Universal Health Care is the mark of a moral society

Address to the Yale Political Union , November 3, 2008

John R. Battista, M.D.

Speaking on behalf of Physicians for a National Health Program and the Connecticut Coalition for Universal Health Care

     I am pleased to have this opportunity to affirm for you the resolution: universal health care is the mark of a moral society.  The basis for affirming this resolution is clear: societies with universal health care have improved health and life expectancy relative to those that do not.  In addition, universal health care particularly improves the health and life expectancy of the most vulnerable members of society, the sick and poor, by improving or equalizing their access to health care.  Universal health care is thus particularly the mark of a moral society because it specifically improves the health of its most vulnerable members.  This is in accord with the fundamental moral belief that the morality of a society derives from the way it which it attends to the needs of the most vulnerable. 

     And health care is certainly one of our most basic human needs, for without health care we are deprived of life, the ability to love and work, and the freedom to pursue happiness.  Perhaps this is why Martin Luther King, a moral beacon of our society, proclaimed, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

     We can deepen our understanding of why universal health care is the mark of a moral society by examining the case of Canada ’s conversion to a universal health care system from one essentially identical to our own.  When Canada passed universal health care legislation thirty-five years ago, guaranteeing equal access to equal health care for all Canadians, it had essentially equivalent longevity and greater infant mortality than the United States , while spending about the same amount per capita on health care.  Now it surpasses the United States both in terms of life expectancy and lowered infant mortality.  In fact, the infant mortality of the poorest sector of Canadian society is superior to the average infant mortality of the United States .  This is a truly remarkable moral accomplishment that should empower us to fully affirm universal health care as the mark of a moral society.  It improves the health of the poorest and most disadvantaged members of society by providing them, at least in Canada ’s case, with equal access to equal health care.  Equality is a moral virtue which is central to the Canadian health care system, but sadly lacking in our own, where the uninsured get nothing but emergency care, the poor get inferior care, and the vast majority of people have to suffer the horrors of managed care, while those that have sufficient money can get whatever they want and need without waiting for pre-approvals.

     But moreover, when we grasp that Canada has been able to accomplish this moral feat while spending less than half of what the United States spends on health care per capita, and having much greater satisfaction with its health care system than we do, the Canadian conversion to universal health care becomes truly compelling and empowering.  Just think of it: improved health for everyone, improved health for the poor, equality in health care, and health care justice, at half the cost. 

     Canada has succeeded in lowering its health care costs by specifically removing the unjust wastes of the American health care system, which have everything to do with putting profit over health.  Some of these wastes are the obscenely high salaries paid to for-profit health insurance executives, the use of expensive managed care procedures to deny needed care, the horribly high cost of insurance premiums because insurance companies have a fiduciary responsibility to make a profit for their stock holders, and the fractionation of the population into thousands of risk groups thereby not only increasing the cost of insurance but also increasing the administrative costs for insurers and health care practitioners.  All of these factors result in the obscene, wasteful reality that we spend 25% or more of our precious health care dollars on administrative overhead, while Canada spends only 3% of its dollars to do the same tasks. 

     The study of the Canadian health care system relative to the United has inspired thousands of dedicated health care advocates around the United States to tirelessly speak out on behalf of universal health care despite the slow response of society to respond to their cry for morality and justice in our health care system.  It has inspired thousands of dedicated health care advocates to spend their free time and personal income to contradict the myriad falsehoods and myths that have been promoted by the for profit health care industry to justify the continuation of our wasteful, immoral, unequal, for-profit health care system that causes the unnecessary deaths of tens of thousands a people a year, while bankrupting more people in our society than anything else. 

     In Canada there is free choice of health care providers, in the US there commonly is not.  In Canada , health care insurance is fully portable, in the US , it is not.  The Canadian health care system is much more administratively efficient and less bureaucratic that the US health care system, even though it is run by the government.  Although there are waiting lines in Canada for non-emergency surgeries, overall the wait for health care is no longer than the wait for health services in our health care system, except for those who pay for health care out of pocket.  Finally, decisions about health care are made by health care providers in Canada .  In the US they are unduly influenced by health care insurers more than half the time.  Insurance influenced decision making has been unequivocally shown to result in inferior care on all quality of care indicators.  It leads to poorer satisfaction with health care.  It leads to increased death rates.  

