Two Logics of Health Care: Replies
Fein, Rashi
Few Americans, of whatever political persuasion, would disagree with David Plotke's four "good things that health care reform should try to do." My own list of the aims of health financing...
...We believe in a system that finances the "basic" coverage that Plotke refers to—our definition of "basic" is probably broader, deeper, and more comprehensive than his—in a progressive and equitable manner...
...Put simply: "Not true...
...The left must remain concerned with distributional equity and progressive financing...
...Had he fought for a more equitable and less complicated program, he might have educated the American public to the real issues in taxation, finance, and delivery...
...My analytic conclusion that a single-payer mechanism can provide more of the things we seek with less dislocation than other systems has been reinforced by a political observation...
...In that sense, rather than in the senses outlined in Plotke's first paragraph, we on the left remain predictable...
...Plotke is quite correct in suggesting that we must address many issues, distinguish between medical care and health care, be sensitive to the need for continuing growth in our scientific knowledge base, encourage change in health care delivery arrangements and organizations, and understand the public's needs and desires...
...Agreed...
...Had that occurred he could have said, "We lost, but it will be easier next time...
...Many who support a single-payer system have wrestled with and continue to wrestle with the need to deal with the danger of underspending...
...We know that Head Start appropriations fall below authorizations and that this is true for many social programs, even including those that President Clinton has termed "investments" and that he considers fundamental for our long-run economic growth...
...We also believe in a system that enables patients and prospective patients (in today's vernacular, "consumers") to influence how much money is allocated to the medical sector and, thus, how much is available to meet other societal needs...
...My own list of the aims of health financing reform (as distinguished from delivery system reform) includes those and more...
...In a single-payer system it would come out of a collective political decision...
...Among the "more" are goals that have been—and, I trust, remain—embedded in the aspirations of the "left...
...One's preference for a collective response is not a mere incantation of old ritualistic formulae...
...That system has come to be known as "single FALL • 1994 • 541 payer...
...See my "National Health Insurance: Telling the Good from the Bad," Dissent, Spring 1992...
...Presumably, but not necessarily, we would opt to restrain the explosive growth in expenditures...
...It is incorrect to state that the left "presumes that a single-payer system is the best way to organize health care...
...Those of us who believe that the United States should adopt a program of universal insurance (and many on the left reject that, preferring a British-style national health service), have concluded—not "presumed" —that a system financed through a broad-based general tax helps point in the direction of progressivity and equity...
...Managed competition may be some sort of a compromise, but assuredly it is not a compromise on the way to a single-payer system...
...This is no trivial difference...
...542 • DISSENT...
...That, too, is a posture the left may find useful: to recognize that our victories have not and will not come easily, but that they are more likely to come if we know what we believe and are willing to articulate our goals and beliefs...
...It turns out that the administration's attempt to finesse the issue of taxes by opting for employer mandates has not made enactment of reform any easier...
...I have noted the need to create a mechanism that permits us (indeed requires us) to decide how much we would spend on medical care...
...Plotke believes that like knee-jerk leftists we repeat "conventional left formulas about maximizing public control...
...None of us need apologize for concluding—after careful analysis—that it is a sensible way to finance universal insurance...
...Out of that would flow—so we are told—all sorts of benefits: improvements in quality, advances in effective delivery of care, and expenditure restraint...
...Nevertheless, none of us who claim these are important matters would suggest they are the entire story...
...If that happens, the best he will be able to say is that "we lost...
...We are aware of deteriorating roads, rusting bridges, declining educational quality...
...Whatever one might say about this theory, one thing seems clear: it is not a step "on the way" to a single-payer system, in no small measure because it has very little to do with such a system (and what implications it does have are at variance with the general tax-based approach...
...It calls for price competition among deliverers of care (increasingly organized into larger and larger units) and responses by knowledgeable and cost-conscious consumers in the marketplace to the array of prices associated with the different "products" of the various health care deliverers...
...Nor should the left engage in a debate about whether managed competition (even if the "managed" part is emphasized and the "competition" part is pursued in moderation) "is an acceptable compromise on the way" to a single-payer system...
...It is quite possible that the president will not attain the universality, community rating, and cost containment goals he seeks...
...The importance of the issues I have discussed and of the issues addressed in various articles in Dissent cannot be minimized...
...In managed competition, that restraint would be the sum of a set of behavioral decisions that we would make as individuals, sensitive to price and influenced by the existing distribution of income...
Vol. 41 • September 1994 • No. 4
