The business of care

Abstract

In his recent book What money can’t buy Harvard philosopher Michael Sandel examines the role of markets in contemporary democratic society. With the current financial crisis the era of market triumphalism initiated by Reagan and Thatcher has ended with devastation for many. But over the last few decades it has expanded into all domains of public life. We now have for-profit education, healthcare, procreation, security, and environmental protection. The problem with a society in which everything is for sale is twofold: inequality and corruption. These are the two prevailing problems of our times, according to Sandel. With the eclipse of the public domain our society has essentially become a market society. Market values are now ubiquitous in all spheres of life. Sandel argues that we need to rethink the role of markets in human relationships and social practices, in order to articulate the moral limits of market (Sandel 2012). Initially it was assumed that the free market would provide the ideal context for autonomous individuals who wish to select the best option for healthcare according to their value preferences. For example, the Cato Institute, an American right-wing think tank, argued in 1992 that there are only two ways to solve the crisis of the American health care system: empowering patients so that they can pursue their interests without government bureaucracy, and creating competitive markets in health care (Goodman and Musgrave 1992). Similar arguments have been used by policymakers in many other countries. One example is the Dutch healthcare system that was traditionally based on solidarity and basic public insurance. Since 2006 this system has been transformed into a market-driven system with managed competition between private insurance companies. In accordance with the market ideology it was argued that creating a healthcare market would increase efficiency and decrease costs, provide more freedom of choice to patients, and enhance quality of care. In practice, healthcare expenditures in the Netherlands have skyrocketed since then. With 14.9 percent of the GNP, the country now has the second highest healthcare expenditures in Europe, only topped by Switzerland that has also ‘marketized’ its healthcare system. Together with the U.S. (17.5 % of GNP) these are now the most expensive healthcare systems in the world (Ten Have et al. 2013: 160 ff). Economists have warned for a long time that the market is not efficient (Stiglitz 2012). Another potential advantage is patient power; but in the practice of the health care industry it is rather limited. With the introduction of the market in healthcare, having insurance is mandatory; one can only choose between different insurance companies. Government as well as insurance companies determine what will be provided. Information concerning insurance packages is highly complicated. In principle, one is free to contact any physician or health facility but in practice the insurance company has made deals with specific health providers. For example in Pittsburgh, the two major insurance companies own most of the health facilities and physician practices. Of course, one is free to visit a medical service that is not affiliated with a specific company; however this might result in an invoice that is seven times more expensive. The quality argument in favor of creating a healthcare market is even more disputed. In a recent report of the Institute of Medicine an expert panel concluded with surprise that although Americans spend more per person on healthcare than other countries, they live shorter lives and experience more injuries and illnesses than people in other high-income countries (Woolf and Aron 2013). In 27 H. ten Have (&) B. Gordijn Pittsburgh, PA, USA e-mail: tenhaveh@duq.edu