     I ask you to wake up and become empowered by the reality that universal health care is the mark of a moral society.  Comprehensive, universal, public funded health care systems administered through a single payer system, like that of Canada, is the mark of a most moral society, because it addition to improving health care outcomes by improving access, it most effectively inhibits waste and most effectively provides equality in health care access and health care received.  Don’t take my word for it, investigate it.  Go to the websites of PNHP and the Connecticut Coalition for Universal Health Care and learn the case.  It’s a slam dunk from the moral perspective, as well as the perspectives’ of cost-benefit and cost-value analysis.

     Now, let’s pull back from empowered moral outrage and try to discuss the situation from a cooler and more rational point of view.  Given that universal health care is a mark of a moral society, what does it imply about what should be done and by whom?  Is universal health care a moral obligation?  Is universal health care a right that should be enacted, whatever its consequences to other values of American culture, such as personal responsibility, and our dominant cultural belief in capital market solutions.  What, if any, are the limits of such a commitment?  Does it mean that all medical care must be provided whatever the circumstances?  Does it mean a person who is brain dead should be sustained on life support indefinitely?  Does it mean that a person with advanced and irreversible Alzheimer’s disease should be given kidney dialysis or a kidney transplant to correct an unrelated case of kidney failure?  If it does not mean that all medical care should be provided whatever the context, who should make such decisions?  Furthermore, if there is a moral imperative to provide universal health care, where in our society does that moral  imperative reside?  In all  of us?  In civic or religious organizations?  In local government?  In state government?  In the federal government?  How are we to find answers to these questions?

     Furthermore, it is critically important to realize that moral questions about universal health care are also being driven by three distinct sets of very significant empirical findings about the US health care system.  The first set of data concerns the uninsured.  As is well known, about 47 million Americans are without health insurance, some 15% of our population.  These people are predominantly the working poor and their families, and predominantly people of color.  The uninsured are in poorer health than the general population and die younger.  They seek less preventive care but utilize more emergency services.  They drive up the cost of medical care not only by overutilizing emergency care, but also by failing to utilize outpatient care, resulting in hundreds of thousands of avoidable hospitalizations, and seeking health care later in the course of an illness when it is more expensive and less effective to treat.  The reason for this is clear: the United States guarantees the right to emergency care regardless of the ability to pay, but insists on payment for outpatient care.  As a consequence, at least 18,000 persons die each year as the result of the lack of health insurance.  What, if any, moral obligation does our society have to address this mark of immorality in our health care system?  Where in our society does this moral obligation reside? 

     There is a second, less well-known but very significant, set of empirical data about the United States health care system that concern medical bankruptcy.  Health care expenses are the leading cause of bankruptcy in the United States .  There has been a 2200% increase in medical bankruptcies since 1983.  Furthermore about three fourths of Americans who are bankrupted by medical expenses had health insurance at the time they became ill.  So I ask you, what is the moral obligation of society to ensure that health insurance does not result in bankruptcy?  Would you support legislation to correct this marker of immorality if it meant that health insurance would become more expensive than it already is?  How would you decide if such legislation is just?

     Finally, there is a third set of empirical findings about the American health care system that is, for the most part, only known to health care advocates and health care analysts.  They concern for-profit care.  For-profit health care is between 12 and 25% more expensive than not-for-profit health care, averaging about 19% more expensive.  For-profit health care is significantly poorer than not for-profit health care on all 14 recognized quality of care indicators.  For-profit health care is associated with increased death rates over not for-profit health care.  Finally for-profit care is associated with poorer satisfaction than not for-profit care.  Now I ask you, does this mean the United States should forbid for-profit care on a moral basis?  Does this mean that the United States should outlaw managed care on a moral basis?  Is it morally right for a government to regulate how a health care insurance industry operates?  Is it morally right to limit their profits or constrain their overhead?  Is it ethical to eliminate for-profit health insurers all together, as other industrialized countries have done? 

