Health Care Reform and the Public option in Theory and Practice

by Christopher O. Tollefsen
Those who favor providing health care to all shouldn’t necessarily oppose the “public option,” but they will be unable to support a bill if it endorses and entrenches the taking of innocent human life through abortion.
Opposition to the health reform plans being put forth by the White House and the Democrats in Congress has centered on antipathy to the so-called “public option.” In my view, the reasons for this opposition are not uniformly sound. Indeed, insofar as the opposition is largely based on theoretical or ideological opposition to “government-run” health care, it has been relatively weak. But insofar as it has been based upon practical concerns for this administration’s and this Congress’s agendas, legitimate points have been made which need to be more adequately addressed as part of the large-scale effort at reforming health care in the United States.

Opposition to the public option at the level of theory seems in large part to reflect an animus towards the removal of health care from the sphere of the market and the kinds of healthy competition that drive that market. Critics are probably right in claiming that the public option would drive some insurers out of business, and that for-profit insurance would be at a great disadvantage in competing against the state, which, by the additional provision of resources, could always undercut the competition and provide the most attractive of the various public and private options.

Often embedded in opposition to the public option is an additional antipathy to the idea that health care is, or should be, a political entitlement, and that it is, or should be, considered to be a natural or basic human right. The proliferation of entitlement rights strikes many as problematic—such rights are rarely well-articulated, the means necessary to deliver them are rarely well investigated, and the assertion of such rights is often used more as a club to beat opponents in debate than as a serious tool for political discourse.

Nevertheless, the assertion that there is something like a natural right to health care that should be made into a political entitlement in at least some circumstances does not seem unreasonable. As I have argued in Public Discourse before, human beings have natural “Good Samaritan” duties to others to come to their aid when their needs are great. Health care needs are among the most significant and urgent of our needs as human beings whose lives are, in large part, bodily. Those needs thus ground duties on the part of others to provide aid when they can and when the need is great. The political state exists in part to assist people in fulfilling their responsibilities more effectively than they might otherwise be able to, and it exists in part to assist those incapable of meeting their own needs, and whose needs are not being adequately met by others.

Given this, the fact that a public option as part of a solution to the problem of inadequate health insurance for the poor and lower middle class is public—that is, involves government intervention—is not terribly worrisome. Were the public option able to do its job successfully, then government would be doing its job.

Nor are worries about diminishing competition convincing, for two reasons. The first is that health care is in some respects not the sort of thing for which there can be a genuinely free market. Health care decisions are made under great uncertainty, and those with knowledge—professional physicians—have an overwhelming advantage over their clients that renders the exchange of healthcare for money unlike the exchange of other commodities in a free market. Nor does the introduction of insurance schemes restore health care to the context of free exchange. Insurance companies must find ways to reduce the power of doctors without empowering patients to the point that they begin to thwart the ability of insurance companies to make a profit. Given that the health-care needs of the patients are the foundation for society’s health care duties, intervention into this triangle of patient-doctor-and-insurance company by the state to level the playing field in favor of the patient does not seem intrinsically unreasonable.

Second, the dominance of American health care by for-profit physicians and insurance companies seems at least somewhat in tension with the professional ethic of medicine. If that profession is seen as a vocational commitment to a form of service oriented around the basic human good of health, then service, duty, and responsibility, rather than competition, should play a greater role in conceptualizing how health care should be provided. Physicians and insurers in other developed countries are, it is true, simply not as wealthy and as well compensated as they are in the U.S. It is not at all obvious that this is a bad thing, from the standpoint of the medical profession.

Theoretical or ideological objections to the public option—that is, principled objections—seem ungrounded. But there are other reasons to be concerned here and now about the public option being put forward. Four such concerns are especially pressing.

The first is its effectiveness in dealing with the specific problems that need to be dealt with. Would the public option really redress our health care system’s injustices in an economically effective way? Justice in health care cannot be achieved by implementation of a plan that threatens to impose unsustainable costs—that would only defer our problems downstream and make them ultimately more intractable. Critics of the “economic prudence” of the public option, such as Ramesh Ponnuru and Yuval Levin, have raised real and troubling objections to the current proposals. These objections need to be answered with equally compelling answers and arguments by supporters of a public plan.

