Resisting U.S. Social Ethics
2003; Project HOPE; Volume: 22; Issue: 4 Linguagem: Inglês
10.1377/hlthaff.22.4.257
ISSN2694-233X
Autores Tópico(s)Healthcare Policy and Management
ResumoBook Review Health AffairsVol. 22, No. 4 Resisting U.S. Social EthicsUwe E. ReinhardtPUBLISHED:July/August 2003Free Accesshttps://doi.org/10.1377/hlthaff.22.4.257AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSSystems of careEthicsHealth reformCosts and spendingSocioeconomic statusPrivate health insuranceFirst Do No Harm: Making Sense of Canadian Health Reform by Terrence Sullivan and Patricia M. Baranek (Vancouver, B.C.: UBC Press, 2002), 120 pp., $14.95 For several years Health Affairs has featured annually in its May/June issues cross-national surveys designed to fathom public sentiment on health systems in several nations. The surveys have revealed a remarkably uniform degree of malaise with health care across nations, malaise that does not vary with levels of health spending or structures of the various national health systems. The overt driver of this global malaise is the ever-rising cost of modern health care everywhere. Beneath its surface, that cost escalation has begun to feed a nascent, still partly disguised class struggle in countries whose health systems have thus far operated on the principle of social solidarity.Observing what luxury, technical sophistication, and immediacy of access in health care money can buy in the much less egalitarian U.S. health care system, some increasingly vocal members of the upper-income classes in these other nations have begun to fancy the same level of luxury for themselves without, however, wishing to be forced, through social solidarity, to subsidize that same level of luxury for their lower-income peers who are unable to pay for it with their own incomes. The solution, of course, is a multitier health care system. The bottom tier will guarantee all citizens a limited, collectively financed package of “socialized” benefits delivered under tight regulation and subject to rationing. One or several commercialized tiers will cater to those able to afford additional health care, or “socialized” benefits of a higher quality, including the ability to move ahead of any queue in health care. While this idea tends to be marketed under the politically more salable promise of “greater efficiency,” that banner is merely camouflage for an entirely new deal in health care. It would have been a miracle if Canada, both spatially and culturally tied to the United States, had escaped this yearning for the new deal. It has not. A subtext in Terrence Sullivan and Patricia Baranek’s fascinating little book, First Do No Harm: Making Sense of Canadian Health Reform, is that the almost decade-old debate on health system reform in Canada, at its core, is really a struggle over this proposed new deal. The authors firmly come down on one side of the issue: They prefer the traditional deal. In developing their argument, the authors provide a quick but inevitably superficial tour through the Canadian health system, deftly de-construct a number of myths and misconceptions commonly held about Canadian health care, and explore major shortcomings in the current system. These are chiefly (1) remaining gaps in public coverage of prescription drugs and home care; (2) the “passive privatization” of Canadian health care by removing from public coverage services hitherto rendered in covered settings (such as hospitals) but now more commonly provided in uncovered settings (such as the home); and (3) Canada’s widely publicized queues for services. On the latter, the authors provide an illuminating lecture on methodologically sound ways to define and measure queues and on their efficient management.However, I find most engaging the authors’ clear and explicit affirmation of Canada’s ethical values. These, argue the authors, are quite distinct from those evinced, if not openly professed, by Americans. “The U.S. value system respects, above all, the [individual’s] freedom not to be interfered with,” they write. Within that hallowed individual freedom, imply the authors, is the freedom to use one’s own money to jump queues in health care and to procure better health care than others can afford. “We [Canadians],” the authors continue, “balance the freedom of non-interference with the freedom to choose governments that will act in ways that legitimately constrain individual choice for the public good…Literally in order to save each other’s lives, we have constrained (but not prohibited) Canadians’ freedom to buy their way to the front of the line.” Citizens’ free choice to constrain the ability of the well-to-do to buy their way to the head of the queue, write the authors, is also a way of expressing individual freedom, different from but not inferior to a well-off person’s freedom to jump the queue.While Americans may claim that these are just word games—that Americans, too, favor an equitable distribution of health care—a distinct U.S. ethic comes across in what Americans actually do in health care, rather than what they merely profess to espouse. Canadian provincial legislators, for example, put the same monetary value on a pediatrician’s treatment of a child, regardless of the child’s socioeconomic status. It is achieved through uniform fee schedules. By contrast, U.S. state legislators think nothing of paying a pediatrician only $10 or $20 to see a poor child covered by Medicaid, but $50 or more to see the legislators’ own children. A good many U.S. physicians respond predictably to these value signals by refusing to treat Medicaid patients altogether. To illustrate, the Wall Street Journal recently (2 April 2003) reported that a member of the South Carolina National Guard called to active duty during the war on Iraq lost the private health insurance that came with his civilian job. He then discovered that a local doctor would not perform a colonoscopy on his sick daughter because her military coverage, Tricare, pays such low fees. To Canadians such a vignette must appear unimaginable. As the Wall Street Journal reported, such vignettes are not at all uncommon in the United States, where the expressed social value of health care frequently is a function of the recipient’s socioeconomic status. This stark divergence in social values may help explain the widespread opposition to American-led globalization. Economists can demonstrate that abstracting from distributional effects within nations, free international trade makes all trading nations better off overall. In First Do No Harm, Sullivan and Baranek alert readers to an additional twist: the associated mutation of social values. Along with many other Canadians, the authors worry that international trade agreements will serve as the Trojan horse onto whose back U.S. corporations will load health care and health insurance services to be sold in Canada, but in whose belly they will smuggle into Canada the social ethics and raw political muscling to which these corporations are accustomed at home. U.S. companies may view such excursions into Canada as just another harmless way to garner a few extra pennies of earnings per share. Canadians who are fiercely proud of their traditional social contract in health care are likely to view them as threats to their preferred way of life. Uwe Reinhardt is the James Madison Professor of Political Economy at the Woodrow Wilson School, Princeton University, in Princeton, New Jersey. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 July 2003 InformationCopyright 2003 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download
Referência(s)