     How are we to answer these questions?  On what basis can we decide between a historical commitment to for-profit care and its negative consequences: lack of health insurance, bankruptcy, increased costs, poorer quality of care, decreased satisfaction with health care, and people stuck in unwanted jobs because of non-portable health care benefits?

     There are three basic ways to try to answer these questions.  The first is in terms of fundamental moral principles: equality, justice, concern for the sick and poor, avoidance of waste.  The second is from a cost-benefit analysis.  What leads to less cost? What maximizes benefit?  The third is the most difficult to employ, a cost-values analysis.  Such an analysis is concerned with how a health care benefit may conflict with a perceived value, such as the sanctity of the individual to make their own health care decisions, or that a universal health care system would cause private health insurance workers to lose their jobs.

     Let’s take up these three modes of evaluating the value of universal health care systems relative to the US health care system.  However, before we do, we need to clearly understand what universal health care systems are, and how they differ from the system employed by the United States .  Universal health care systems exist in all other industrialized countries and come in three basic forms: single payer systems, socialized systems, and multi-payer, not for profit systems.  However, they share many common principles.  First, they all cover all health care services.  That is, they all cover preventive health care, the treatment of illness, the palliative and supportive care of chronic illness, including nursing home care, and the cost of medications.  They are comprehensive in scope.  Second, they cover those services for everyone in society- they are universal.  Third, they all negotiate for the bulk purchase of prescription medications and durable medical equipment on behalf of their populations.  Fourth, they pay for health care services and medications by taxes on income and payroll.  None of them utilize risk adjusted insurance premiums. They all directly, or indirectly, use extremely large and encompassing insurance pools relative to the US .  All of these insurance pools operate not for profit by law.  These insurance pools negotiate for rates with providers.  None of them set rates by fiat, as is the case in the United States .  Socialized systems in industrialized countries, like Great Britain and Spain , in which the government owns the hospitals and health care workers are employees of the government, allows individuals to opt out of the system.  This is not true in socialized universal health care systems in non-industrialized countries such as Cuba .  Both single payer universal health care systems, such as Canada , and multi-payer universal health care systems, such as France , do not allow individuals to opt out of the public health system, because they perceive such a provision tends to degrade the public health system and result in a two tier health care system.  We can thus see that all universal health care systems are not identical, although they are much more similar to one another than any of them are to the United States . 

     The main difference between universal health care systems and the United States is the absence of for-profit health care insurance companies.  It is for-profit health care in the United States , which makes health insurance contingent on the ability to pay for risk-adjusted premiums, and which limits medical benefits to particular aspects of health care, commonly associated with caps on benefits, that results in the problems of the uninsured and medical bankruptcy.  Furthermore, the managed care system utilized by most for-profits is the cause of a significant degradation of health care outcomes in the United States . Thus, the basic question for us to consider is whether the United States should replace its for-profit-public health care system with a publicly funded, comprehensive, universal health care system.