Does the administration and Congress have answers to the critics of the economic feasibility of the public option? I do not know, but this raises the second problem. There simply has not been enough information provided, enough honest debate, or enough time to consider the merits of the public option. Nor has there been adequate comparison of this possibility with other suggested ways of reform, including more private but more transparent ways of financing health care. Nor has there been adequate consideration of alternative forms of government intervention that focus on public health concerns such as obesity and food options. The stated effort to get health care reform passed by August could only have been predicated on the supposition that the nation should simply trust the administration and Congress to come up with a just and efficient plan. But that is a wholly inadequate way to move reform along. It is true that at some point a decision will have to be made about how to proceed, but the lack of transparency to this point has been striking, and it demeans citizens who reasonably want a voice in our national deliberations.

A third point, however, is that the lack of transparency has tended to shade into something worse: dishonesty. Is the public option merely one step towards a single payer system? Would it pose a threat to existing insurance companies? Would there be adequate safeguards to ensure that only qualified citizens, and not illegal immigrants, were eligible? These and other questions have been answered with an apparent disingenuousness and lack of frankness that is more than a little disturbing. The goals that different answers would give evidence for are, in each case, debatable and should be debated—perhaps there should be coverage for, e.g., the children of illegal immigrants. But proponents and opponents need to know what, in reality, they are arguing about.

Nowhere has the lack of candor been more grievous than on the public option’s treatment of abortion. Current federal law prohibits the use of taxpayer money for abortion, and the architects of the public option have relied on this to duck responsibility for speaking forthrightly about the final configuration of the plan. That plan, in all likelihood, would include abortion coverage financed through patient premiums, rather than government subsidies. But the plan would still be a public plan, administered by the state. The money contributed by any premium payer would go towards the funding of abortion, and, as Cardinal Rigali has noted, “funds paid into these plans are fungible, and federal taxpayer funds will subsidize the operating budget and provider networks that expand access to abortion.”

Such considerations have led even mainstream media outlets like Time magazine to note that the proposed reforms would “mark a significant change in the Federal Government’s role in the financing of abortions.” Yet the President has referred to such concerns as “myths” and “fabrications.”

It should go without saying that abortion is not a form of health care. That alone should remove it from the realm of the debate. Defenders of the public option, or of any other reasonable proposal for health care reform, need to decide where their priorities lie. If health care reform turns out to be a way of expanding an entitlement right to abortion, it will alienate many people, and, in all likelihood, not move forward. If the concern of the proponents of health care reform really is to address the genuine inefficiencies and injustices of the current system, while maintaining the federal government’s hands-off approach to abortion, then reform might be a genuine possibility. Whatever the nature of the reform, some people will be unhappy with it, for varyingly good and bad reasons. But government involvement in abortion is not simply a reason to be unhappy. It is, as many pro-life but also pro-reform leaders have indicated, a dealbreaker.


Christopher O. Tollefsen is Professor of Philosophy at the University of South Carolina and a senior fellow of the Witherspoon Institute. His latest book, co-authored with Robert P. George, is Embryo: A Defense of Human Life (Doubleday, 2008). Tollefsen sits on the editorial board of Public Discourse.

Heath Care Reform - What Arthritis Patients Are Saying

with Carol & Richard Eustic


Health care reform -- a hot topic to say the least. Most Americans believe we need it, but there's less agreement about how to achieve it. We pitched the topic of health care reform in our arthritis forum and there have been some interesting responses -- especially those offered by forum members in the U.K. and Canada. Both expressed their displeasure with what's been said about their health care systems -- and they were quick to defend what seems to be working.

As for those living on American soil, there seemed to be concern over how health care reform will be paid for, forced changes that may be a consequence of reform, and trusting information that comes out of the White House. Are these valid concerns in your opinion? Do you have other concerns? Share your opinion on Health Care Reform.

Health-care Reform;An Original And simple proposal

With over 300,000,000 people in America, it figures there must be someone who has the experience and skill set to reliably solve the health insurance and access problems besetting our country without throwing away the most excellent and caring medical system in the world.

Recently, when an old friend, a seasoned educator, and I, a seasoned physician, got together on a vacation in Colorado, he asked me if I had a simple solution for the medical insurance and access problems on the front pages of America's newspapers.

