Introduction

The fundamental health care issue in the United States is neither excessive costs nor lack of access, but lack of national purpose. We have no consensus about what we want or expect from a health care system. In the absence of such a consensus, entrepreneurial forces remain in ascendancy. Instead of solving the costs and access problems, these forces have shifted costs to others while making access to services even more difficult. Defining a purpose for the health care system means seeking self-consciously to discern its proper goals, rather than assuming that these goals are self-evident or can be safely inferred from the priorities of doctors, hospitals, insurers, or other powerful actors. A health care system is, finally, a political and social creation, and decisions about it are decisions about national values. It is argued that health security and social solidarity are the true goals of the American health care system, and that even those who are currently well insured would be prudent to support coverage for everyone. In the final section, three ethical prerequisites for achieving these goals are presented.

The demise of the Clinton health care reform initiative in 1994 was only the most recent in a long series of failed efforts to provide access to health services to all Americans. Universal coverage has been a prominent part of the national consciousness since 1912. When this goal—long ago realized by other industrial democracies—will be achieved in the United States is a matter of uncertainty. What is not uncertain is that the pressure for it will increase in the years ahead, and that it will be a growing part of national politics for the next decade as the traditional employer-based system continues to unravel. This chapter addresses some of the components of an interim ethic, reforms in our thinking that will be important in achieving a more just and inclusive system.

Misidentifying the Problem

For the past several decades, most observers have characterized the key issues in U.S. health care as ones of cost control and expansion of access. The available information seems to confirm this assessment.

Cost escalation is such that in the nineteen year period between 1980 and 1999, expenditures for health care quadrupled, from $1,000 per capita to over $4,000 per capita and from 9 percent of the gross domestic product (GDP) to over 13 percent.