     First, lets us examine this question from a moral point of view by evaluating it in terms of the basic moral values of equality, inhibition of waste, efficiency, and efficacy.  Our current health care system is sorely lacking in equality.  It results in massive disparities in access to health care.  Access to health care is limited by the cost of health care for the uninsured and the lack of comprehensive insurance coverage which makes people uninsured for many aspects of health care treatment, such as dental care, even if they have health insurance.  In addition, access to health care is limited by the use of managed care programs which seek to limit care to maximize profit.  Even though the total cost of health care in universal health care countries is about half of what the US spends, they actually provide more outpatient and inpatient care per capita.  Our cost is so high, not because we consume more care, but because our health care system is grossly inefficient and wasteful relative to universal health care countries.  This is because we utilize a vast number of health insurers with a wide variety of plans which tremendously increase our administrative costs relative to other industrialized countries who use, at most, a few insurers.  In addition, managed care further increases wasteful administrative costs even though it results in poorer outcomes.  Also, the high salaries offered in for-profits, their marketing expenses, and need to exact a profit, all contribute to wasteful administrative costs.  There is no bang for these bucks, quite the contrary, they only result in higher insurance premiums and poorer outcomes.  Furthermore, our current health care system lacks efficacy due to the uninsured and the use of managed care both of which have a deleterious effect on the health of our population.  Even if the problem of the uninsured were solved by the public funding of comprehensive health insurance, and the problem of medical bankruptcy were solved by forbidding caps on insurance, and the problem of efficacy were solved by forbidding managed care, and the problem of inefficiency were diminished by constraining the overhead and profits of private insurers, such a system would still remain inefficient relative to the single payer and not for profit, multi-payer systems utilized by other universal health care countries, unless the United States were to limit the number of insurers and limit their profits and overhead to the level of not for-profits.  If all that were done, guess what, we would end up with the very system employed by other industrialized countries.

     When we realize that universal health care systems do not manage care, we can obtain an answer to our question if universal health care demands that all medical procedures should be covered whatever the circumstances.  The answer is no.  Such systems allow health care professionals to determine the appropriate care in consultation with patients and their families.  They do not constrain care by the insurer.  When patients or families disagree with the recommendation of their health care provider that recommendation is reviewed by a board consisting of other health care providers and medical ethicists.  The result is a morally superior system to our own, in which decisions about health care are commonly dictated as much by insurance coverage than any kind of reasoned negotiations between health care providers and their patients. 

     Now, lets look at the question of whether the United States should reject our current private-public health care system in favor of a universal health care system from the standpoint of a cost-benefit  analysis.  First, let’s turn to the cost side.  We know for-profit health care is much more expensive than not-for-profit health care.  There are multiple reasons for this: higher salaries, the fractionation of the insurance pool, marketing costs, increased costs associated with managed care, increased costs to providers having to deal with multiple insurers, limited provider pools that necessitate changing health care providers, and profit.  In addition, for-profit health insurance results in the uninsured because hourly workers, the near-aged and sick individuals are frequently unable to afford the cost of risk-based health insurance premiums.  The uninsured increase the cost of health care for the insured who experience higher taxes and higher insurance premiums by having to fund the emergency health care and hospitalization costs of the uninsured.  We know the same set of procedures carried out by for-profits costs anywhere between 12 and 25% more than if it were carried out by not for profits.  We know that running a for-profit health care insurance system in conjunction with a publicly funded system for the poor, disabled and retired, as the US does, costs about twice as much as running a publicly financed, comprehensive universal health care system for everyone.  Therefore, a publicly funded, universal health care system would cost less than continuing our current public-private system, even if were modified by public funding and constraints on overhead and profit.

     Hopefully you can now see a very important truth: the more we aggregate insurance pools the more we lower the cost of health insurance.  Thus, we can answer the question, where in our society does the moral impetus for universal health care fall?  Although, from a moral point of view it clearly falls on all of us, from a cost-benefit point of view it most clearly falls on the federal government.  This is because federal legislation empowering the aggregation of its population into a small number of insurance pools is the most efficient and effective means by which a moral value for our society, improved health care for the nation, the poor, and the ill, can be accomplished.  This is in accord with the principle that efficiency and inhibition of waste are moral goods that should be maximized in a society. That is to say, although it is morally correct to do all we can to provide universal health care at all levels of our society, it is most moral to enact legislation at the federal level, because federal legislation is the most efficient means to bring about improved health and the most effective way to avoid waste, if properly done.

