guthealthcare.com

Principle 4 - Healthcare coverage must be universal

This is more than just a matter of fairness (though it is that).  All citizens, and all tax-paying non-citizens, have the right to be included in our new health care system. The reasons for this should be clear by now.  First, all taxpayers support the health care system with their dollars, and deserve to participate in it.  Second, under open rationing the limitations that the health care system imposes on all other public services, as we have just seen, become quite explicit.  All citizens have to live with those now-obvious broader limitations, and so they clearly deserve to participate in the health care system that produces those limitations.

Furthermore, all citizens (even the rich – and even Congressmen!) should be required to participate in our system of rationing. Only by including the rich and influential will the rationing system be designed with the care and consideration it deserves.

This is not to say, however, that we should prevent the rich from purchasing health care services outside the rationing system.  We should not; any system we devise simply will not work if we artificially restrain people of means from exercising their fiscal freedom.  However, we can mitigate any disruption that might be caused by such a freedom. First, we can strive to assure that truly “essential” services will be included in the rationing program, so, to the furthest possible extent, those who choose to go outside the system will be doing so for services that really are “non-essential.”  If it appears that the rich are, in fact, receiving essential health care by going outside the system, that fact would be an incentive to increase the priority of those services within the rationing system, or to increase the health care budget to allow coverage of those services. In this way, the rich can function as volunteers for “testing” the efficacy of services that society has deemed “borderline.”  Second, we would be entirely within our rights to charge individuals a stiff “external care tax” whenever they choose to go outside the rationing system.  The dollars thus collected could be added to the health care budget, and used to expand the services available for everyone else.  This tax would provide a disincentive for individuals to go outside of the system (so while they are not forbidden, they also will not be particularly anxious to do so). Such a disincentive should keep everyone, including the rich and influential, interested in assuring that truly “essential” health care services are covered under the rationing program.

Principle 5 - Clear rules of rationing must be decided in an open forum

Rules for the open rationing of healthcare should be decided from the perspective of patients (that is, of the public), not of economic, medical, policy, or ethics experts. Experts will introduce conflicts of interest. Healthcare economists will favor sacrificing fairness in favor of maximizing total societal good (more on this later). Medical experts will want to include whatever services and procedures they get paid to perform. Policy makers will want to include only services they can easily regulate. And who knows what the medical ethicists will want to do!

Only the public has the right to make these determinations. They are the ones paying for the services (because the services are not being given to them as an entitlement); and they are the ones who will have to live with the results.

Thus, whatever rationing methodologies are to be used, they must be open, widely discussed, and based on a broad consensus.

Principle 6 - Healthcare services must be prioritized according to clear ethical standards

Open rationing of healthcare must be grounded in ethics. If we were not concerned with maintaining our ethical principles, we might as well let covert rationing persist. So we have to articulate the ethical precepts we will abide by as we do the actual rationing-that is, as we prioritize healthcare services to determine what will be covered and not covered.

The ethics of rationing are not straightforward, however, because the ethical precepts we would wish to follow, instead of giving us clear guidance as to how to go about prioritizing healthcare services, contradict each other. Specifically, no rationing system can both maximize the fairness and maximize the good that is achieved with the dollars spent. We are going to have to make some sort of a choice between optimizing fairness and optimizing overall good. Such ethical decisions will be the most difficult step we'll have to take in devising a system for rationing and will be the strongest determinant of our success or failure. Furthermore, the choices we make will go a long way toward determining what kind of society we will become during the twenty-first century-and thus we should not leave these choices up to professional ethicists. They are going to have to be decided through a broad public consensus. We should therefore consider very carefully the ethical precepts that will guide our rationing.

Next: What might an upper-quadrant healthcare system look like?