A critique of the innovation argument against a national health program

Bioethics

Volumn 21, Issue 6, 2007, Pages 316-323

  Rajczi, Alex ^a  

^a CLAREMONT MCKENNA COLLEGE   (United States)

Author keywords

Council of Economic Advisors; Innovation; National Health Insurance; Uninsured

Indexed keywords

ARTICLE; HEALTH CARE; HEALTH CARE SYSTEM; PUBLIC HEALTH; UNITED STATES; WELLBEING;

HUMANS; NATIONAL HEALTH INSURANCE, UNITED STATES; POLITICS; UNITED STATES;

EID: 34249812944     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2007.00559.x     Document Type: Article

References (27)

1. The most comprehensive discussion of this point is the Institute of Medicine' four-volume series on uninsurance: Institute of Medicine. 2003. A Shared Destiny: Community Effects of Uninsurance. Washington, DC: National Academies Press; Institute of Medicine. 2002. Care Without Coverage: Too Little Too Late. Washington, DC: National Academies Press; Institute of Medicine. 2002. Health Insurance is a Family Matter. Washington, DC: National Academies Press; Institute of Medicine. 2003. Hidden Costs, Value Lost: Uninsurance in America. Washington, DC: National Academies Press. For a summary of the facts on uninsurance, see: T. Bodenheimer & K. Grumbach. 2002. Understanding Health Policy: A Clinical Approach. 3rd ed. Chicago: McGraw-Hill: ch. 3.
2. R.M. Sade. Medical Care as a Right: A Refutation. N Engl J Med 1971 285: 1288 1292.
3. See, for example: R. Epstein. 1997. Mortal Peril: Our Inalienable Right to Health Care? Reading, MA: Addison Wesley Publishing: 70ff.; W. Irvine. 1990. Can National Health Insurance Solve the Crisis in Health Care? In: Biomedical Ethics Reviews - 1990. J. Humber and R. Almeder, eds. Clifton, New Jersey. Humana Press: 61-86. I should note that Epstein puts forward several different arguments throughout the book. One is the consequentialist argument I have alluded to. Another seems to be an argument from libertarian side-constraints. (These two could be made consistent if he were a rule-consequentialist who believed the right rules were libertarian.) Like the arguments cited in the previous note, these arguments are subject to challenge.
4. E. Reinhardt et al. US Health Care Spending in an International Context. Health Aff 2004 23 3: 10 25 et al. Costs of Health Care Administration in the United States and Canada. N Engl J Med 2003 349 8: 768 775 Anderson et al. Health Spending and Outcomes: Trends in OECD Countries, 1960-1998. Health Aff 2000 19 3: 150 157 Friedman. How to Cure Health Care. The Hoover Digest 2001 3: 3 30
5. G. Anderson J. Poullier. Health Spending, Access, And Outcomes: Trends In Industrialized Countries. Health Aff 1999 18 3: 178 192.
6. President G.H.W. Bush. 2004 State of the Union. Available at: http://www.whitehouse.gov/news/releases/2004/01/20040120-7.html [accessed 8 Jun 2006]. In this speech, the President advocated a variant on the current system, which is compatible with the definition of 'our current system' that I give below.
7. See: Council of Economic Advisors. 2004. Economic Report of the President, 2004. Available at: http://a257.g.akamaitech.net/7/257/2422/ 17feb20051700/www.gpoaccess.gov/usbudget/fy05/pdf/2004_erp.pdf: 190-193 [accessed 8 Jun 2006]. For a popular treatment, see R. Herzlinger. 1997. Market-Driven Health Care. Cambridge, MA: Perseus: esp. p. 275ff.
8. Why our best 'philosophical' option? Because one could also mount a plausible critique of the argument by challenging the notion that our system really produces 'the best health care in the world'. The odd structure of the US health system may result in problems even for those who receive the best care the US has to offer. For example, such people may get too many tests, drugs, or procedures. They may be steered into research programs designed to benefit drug companies, not patients. For a more complete description of these worries, see: Angell, M. 2004. The Truth About the Drug Companies: How They Deceive Us and What to Do About It. New York: Random House. For these and other reasons, a complete assessment of the argument from innovation would also require extensive empirical assessment of this sort.
9. Bodenheimer & Grumbach, op. cit. note 1, ch. 15.
10. Orwell, George. 1968. Politics and the English Language. In: The Collected Essays, Journalism, and Letters of George Orwell; Volume IV: In Front of Your Nose, 1945-1950. S. Orwell & I. Angus, eds. New York: Harcourt, Brace & World: 127.
11. For details on the complicated structure of our current system, see Bodenheimer & Grumbach op. cit. note 1, chs. 6 and 7.
12. See note 1.
13. One of the most comprehensive overviews of national health programs is: M. Roemer. 1991. National Health Systems of the World. Oxford: Oxford University Press. A succinct overview of ten western systems can be found in the appendix to: Rice, Thomas. 2001. The Economics of Health Reconsidered. 2nd ed. Chicago: Health Administration Press.
