Two Logics of Health Care
Plotke, David
Recent articles in Dissent on health care (Winter 1994 and Spring 1994) have been valuable but add up to less than might be hoped. Not so long ago it was often true that one could predict the...
...Politically, this road promises once again to stigmatize the left as statist, rigidly egalitarian, and hostile to innovation...
...instead, they want to live long, healthy lives, and want their prospects (and the prospects of others, especially relatives and friends) to improve over time...
...I suspect that this backsliding occurs for two reasons...
...3. Health care as an advanced industry...
...Thus debate on the left seems to presume that a single-payer system is the best way to organize health care, leaving for argument only whether some form of managed competition is an acceptable compromise on the way to that solution...
...Faced with a debate as sprawling and critical as that underway about health care, however, the subtlety of these discussions seems to have been put aside in favor of familiar positions: the more public authority over health care, the better...
...Yet the current discussion doesn't pay much attention to this second logic of health care as a dynamic industry producing an expanding stream of rapidly changing goods...
...We need both distributive fairness and rapid development, and that double need, given the two logics of health care, is a source of recurrent conflict...
...4. The trap of a distributive politics...
...Moreover, the state is a reasonable instrument for making sure of that distribution (which is not necessarily the same thing as directly organizing it...
...These expectations are criticized and sometimes ridiculed by economists and policy makers concerned about mounting costs...
...It is crucial to assert a right to health care...
...This second logic of health care is more like that of other advanced industries: lines between goods and services are blurred, scientific and technical innovation is both an input and a product, and organizational flexibility and creativity are rewarded...
...Such positions make easy targets for forces on the right who insist that any commitment to universal coverage is logically a commitment to stringent government control...
...If we spelled out a basic list of health care services, would we presume that anyone who has received them is healthy...
...Health refers both to our present condition and our expectations...
...and the closer to total equality, the better...
...Thus, market—linked growth usually includes elements that reasonably offend democratic sensibilities—big profits for drug companies, high salaries for medical specialists, and so on...
...Thus, in Rashi Fein's conception ("The Politics of Health Reform," Dissent Winter 1994), we can talk about running 10 percent to 15 percent of the American economy through collective decisions about allocation, with a predetermined budget...
...2. The double logic of health care...
...Through long controversies and even more due to the massive force of political events, most currents on the left turned both claims into questions...
...There are forms of health care for which this might be a good model—perhaps immunization and routine pediatric care...
...and encourage organizational innovation and diversity These aims are often in tension, and every point of tension is a point of political argument...
...The left is on solid ground in insisting that health care should be available to everyone...
...We want this development to occur because the result can help more people to live long and well...
...encourage technical and scientific advances...
...At least that is how it seems from most of what has been written, not only in Dissent but generally in liberal and left publications...
...The logic of meeting basic needs and the logic of growth in a powerful service industry don't mesh easily...
...The better reason: familiar left positions provide a framework for insisting that whatever changes are made in health care, priority should be given to providing decent medical care to the large number of Americans who lack it...
...Is health the absence of illness or of immediate medical problems...
...Not so long ago it was often true that one could predict the left's position on just about anything: the more state/public control, the better...
...As the answer to both questions is no, the following statements make sense: today I have a cold, but I am pretty healthy...
...But the left talks almost exclusively about distributing care...
...Concern about health costs is legitimate, especially when people cannot afford to buy what they reasonably believe they need...
...Health care is also a bundle of social technologies that we want to develop, often as rapidly as possible (for example, in finding cures for fatal diseases...
...To stress individual choice in health care is a position with wide appeal, yet one able to provide only limited advantage...
...But when one hears economists complaining about health care costs—orthodox neoclassical economists committed to the idea that the right amount of GNP to spend on x is whatever sum results from individuals' choices—one wonders...
...In this first logic of health care, our primary concern is for inclusiveness, irrespective of the condition of those in need...
...The beneficiaries always claim their gain is essential to overall social welfare...
...Such statements make sense because we regard health as a developmental process...
...improve quality...
...The resulting inquiries have been appearing in the 1990s in broad discussions about relations between public authority and markets, the complexity of equality, the importance of taking account of distinctive features of different social goods, and so forth...
...But both logics register widely held aspirations: more people should get more and better health care...
...The main contending plans for reform in 1994 would not reduce the range S40 • DISSENT of choices that most people have, and it is evident that a large part of the population doesn't yet have the choice of any decent medical care...
...Nor would many doubt that market elements should play a considerable role in setting prices and encouraging technical and organizational change...
...If health care is a basic element of what it means to live a decent life in the United States, it is also a large and growing industry...
...the left sounds similar themes, perhaps believing that the only way to get funds to expand coverage is by discouraging expensive procedures as excessive and even selfish...
...Its capacity for development is based on technical and social innovation...
...Putting it simply—probably too simply—to be healthy means to be able today and to expect to be able tomorrow to make full use of one's physical and mental abilities...
...And by quality they mean both the direct effects of the services provided and the form of their provision...
...The health care problem is about how to distribute health care and how to produce health care in response to old and new problems...
...Or are these complaints another front in the long war against excessive popular expectations and entitlements...
...Perhaps because the left is unused to having a real chance of winning on a major public issue, the temptation to stop the discussion here seems strong...
...Extensive regulation and large public roles in funding research and development and influencing investment choices are closely linked to its achievements as well as its problems...
...This would be an ironic outcome, because health care is an area where the political and intellectual right is on weak ground...
...Rather than marking a fixed condition, health refers to a range of complex activities and goods, and relations among them...
...or, there's nothing really wrong with me, but I don't feel healthy...
...Americans expect the quality of health care to FALL • 1994 • 539 improve steadily over time...
...Do they really know how this money could be better spent...
...The main discussions of health care reform (especially but not only) on the left proceed as though health care were a relatively fixed and simple good—the problem is how to distribute this good fairly...
...But these conflicts cannot even be understood, much less partially resolved, if we retain state control and equality pure and simple as the basic criteria for evaluating proposals about how to reform the health care system...
...The services and goods that a health care system provides are meant to enhance health—a dynamic aim, given the nature of that good...
...1. What is health care about...
...What it means to be healthy changes during any individual's life: as a function of prior efforts and experiences, as a function of what is socially understood as a normal life, and as a function of physical capacities...
...Sorting out when such claims are right and when they are fraudulent requires political argument and economic analysis, neither of which gains from populist complaints about profits and salaries...
...There is a double logic in the health care system...
...There is not much evidence that people expect to live forever...
...savings and quality...
...But it doesn't get at what people mean by health and why they care about it so much...
...The bad reason: it is reassuring to combine such a powerful claim with conventional left formulas about maximizing public control...
...Health care is a basic element of membership in a political community or of equal opportunity in social and economic relations...
...In fact, the health care system exemplifies the industrial policies that opponents of industrial policy claim cannot work...
...I happily add the following to the many lists of good things that health are reform should try to do: expand "basic" coverage to include everyone...
...Nor does it take seriously the last twenty years of debate about markets and planning...
...Moreover, the health care industry is not one that the American right can easily use to illustrate the virtues of pure markets...
...Clinton's principles (security, simplicity, savings, quality, choice, and responsibility), each one is certain to result in sharp conflicts with at least one other (for example, security and choice...
...and the more fully equal provision, the better...
...Not many on the left would now say that such industries are best run by the state or that innovations in such industries should be discouraged when their immediate results are not egalitarian...
Vol. 41 • September 1994 • No. 4
