Democracy and Justice in Health Policy

Abstract

Democracy and Justice in Health Policy On July 23, 1990 Dr. Louis Sullivan, Secretary of Health and Human Services, gave the first of a series of planned speeches on the Bush administration's view of U.S. health policy. Saying that he was beginning "a conversation with the American people on what they want from our health-care system and what we're willing to pay," Dr. Sullivan asserted that Americans would reject a radical revamping of the system,. and would not hold still for the "de facto rationing" that supposedly occurs in "nationalized" systems like Canada. As the articles comprising this update on the community health decisions movement indicate, the conversation that Dr. Sullivan seeks has already begun in earnest, if not in Washington, DC, then certainly at the grassroots level in many states. De facto rationing is not something peculiar to national or universal health care systems, it is a grim fact of life in American health care, too. And it is a nice question whether our quiet, de facto rationing (based on ability to pay) is better or worse, from a moral and a political poilt of view, than the best achievable policy of explicit, de jure rationing would be. Reform at the State Level. Whether Dr. Sullivan is right in thinking that Americans will tolerate, at best, incremental change in the health care system remains to be seen. What is clear is that the health care system will change and is changing presently, will nilly. The important questions now involve matters of ends and means: What basic values do we want our health care system to serve" And how should we arrive at public policy decisions that do set limits and do have the painful effect of redistributing finite beneficial resources? It is interesting to note that the most innovative ideas for reform and redistribution are coming from the state level rather than from federal policymakers or national opinion leaders. The basic lesson in social policy since the 1960s has been that marginalized and disenfranchised constituencies can get a fairer, more effective hearing in Washington than in the state capitals where they live, and that welfare problems can't be tackled at the state level anyway. However valid these lessons may still be in other policy areas, it is not obvious that thinking at the federal level about health care access and cost containment is more progressive and responsive to the needs of the least well-off than thinking at the state level. National proposals for reform have continued the traditional call for vastly expanded access for the underserved--primary care for poor women and children, long-term care for the elderly--but without specifying where the additional money would come from. Debates at the state level, by and large, have been more prone to link the problem of expanding access with the problem of setting priorities among health care services. The situation today seems to be that the philosophical argument about the justice or rightness of equitable access to basic health care for all has pretty much been won. It is no longer enough, then, only to assert the right to a "basic package of care," or a "decent minimum." Now it is necessary to define specifically the components of the health care floor below which no one will be allowed to fall. In several states it is precisely this debate that the community health decisions grouns now find themselves caught up in. Moving beyond Individualism. Is this a healthy place for them to be? In one sense they have no choice but to respond to the sitution, for if they were unable to rise to the occasion of this debate, they could hardly claim much credibility among their constituents or the public-at-large. …