14. Of course, a national health program wouldn't cover every possible inpatient procedure, prescription drug, and so on. The question of how to set limits on care is difficult, but because the precise limits are irrelevant to this paper, I won't discuss them.
15. Council of Economic Advisors, op. cit. note 7, p. 191.
16. A related and perhaps less problematic rationale would be this. Proponents of the argument from innovation might say that we should maintain the system that produces the best top-quality care because top-quality care eventually filters down and becomes commonplace. Perhaps it does not do so very quickly; there are now poorly-off people who will never receive our best medical therapies. But over time the best care becomes standard, so that the poorly-off in the future will have access to the best technologies now. The process continues over time, with the result that the poorly-off, throughout time, are better off under our current system than they would be, in aggregate, under a national health program. This rationale has several problems. It rests on speculations about future utility that there is no obvious way to defend. In addition, the argument advocates applying a simplistic utilitarian criterion to the worst off, taken as an aggregate over time, so can still be criticized for its simplistic utilitarianism. Finally, the argument is subject to several criticisms given in the text below, including the rather severe criticism that it falsely assumes that we cannot obtain top-quality care in a national health program.
17. I choose this example because CABG is deemed to have 'originated' in the US by the President's Council. (Council of Economic Advisors, op. cit. note 7, p. 192.) It should be noted that they offer no reference or backing for this claim and that I have no independent verification that it is true.
18. After all, it's not as if the proponents of this rationale can maintain that health sacrifices, even great ones, are never required. The recipients of top-quality care currently participate in a government-run system with a safety net - a system that presumably slows innovation somewhat compared to more market-oriented alternatives, and hence already imposes health sacrifices.
19. On the ubiquity and intentionality of corporate propaganda generally, see: A. Carey. 1995. Taking the Risk out of Democracy: Propaganda in the US and Australia. Chicago: University of Illinois Press. On the truth of the claim, see footnote 5 above, as well as: Organization of Economic Cooperation and Development. 2001. Science, Technology, and Industry Scoreboard 2001. Available at: http://www1.oecd.org/publications/e-book/92-2001-04-1-2987/PDF%5CA13.pdf: 62 [accessed 8 Jun 2006]; D. Rosselli. Geography of Biomedical Publications. The Lancet 1999; 354, no. 9177, 7 August: 517. There are also some related points in Angell, op. cit. note 8.
20. See footnote 13 above.
21. Here I do not assume that the current health system, and its innovativeness in particular, would not be affected by a large-scale change. It obviously would, if for no other reason than that massive numbers of patients would be added to the system, thereby restructuring incentives to providers and producing change. This point doesn't affect the central argument, though, because those who defend the argument from innovation can't plausibly be maintaining that any change to our current system is unjust. Instead they must be maintaining that we must maintain something like our current system, and voucher proposals do this.
22. E. Emanuel V. Fuchs. Health Care Vouchers - A Proposal for Universal Coverage. N Engl J Med 2005 352 12: 1255 1260.
23. Ezekiel Emanuel, personal communication, August 2005. The estimate is based upon a benefit package like the one delineated in my definition of a 'national health program'.If it seems shocking that one can merely redirect current spending and cover the un- and under-insured, see footnote 4 for information on the wastefulness of the current system.
24. For a discussion of in-kind and wealth transfers, see T. Rice, op. cit. note 13, p. 189ff.
25. Nagel, T. Libertarianism Without Foundations. Yale Law J 1975 85: 136 149.
26. For a discussion of these conceptions, see: D. Parfit. 1984. Reasons and Persons. Oxford: Oxford University Press: 3ff.; J. Griffin. 1986. Well-Being. Oxford: Clarendon Press. The second and third conceptions could be combined in various ways, e.g. by weighting preferences according to the objective quality of their objects, or by weighting (objectively) listed goods in part by how strongly preferred they are (while giving no weight to preferred but unlisted goods).
27. The point about revisability comes from: N. Daniels. 1985. Just Health Care. New York: Cambridge University Press: esp. ch. 2.