I told him "Yes, I do," but that it is so simple and inexpensive, without taxes or cuts in medical quality, that no one would believe me. It was he who insisted I put pen to paper because he felt there was an audience for a common sense solution to the health care ailments of America.

So here is the distillation of my 40 years' observation.

First, we should change the current 50 state patchwork of private insurance programs -- which cannot cross state borders -- to a national clearinghouse of private insurance choices that can compete across the whole country. Meanwhile, we should regulate the competing companies so that they must take all comers, regardless of pre-existing conditions.

Secondly, we should return health care insurance companies to the pre-1984 federal regulations that limited their fees to administration only (about 15% of medical dollars), without excessive profits going to their boards of directors, CEO's or shareholders. The provision of medical care is not the type of profession that can be treated as a simple commodity. The corporatization of health care was a bad idea, and it's getting worse. It has contributed tremendously to the crisis we're in now where hospitals and doctors feel squeezed -- forcing some of them to shut their doors or quit -- while insurance company profits soar.

Third, we need to make health insurance plans completely portable for individuals with life changes, in order for the insurance companies to compete on a flat playing field for the whole U.S. population. Ideally we should move away from employment-based health care. If employers do not have to pay the soaring costs of healthcare for their employees, they can raise their employees' salaries in a commensurate manner, and the employees, in turn, can choose which level of health care plan they want to purchase.

Of course, people who can afford it should be required to purchase health insurance, in the same way that we are required to purchase car insurance, but they would have the choice of which plan to purchase.

And last, the health care overhaul should include meaningful tort reform that caps frivolous malpractice suits. Such a policy has seen great success in California for 34 years.

With the four above changes, competition across the whole country should prompt health insurance companies to improve efficiency and cost-effectiveness (similar to what GEICO has done in the car insurance arena). Notice that the government has not had to spend significantly or nationalize health care to accomplish this. All that is needed is thoughtful insurance company regulation, and the mandatory participation of all citizens who can afford what will be competition-driven reduced premium costs.

But what about the indigent and illegal alien populations who still need access to good medical care? How do you take care of them without an extra tax burden on the working population? This is easy for me to envision because I did it for decades via the model of our USC/Los Angeles County Medical Center -- the busiest teaching hospital in the United States.

"County USC" handles hundreds of thousands of clinic visits by indigent and illegal alien patients every year, allowing for wonderful experience for our doctors-in-training under the guidance of a great faculty. Because our hospital has 2000 penetrating-wound (knife or gunshot) patients per year, the U.S. military rotates its trauma surgeons here for 6 months at a U.S. Naval sub-station, before deploying them to Iraq and Afghanistan.

Thus, the final no new-tax solution to the health care problem is to get all of the urban medical schools back to serving their local indigent populations, with a standing "open door" policy, and no dumping of those patients off to other private hospitals or clinics while still obtaining Federal Grants (such a dumping policy was recently disclosed to have taken place at the University of Chicago Medical School).

If the large urban medical schools remember that "school" is in their name, they will use the teaching environment to promote great care as we've done for over 100 years at County USC. Also, in carrying out this primary teaching function, the schools could be subsidized (as has been done for decades by Federal, state and county funds), but with the money going directly to the delivery of medical care, rather than the expansion of bricks and mortar.

Great American-style medical care can be provided cost-effectively in simple perk-free settings, as in the U.S. military hospitals, without requiring the private rooms and flat screen TV's for every patient that have contributed to bankrupting many hospitals.

Federal regulations and mandates of all U.S. medical schools to emulate the County USC model would address the load of indigent patients and give our medical schools back the patient experience they sorely need for continued training of our physicians.

This plan represents my simple solution to preserving all of the best aspects of choice and quality and access in the American medical system, without the need for new taxes at all. Nor does it require nationalizing under a government-run plan, which is guaranteed to increase bureaucracy as well as the delay of essential medical services, such as seeing a specialist, undergoing surgery, or obtaining cancer treatments.

And an added plus is that our medical schools can get back to their teaching mission as best exemplified by the County USC model, while providing great training for our future doctors
by Dr Paul Toffel