Ethical dilemmas of universal health care in the United States
Despite the fact that the United States continues to have the highest health spending in the world, the country ranks low among developed nations in terms of health-outcome measures, and many Americans remain without care. In my attempt to better understand the system, both as a public health professional and as a patient, I turned to Uwe E. Reinhardt’s book Priced Out: The Economic and Ethical Costs of American Health Care. It was a fascinating read and an excellent introduction to the topic for those who do not deal with health policy issues on a regular basis.
Put simply, the following issues are problematic for the U.S. healthcare system:
High costs of health care - Despite the fact that the relatively young American population uses fewer health care services then other developed nations, Americans pay nearly twice as much as citizens of other countries. On top of that, a lot of resources are wasted on unnecessary services, inefficiently delivered care, excess administration, or missed prevention opportunities.
Highly variable costs of medical procedures - Costs of services vary greatly, not only between different states but even within the same hospital, and patients are often not aware of this. In a given health facility, the price of a particular procedure paid by a specific insurer differs depending on the type of insurance policy the patient has. Moreover, uninsured patients are typically charged the highest rates.
High administrative costs - The U.S. is also the leader in terms of spending on administrative overhead for health. In 2013 alone, for every doctor, only six workers provided clinical support, with the remaining ten engaged in administrative and management jobs that do not provide care. This administrative overhead is likely to grow further over the next years.
High complexity of the system - The health insurance system is extremely complex and fragmented, with multiple insurance schemes that differ according to the socioeconomic and demographic status of the insured. As a result, such a complex system is nearly impossible to reform.
Although some forms of public support exist, including Medicare for the elderly and the disabled, as well as Medicaid for those with low incomes, health care has never been treated as a social good (even under Obamacare), in line with postulates of economic freedom prohibiting government intervention to make access to health care more equal. And patients are the ones who are most affected. Expected to behave like consumers and shop around for the most cost-effective services in a system that lacks transparency, they end up confused and unable to comprehend usually unclear medical bills, the majority of which represent unexpected medical costs.
Living in the United States, I find myself thinking twice before using any health services. I had my first encounter with the system a year ago, when I needed an emergency dental appointment. Instead of asking what the problem was, I was asked if I was insured, and I recall how odd that conversation felt. As someone who comes from a country with universal health care, where access to health is considered a right rather than a privilege, I must admit that I strongly agree with Professor Reinhardt’s assessment that the U.S. system is deeply unjust in its design. How do you implement a single-payer system in a context where health care is primarily provided by private institutions? How do you persuade those Americans who choose to remain uninsured to opt in and direct resources toward the-worst off members of society, giving up their autonomy? There are no simple answers. I firmly believe, however, that health issues deserve special consideration and should not be discussed without due ethical considerations, nor should they be dependent on political consensus. These existing dissonances are what keeps me going in my work.