     Now let us turn our attention to the benefit side of considering the question, should we discard our public-private health care system in favor of a universal health care system? We know that our public-private health care system yields poorer outcomes than publicly funded systems.  The US consistently ranks in the lower third of industrialized countries with regard to the two universally accepted measures of health care system efficacy: infant mortality and life expectancy.  The US has dropped over time with regard to these measures, while increasing our negative cost differential.  The efficacy data with regard to the treatment of acute illness, US vs. universal health care countries, by the way, is generally comparable.  Furthermore, when we compare for-profit health care with not-for-profit health care within our own health care system we find that for-profit health care lags behind not-for-profit health care on all quality of care indicators, death rates and patient satisfaction.  In addition to improved health care outcomes and satisfaction, we find that a universal health care system results in an additional benefit: the avoidance of medical bankruptcy.  Medical bankruptcy is the leading cause of bankruptcy in the United States but is non-existent in universal health care countries.  Furthermore, we find that a universal health care system results in the added benefit of more equality in health care access and more equality in the quality of the health care received.

     Thus, for-profit health care is inferior to not for-profit health care in terms of cost and benefit, as well as maximizing the moral benefits of reducing waste and maximizing equality.  Therefore, from a cost-benefit analysis, as well as a moral point of view, it is rational to conclude that the US private-public health care system should be replaced by a universal health care system. 

     I would further assert that a publicly funded, single payer, comprehensive, universal health system is the mark of a most moral society.  This is because single payer systems provide greater efficiency in delivering health care than not for profit multi-payer systems, and provide greater equality in health care access and quality of health care relative to socialized systems that allow individuals to opt out of the public system.  Morality in health care derives from maximizing efficiency, effectiveness, satisfaction, and equality in my opinion.  It does not necessarily, and less persuasively, derive from doing what you a priori believe to be right. 

     However, the case for a universal health care system is muddied, to some extent, by engaging in a cost-value analysis concerning this issue.  This is because opponents of such a conversion argue that it conflicts with values they hold dear, and thus appears wrong-minded or immoral to them. 

     For example, opponents of such a conversion argue that a publicly funded system would cause increased costs to the wealthy because each person would be expected to pay for something like the same percent of their income or payroll as tax for health insurance, whereas the wealthy could obtain the same services for a lesser percent of their income under a private system.  Opponents thus argue that a universal health care system would constitute an unjust exaction on the wealthy based on a socialistic form of income distribution to which they are morally opposed.  On the other hand, advocates of such a conversion state that making all people pay the same per cent of their income for health care is just and morally superior to our current system in which the working poor are asked to pay a higher percent of their income for the same services as the wealthy. 

     Similarly, opponents of converting our health care system to a universal health care system state that a publicly funded system would replace capitalism with socialism, and they are opposed to this by both belief and moral conviction.  Advocates point out that a publicly funded system does not necessarily result in the state socializing the health care delivery system by owning the hospitals and having workers paid as salaried employees.  It could represent just a social insurance funding mechanism, leaving the health care delivery system intact as fee for service, but freed of the managed care system and allowing free choice of medical provider.  In fact, this model, the so-called single payer model, is the model most widely advocated for the conversion of the American health care system. 

     However, opponents of such a conversion state it would force people to pay for health insurance they do not want or need.  They argue, why should I have to pay for long term health care, for example, when the odds of my needing it at this point in my life are slim?  I would rather bear the financial risk of being uninsured for these services than have to pay more for health care insurance I do not want or think I need.  Forcing me to purchase such insurance against my will through the tax system is a form of coercion that breaches the moral values of individual responsibility and freedom from unjust taxation.  Advocates argue this issue from a different moral position, asserting it is morally good for people to make a limited financial sacrifice for the good of society, particularly because some day you could be the recipient of that benefit, and furthermore, it is morally just to have everyone pay a small expense so that people who need the coverage will not be bankrupted by it, resulting in the public paying for these same services anyway, through health care coverage for the poor.  In accord with this position, well known work in psychology by Kohlberg and others, has shown that people who are willing to sacrifice for the common good are more morally mature than those who are not.  Thus, a health care system that embodies this moral virtue is more morally developed that one that does not. 

