

Just caring: health reform and health care rationing.

Health reform must include health care rationing, both for reasons of fairness and efficiency. Few politicians are willing to accept this claim, including the Clinton Administration. Brown and others have argued that enormous waste and inefficiency must be wrung out of our health care system before morally problematic cost constraining options, such as rationing, can be justifiably adopted. However, I argue that most of the policies and practices that would diminish waste and inefficiency include implicit (and therefore morally problematic) rationing. Critics of rationing see as its most morally and psychologically troubling feature that an identified individual is denied potentially beneficial care. That psychic anguish may not be eliminable, and perhaps ought not be eliminated. But if rationing protocols are fairly adopted through a process of free and informed rational democratic deliberation to which all have access, the moral objections are largely overcome. Such a process is possible only if implicit rationing is recognized and rejected.

Advisory Committees↗
PubMed1994

Of rescue and responsibility: learning to live with limits.

Universal access to health care is still a dream rather than a reality in the United States. This is partly because a rule of rescue, by impelling us to help people in need, urges us to ignore the limits of our health care policies wherever those limits would adversely affect a given individual. As the rule of rescue undermines whatever limits we set on health care entitlements, it can thwart the cost containment so essential to expanding access. Rather than accept unlimited expense, we have thus far declined to universalize health care. The situation is exacerbated by an economic insulation shielding patients and physicians from the costs of care, prompting both to regard health care as free, an unlimited right. To reverse this costly entitlement mentality and place reasonable limits on rescue, patients must exercise greater personal responsibility for the costs of their care by directly experiencing some of the economic consequences of their health care decisions. Several mechanisms are available to accomplish this goal without posing economic barriers to needed care or penalizing people for becoming ill.

Federal Government↗
PubMed1994

Should we create a health care system in the United States?

An orthodoxy has arisen which claims that there is a crisis in the United States health care system such that the system needs to be reformed. This essay challenges that orthodoxy by showing that we do not have a health care system in the United States. We have a non-system of health care, just as we do for virtually all basic social institutions. Challenging the current orthodoxy surfaces two ethical issues that have been ignored: creating a health care system will (a) cause resurgent paternalism and (b) pose a threat to moral pluralism.

Advisory Committees↗