Framing the Health Reform Debate

Abstract

President Clinton's health reform speech to Congress in September 1993 was notable in two ways. Besides being the first U.S. president since Truman to recommend a major overhaul of the American health care system, he also took care to identify the most important moral values that served to justify his proposal. In part, his statement of values was based on the deliberations of an ethics advisory group, one of the thirtyfive working groups convened in the spring of 1993 to advise the White House on the substance of health reform. The optimistic voter tends to assume that the health reform debate is about the policy and economics of health care; the pessimistic voter tends to assume that the debate is a smoke screen behind which the various powerful interest groups will assure that no change in health care cuts too deeply into their profits or privileges. Either way, ethics appears to be a foreign language to the debate. There are, however, important reasons to follow in President Clinton's footsteps and to continue to frame the debate in terms of the moral values at stake. One reason is the greater likelihood of principled compromise. All agree that the health care system eventually resulting from today's debate will be some sort of compromise plan rather than the full implementation of any current proposal. In playing the inevitable game of mix and match, we might end up with a practical plan that continues to promote the most basic moral values at stake; we may end up with a plan that best suits the interest groups with the most power; or we may end up with a plan whose individual elements are defensible, but fail to cohere into a meaningful and workable whole. Continuing to remind ourselves which basic values are at stake, and continuing to hold feet to that fire when important decisions must be voted on, seem a good way to raise the odds of a desirable outcome. Another reason to frame the debate in moral terms is that it ought to engage the public at large and not just the so-called wonks. The technical terms of reform are unfamiliar to even the educated voter--not surprisingly, since we have not seen such a debate in the American political arena within the past fifty years; as recently as the summer of 1991 no one would have predicted that health reform would be a major issue in the 1992 presidential elections. By contrast, the moral values at stake--universal access, reasonable equality of benefits, fairness of burdens, quality and efficiency of care, and so forth--are readily grasped by most people, and form the basis for a serious community discussion of what sort of system would best suit this nation and what sorts of trade-offs ought to be made in implementing it. Starting with the Oregon Health Decisions project and spreading to numerous other states through the grassroots bioethics movement, numerous citizens and communities have become educated participants in the debate, and elected officials have been served notice that thoughtfulness and not mere rhetoric will be demanded of them. …