     However, opponents of a universal health care system argue that such a system would result in lines or constrain available services.  Advocates argue this is not true.  If the American system were funded at its current levels there would be no lines, just as there would not be in Canada if they were to double their per capita spending on health care.  Furthermore, individuals would still be free to obtain medical services that were not covered by the publicly funded system. 

     However, opponents of a universal health care system argue that such a system would be a government run bureaucracy, which they believe would be inefficient, ineffective, and result in costs spiraling out of control.  Advocates argue that empirical data based on international experience reveal just the opposite to be true, and that our own experience with Medicare reveal it to be a more efficient and effective provider of health care than the for-profit sector, with at worst equally annoying administrative problems.  In addition, many universal health care advocates respond to the criticism of a government run system by suggesting the government not run the universal health care system.  Instead, they propose it be administered by a not-for-profit public trust run by a board composed of all groups that have a stake in the system: health care advocates, health care providers, and taxpayers, with the advice of health care experts.

     Wherever one stands in terms of these values, it is easy to see that it is difficult to bring a cost values analysis of a universal health care system to consensus.  In fact, currently in the US , although around 60% of health care providers and around 60% of the general population support such a conversion, 60% percent or more of elected officials are opposed to it.  Health care reform advocates are extremely annoyed by this disparity and argue that it is the result of the undue influence of the insurance industry on public officials.  They consistently call for publicly funded elections and the inhibition of campaign contributions and financial perks for elected officials in the hopes this would bring elected officials to represent the wishes of the population rather than those that fund their campaigns and up-scale their life-styles.

     Whatever the basis, it is a reality that our two major political parties do not support a publicly financed, comprehensive universal health care conversion for the United States , although this position is supported by the Green Party and its presidential candidate, Cynthia McKinney, and some independent candidates for President, such as Ralph Nader.  In addition, a single payer house bill, HR 676, is currently under consideration with about 93 co-sponsors, none of whom are from Connecticut . 

     John McCain, the Republican presidential candidate, calls for deregulating the health care insurance industry to allow people to purchase high deductible individual health insurance with caps at lower prices, and medical malpractice tort reform to inhibit wasteful defensive medical procedures.  He argues these free market empowering measures will lower the number of uninsured and lead to lowered health care expenditures.  Critics suggest his plan would only result in increased medical bankruptcy and further dismantle our already dysfunctional employer based health care system. 

     Some leading Republicans, like Mitt Romney and Arnold Schwarzenegger, and Democrats, like Hillary Clinton, advocate mandates on health insurance coupled with premium support for people of limited means, as has been done in Massachusetts .  Critics argue this does not result in full coverage, increases medical bankruptcy, and is grossly inefficient relative to a publicly financed system. 

     Barack Obama, the Democratic presidential candidate, calls for allowing people the option of buying into the federal employees’ health insurance program coupled with premium support for people of limited means, and a health care insurance mandate on children.  This would lower the number of uninsured, but do little to impact the problem of medical bankruptcy, while actually increasing the average cost of health insurance, which could only be significantly lowered by the adoption of a publicly financed, comprehensive, universal system.  Critics further argue these policies would increase public expenditures thereby increasing the deficit, whereas a publicly funded system would not. 

     Perhaps the situation is best summarized by Winston Churchill, who stated, “You can count on Americans to do the right thing, after they’ve tried everything else.”  In conclusion, I affirm to you that universal health care is the mark of a moral society because it improves the health of a society, and most significantly, improves the health of those members of society who are most vulnerable to health care injustice by equalizing or improving their access to health care while decreasing cost.  Furthermore, I affirm to you that a publicly financed, comprehensive, single payer, universal health care is the mark of a most moral society.  It is the right thing to do because it improves the health of society most efficiently and effectively, while equalizing access to equal health care more effectively than other universal health care systems.

     This paper and other papers on universal health care by Dr. Battista are available at the Connecticut Coalition for Universal Health Care Website: http://cthealth.server101.com.  Additional information about single payer universal health care is available at the PNHP website: pnhp.org.