The absent moral case for health care inequality

You should read Bill Gardner’s response to Philip A. Klein about a recent think tank ranking of national health care systems.

equityAs usual the United States doesn’t fare well (dead last, overall, compared to every other peer country). According to the Commonwealth Fund the U.S. ranks lowest in measures like “cost-related problems,” efficiency, equity, and “healthy lives.” Sarah Kliff has a good rundown of these components. But Klein, who certainly isn’t alone in his criticism, thinks the study is fundamentally flawed for several reasons. The most legitimate of those (the rest are the usual zombie stuff) is that Commonwealth measured equity:

The problem with the Commonwealth Fund study is that it’s rigged to produce a result that favors socialized health care systems. The study determines that the U.S. system is worse because it lacks universal health insurance coverage and the report emphasizes “equity” as one of the key factors in evaluating a health care system. But it’s an ideological decision to view equity as one of the most important factors in judging a health care system, just as it is for the study to leave out a factor such medical innovation, which would work to the advantage of the U.S., or choice, which would work against the centralized NHS.

Gardner’s riposte:

Calling the Commonwealth study “flawed” suggests that there are problems in the study that distort the ranking of countries relative to an objective study. Calling it “ideological” suggests that there is a scientifically neutral way to rank countries health systems. Calling it “rigged” suggests that the authors are deliberately distorting the ranking.

These criticisms are misplaced. An evaluation of a health care systems must begin from a framework of values, because health care systems exist to fulfill normative human goals. We have health care because we value health, so we want to see whether the system delivers that. Most of us also want the system to treat people fairly, because we value fairness. And so on.

This is simple enough, I think, and well-put. As Gardner goes on to state in his response the division of values between conservatives and liberals is generally well known and accepted. However, in mainstream practice it often goes unrecognized in favor of faux objectivity. This is a too-common occurrence in subsequent argumentation and I’m not excusing the left, nor myself, in this practice. There is no such thing as an objective measurement of a system that serves to fulfill a framework of social norms, and that subjectivity allows easy disputation when norms conflict.

Yet there is one aspect of the implicit value-baseline phenomenon in the health care debate that is more prevalent than others — the near-complete absence of a moral argument for gross inequality. So while Klein entirely agrees with the point about subjective norms, it also happens to be entirely absent from his piece. His critique of equity isn’t that it’s a disputable metric because they run aground of his value system, but because it is a liberal value against a non-ideological baseline. His objection to false objectivity falls relies on, well, his own false objectivity. In the process it becomes a way to legitimize inequality without making the moral case for inequality. It’s only by inference that choice and innovation (for the ‘haves’) as a normative goal of the system is much more important. Perhaps this is because explaining why equity isn’t a worthy metric for how we distribute health care resources is more difficult than simply saying the results are rigged by underhanded liberals trying to pull a fast one.


2 responses to “The absent moral case for health care inequality

  1. Maybe all that is needed for the program to be more successful is a little more education about what it is and how it works and a little more acceptance by the medical and insurance communities. Prices for services are dropping in many areas of the country already. Ohio is one example I can remember.

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