In the law, politics, and editorial pages, advocacy has a high status. Defense lawyers are expected to zealously defend their clients, not to offer balanced judgments of guilt or innocence. Legislators are expected to vigorously push their party’s agenda. Editorial writers are expected to editorialize, not anxiously wring their hands.
What about those of us in ethics? What are the rules, formal or informal, that should guide us, and particularly when through writing or activism we enter the political arena? Consider the current health reform debate and particularly the dilemma of how to best balance the need for universal access with the no less insistent need to control costs. Many say we should deal with both at the same time. Others contend that access should come first, if only for prudential reasons: cost control is politically toxic, best kept out of sight until universal access is achieved.
A similar issue arose in 1994 for those philosophers invited to work with Hillary Clinton on the task force she assembled to gain universal health care. They were told in no uncertain terms that they were not to use the word “rationing.” If universal care was legislated, everyone knew, rationing would be unavoidable. Everyone no less knew that it was politically dangerous to get anywhere near the subject. So far as I know, nobody broke ranks. They were in ethics but they had entered the political realm, which has different rules.
No such restraint was required of my colleague Willard Gaylin, who was not a member of the task force. He wrote an article for a major national magazine arguing that of course there would be rationing as part of any serious health reform, and he got a very warm response from at least two senators and many others. Someone, they said, was finally willing to tell the truth. But he got a hot response from one of the leaders of the Clinton task force, Paul Starr, an acquaintance whom I accidentally encountered shortly thereafter in the West Wing of the White House. Without so much as a howdy-do, he immediately began yelling for all to hear that “Gaylin is wrecking our work here and he should be ashamed of himself.” He implied that I was hardly less guilty for hanging around such a guy.
The political dilemma of access versus cost control is once again with us. Conservatives are warning that, if there is universal care, there will be government-imposed rationing, which is a deadly feature of “socialized medicine.” Rationing, they say, will stifle technological innovation and interfere with the doctor-patient relationship. There is something to that charge. That’s how the Europeans successfully manage their health care costs. We will need to stifle some innovation, maybe a lot, and on occasion limit what doctors can do for patients on the basis of good scientific evidence. That is what it will take to have an economically sustainable health care system.
Now, it is one thing for me to say such things – writing from an ivory tower on the Hudson River, 300 miles from the Washington beltway – but can we expect any member of Congress to talk that way? Not likely, particularly if they are liberals pushing for universal access. The Obama administration seems to be moving toward incrementalism. It is expected to push for expanded insurance coverage but not for universal coverage. It is also pushing for a number of cost control measures that, by any standard, are soft in their force and uncertain in their benefits (such as technology assessment, expanded use of information technology, and a greater emphasis on prevention).
Some commentators believe that cost management is now Obama’s leading health agenda interest, but if so, the means that the administration is discussing for doing so (which may just be trial balloons) are less than compelling. There is talk of a government program for the uninsured, along the lines of Medicare, that would compete with private insurers and that could make a real difference, but it would have to cover a rocky legislative road to get there.
I assume the Obama administration has chosen the dual course of less-than-full access and soft cost control because it does not believe that a solid universal care plan can make it through Congress – and that a cost control strategy with teeth could deal a lethal blow even to a more moderate plan. I consider that a lukewarm reform agenda at best, but then I do not have to deal with Congress.
The state of Massachusetts offers a different strategic model. The decision of the proponents of its effort to provide health care for all was to aim for access first and then, when achieved, to deal with the cost issue. It was a calculated gamble: get one hard problem out of the way and then move on to the other one. Great strides have been made in moving toward the first goal, but the cost issue has raised its nasty head already, with universal coverage not yet achieved. Now the state is being forced to come up with some good cost control strategies, but in a way that does not alienate the coalition of supporters, public and private, who have already brought it along so far.
Here’s my question. How hard should the cost problem be pushed by the Obama administration, and should it have priority over, or parity with, the access problem? For the sake of argument, let us assume that, if costs are pushed hard and effectively, that pressure could harm the drive for universal access. The political instincts of those worried about the delivery of unpleasant news about costs while pressing for access are probably right.
Yet my judgment is that the risk must be run. A lack of cost control is now ruining the present, already deranged, system. It could quickly ruin even a reformed system, perpetuating harm long into the future. The public needs to know that cost inflation is a cancer that must be stopped, and that doing so will be a fearful uphill struggle. Hardly anyone is eager to take on that struggle. As Ronald Lazewski, a consultant to a fine Frontline documentary on health care, recently noted: “Every doctor I meet says he is underpaid. I’ve yet to meet a hospital executive who thinks he or she can operate on less. I have yet to meet a patient who is willing to sacrifice care. So we have this $2.2 trillion system, and I haven’t met anybody in any of the stakeholders that’s willing to take less. And until we have that conversation, we’re just nibbling around the edge.”
At its present rate of annual spending growth, the Medicare program will be bankrupt in a decade, and over that period, the overall cost of health care will double from the current $2.2 trillion to $4.2 trillion. One might expect figures of that magnitude to get a conversation going on cost containment. In one sense, it has; almost everyone is worried. But the punchline I too often hear is, Yes, we do need to rein in cost escalation, “but not if it’s my wife or child or grandfather.”
If that’s not troubling enough, politicians have been lulled by a plethora of ideas about how to manage costs, confidently put forward without much evidence of their likely success or made aware of how long it would take for them to make a difference. Probably not coincidentally, the most popular nostrums are the least controversial. Who can object to information technology or prevention?
The moral philosopher in me pushes for telling the truth, come what may. The public has a right to know that universal care, to survive in the long run, will need to control costs, and that the time to start is right now. And this time, perhaps, the truth in this case will be more practical than political prudence.
Daniel Callahan is Senior Researcher and President Emeritus of The Hastings Center. He is the author of the forthcoming book, Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System, and will shortly initiate a new Hastings Center blog, The Health Care Cost Monitor.