Yes, we can agree…four liberals, four conservatives answer the central question in health care
[Authors’ Note: This is the third article in an occasional series highlighting the initiative of a diverse group of conservatives and liberals in coastal South Carolina who meet regularly for civil dialogue on difficult public policy issues. Previously published articles have reported agreements reached by our group on gun safety and on congressional censure as the most acceptable solution during the impeachment trial.]
Introduction
As incredible as it may seem, the failure of the US to achieve satisfactory health care reform is attributable to our failure as Americans to clearly answer a single question. That is the conclusion of extensive and in-depth analyses of our health care system by the late Uwe Reinhardt, one of America’s most highly regarded bipartisan experts on health care. The question is “To what extent should the better-off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in health care?” No politically dominant answer to this question has emerged in the US.
Personal vs Social Responsibility
The question is an important one because the answer provides the guiding principle for the design of a health care system. Without a clear answer, the result is the patchwork system that exists now in America which is widely regarded as the best example of how not to create a health system.
Reinhardt’s question reflects the tension between 1) the responsibility each individual has to look after their own health and to pay any desired health insurance premiums, and 2) the responsibility government has to assure that basic common needs such as physical security, clean water, and health care are met. In fact, the strong tension around these two competing values in America — personal versus social responsibility — — helps explain why Americans have not definitively answered Reinhardt’s question. The tradeoffs to be made in answering the question are difficult to accept and choosing to prioritize one of these values is avoided.
To learn if a clear consensus answer to this question is even possible in our highly polarized social context, our dialogue group of conservatives and liberals met and weighed the relative importance of personal versus social responsibility in health care. Our continuing goal is to serve as a model of how well-structured civil dialogue can help find common ground to overcome polarization and help our communities effectively tackle difficult public policy questions.
Individualism
There are multiple reasons why we believe Americans value personal responsibility. We have a firmly entrenched individualist culture which promotes self-reliance and believes in rewards for hard work. Individualism has been a primary force of American society for three centuries and has supplied the motivation for many political and social accomplishments. Citizens are often uncomfortable requiring or accepting government assistance and leery of those who do receive assistance because of recognized abuses. Also, we believe Americans do not want to be taken advantage of by those too lazy to work, or unwilling to adopt healthy behaviors that can prevent illness. Ultimately, it is a question of fairness and the recognition that reciprocity is a key ingredient in sustaining all relationships, be they between citizens or between citizens and their government.
Social Solidarity
Alternatively, when faced with allowing fellow human beings to go without needed or life-saving care, we believe Americans see such a situation as unacceptable. There are multiple reasons for accepting a collective responsibility to provide for a basic need such as health care. American society cherishes Judeo-Christian beliefs that promote love of neighbor and helping those disabled or too poor to help themselves. Also, our founding political documents assert the equality of all persons and the inalienable right to life and liberty.
Furthermore, accepting social responsibility for health care recognizes the importance of social and environmental determinants of health, such as poverty, lack of education, and clean air or water. These macro-level factors are often not under the control of individuals, but are addressable by government policies and interventions at the population level.
The importance of social responsibility for public health has been recognized from the earliest years in America when yellow fever outbreaks were common in port cities. It is essential today in battling the coronavirus pandemic. In short, multiple health conditions and health challenges are not completely matters of personal responsibility and it is in the public interest to support both population and individual level health interventions.
Our Consensus
We concluded from the initial dialogue and multiple subsequent exchanges in person and in writing that our politically diverse group supports health care as a social good. Our consensus conclusion is that Americans should be their brothers’ and sisters’ keepers for health care and that we should design our health care system as a partnership between citizens and government to meet this obligation for all Americans.
Partnership on the part of citizens means willingness to join and support, according to ability to pay, their share of universal health insurance. The extent of coverage or standard of care provided should be more than the bare minimum needed but less than all-out possible or desired care. Which specific package of benefits meets this standard should be defined by government and be continuously evaluated so that it remains highly satisfactory to a large majority of surveyed Americans.
Future meetings of our dialogue group will seek to build on this foundation to reach agreement on how we should design an improved partnership-type health care system that aligns well with our vision of health care as a basic social good essential for all.
The preliminary principles that will guide us and be addressed in the second stage of our effort to design a healthcare proposal include:
· Inclusiveness of Coverage: Minimally universal coverage would include catastrophic health issues for everyone eliminating bankruptcy because of healthcare expenses. Beyond that there may be a range of coverages that may vary from a basic plan to a more inclusive plan. This is also a difficult component to develop.
· Incremental Approach: This will be difficult, but the task is to lay out a long-range plan that would end in a single payer system.
· Shared Partnership: Every person in the plan will contribute in some manner. If financially unable we will need to determine other ways to contribute.
· Public Health Prevention Program: A cooperative effort involving all aspects of the healthcare area will need to be woven together including medical, exercise, nutrition, media and a host of other influencers and providers to focus on prevention.
· Prioritize Reducing Healthcare Costs: Costs acceleration is too rapid and this will need to be addressed in a manner which allows for profitability, but provides some range of standards of acceptable cost based on a host of criteria.
· Social Responsibility: Although we accept that we are our brother’s and sister’s keeper, the plan will need to include emphasis on being personally responsible for good health. This will also be a difficult segment of the plan, but one worth addressing.
The dialogue group is interested in growing larger to help increase its credibility and impact. If you can have an open mind, are willing to learn regardless of your political views or party, and would like to join or learn more about our group, contact Richard Hammes at rhammes@comcast.net
Members of our dialogue group include:
Roger Bernier, Okatie, SC
Greg Blackburn, Bluffton, SC
Bladen Crockett, Bluffton, SC
Rick Dean, Hilton Head, SC
Earle Everett, Bluffton, SC
Richard Hammes, Hilton Head, SC
Thomas Myers, Hilton Head, SC
Emily Oetjen, Hilton Head, SC
