Skimming through the literature on contemporary healthcare, whether domestic or global, the rhetoric that the authors use reveals quite a bit about their intentions and beliefs on healthcare. For example, a 2003 discussion paper published by the WHO stated one of the main priorities when designing a healthcare system is to, “consider fairness in financial contribution” implying that healthcare is a normal good. On the opposing side, physician-anthropologist Dr. Salmaan Keshavjee of Harvard University stated that when we solely consider market ideals in healthcare, “non-market values worth caring about are crowded out.” These two views are telling of our own healthcare system, its history, and where the debate is going.
Within the context of the US, Medicare and Medicaid have been the primary provisioners of healthcare since their inception in 1965. Within their first year, they saw 19 million individuals sign up, covered by a budget of $10 billion. It was not long later in 1972 that former president Richard Nixon expanded coverage to include individuals under the age of 65, focusing on those with long-term disabilities and chronic conditions. Certain facts are clear here. First, Medicaid and Medicare expanded coverage for millions of individuals. Second, in doing so, the burden on tax payers increased to cover the additional costs for paying for a potentially lower-income risk pool. Though they increased healthcare coverage, not all were happy about this new, government-led approach to healthcare. The major stakeholders, particularly the American Medical Association, waged a fierce war on ‘socialized medicine’ that was perpetuated by Medicare and Medicaid.
Fast forward to the 21st century, March 2010 saw the passage of the Affordable Care Act. This act further expanded eligible recipients of healthcare through the insurance mandate and lowering the threshold to be eligible for Medicaid coverage. Additionally, it introduced the Essential Health Benefits (EHB) clause which mandated ten different medical services be included in all health plans. Critics of the ACA claim that it places an undue burden on tax payers, disproportionately harms small businesses, and at the extreme, turns the US into a socialist state. Supporters of the act stated that it brought the US a step closer to achieving universal healthcare, improving the well-being of US citizens. Most recently, the change in presidential administrations saw an attempted withdrawal from this previous healthcare reform. Though original attempts at an ACA repeal were unsuccessful, there have been continuing attempts at ending the legislation. This was largely based on the grounds of increasing consumer freedom, decreased costs, and expanded coverage.
Looking at the two sides of the spectrum of historic healthcare reform, there is one clear theme. Both sides of the debate look to achieve the same few goals: expand coverage to as many as possible, decrease overall costs, and increase access to high-quality medical technology. How is it then that these two warring sides differ? Reviewing the literature from the two opposing sides of the healthcare debate, we see that there are both value and theoretical differences in their approaches. On one side of the spectrum, the libertarian approach to healthcare is very much modeled off neoclassical principles of economics including deregulation to stimulate competition, removal of intellectual property laws, and removal of price ceilings and floors. This approach highlights the adherence to the principle that it is best to treat healthcare as a commodity, where the relationship between the patient and the doctor is equivalent to that of the consumer and producer. Opposing this is the idea is the notion that it is the mandate of the government to supply necessary healthcare services to all without placing an undue financial burden on anyone. On this basis, the doctor-patient relationship is less transactory and more altruistic. Similarly, the basis of the relationship between the state and the citizen is redefined as well. Under the libertarian understanding of healthcare, the state guides its citizens into particular behaviors that align with the goals of the market without taking direct responsibility for their well-being. The opposing view understands the role of the state to be directly responsible for the welfare of the citizens.
As the debate over healthcare rolls forward, the ideological basis of the stakeholders is the determining factor of the resultant policy and forces us to ask many questions. Is healthcare a normal good? Is the socially optimal outcome the same as the efficient outcome? With these in mind, it is key that we reconcile market and non-market values to achieve the most favorable outcome.
Bradley, E.H., Taylor, L.A. & Fineberg, H.V. (2015). American health care paradox: Why spending more is getting us less. New York: Public Affairs
Keshavjee, S. (2016). Blind Spot. Berkeley, CA: University of California Press.
Millenson, M. (2015, September 10). Medicare, Fair Pay, and the AMA: The Forgotten History.
Williams, R.A. (2011). Healthcare disparities at the crossroads with healthcare reform. New York: Springer.