Health Care Reform: Ethical Foundations, Policy, and Law

Abstract

Among economic sectors, health care has led the shift toward government domination for decades. The shift is propelled by the idea that there is a right to health care, a concept that was first articulated by Franklin Delano Roosevelt in his address to Congress in 1944, in which he spoke of a new set of basic rights, including “the right to adequate medical care and the opportunity to achieve and enjoy good health.”1 The debate over whether such a right exists has been ongoing for decades, some claiming it does exist,2,3 others that it does not.4,5 Although a right to health care has never been explicitly recognized in US law, the closest approach is in the new health care reform law with its amendments, the Patient Protection and Affordable Care Act (ACA).6 Various ethical arguments have been made for and against establishment of a legal right to health care in recent years—the current debate about the law rests on those ethical foundations. To clarify competing ethical theories, I will describe 2 distinct ideologies, by which I mean systems of more or less coherent ideas, which bound the ends of a spectrum of approaches to health care reform. The ACA and most other reform proposals are admixtures of elements from the spectrum’s boundary anchors that I refer to as “central planning,” which relies on regulatory controls, and “free market,” which favors minimal government involvement in the health care system. Opposing ideas drive these 2 positions: that health care is an entitlement that must be provided by society and that obtaining health care is the responsibility of individuals. I will start by describing an approach to the ethical thought that underlies free market systems, then do the same for central planning. I will go on to argue that central planning is fatally flawed and that free markets will deliver substantial benefits for individuals and for society. Then I will describe the implications of these ethical considerations for the development of public policy, and will end by briefly describing health care system reforms that are well grounded ethically and are likely to actually achieve the goals of increased access and cost control, namely, systemic reforms using market mechanisms.