Medicine and the Market: Equity v. Choice

Improvements in American health care cannot be made without addressing the fundamental assumptions that underpin our ideas about what health means. That conclusion was the product of a spirited panel discussion on the role of market forces in American health care, hosted on Thursday by the Progressive Bioethics Initiative at the Center for American Progress (CAP).

Panelist Daniel Callahan, Director of International Programs for the Hastings Center, led off the discussion by talking about his new book Medicine and the Market: Equity v. Choice, coauthored with Angela Wasunna. Joining him on the panel were Willis Goldbeck, consulting director for Global Public Health Policy and Government Affairs at UCB, and Jeanne Lambrew, Senior Fellow at CAP. Susan Lee, CAP Vice President for Economic Policy, moderated.

Callahan, whose book took a comparative look at different health care systems from around the world, found that the best systems had “universal health care with carefully introduced and carefully tested market practices.” Key to his understanding is moving past the false choice between markets and government involvement. A better way of framing the issue, according to Callahan, is to view market forces as a set of tools to achieve overall social goals. Under that conceptual model, the value of particular market forces can be tested against a higher standard of equitable access to quality health care.

Callahan pointed out that in many European countries, where universal care is held as a fundamental social value, health care systems are clearly effective. He listed lower costs, higher life expectancies, broad popular support, and quality of care at least equal to the U.S. as the advantages of a comprehensive, universal approach to health care.

By contrast, according to Goldbeck, “The U.S. does not have a system of health anything.” Goldbeck characterized the U.S. approach as a “medical care and repair model” that is fragmented and disjointed. Medical care, meaning specific responses to specific conditions, is emphasized at the expense of health, a broader concept incorporating prevention and overall well-being. Shifting the public discourse to that broader concept could facilitate progress on some substantial fundamental health issues facing the country. For example, distinguishing medical necessity from medical enhancement would enable us to draw some lines around what types of treatments the health system should and should not promote.

All panelists observed that America’s market-influenced emphasis on constantly improving medical technology — called the “infinity model” because it assumes no limit to useful medical progress — has raised the costs of health care across the board. While health care has improved as a result of technology, Callahan said, “The greater the improvement, the more we spend.” An increasingly expensive medical industry raises serious questions about equality of access and long-term sustainability. The basic issue is whether advancing high tech medicine is the best way to allocate limited health care resources that might be better spent on prevention or basic treatment.

Settling the questions will not be an easy task, according to Goldbeck. “We don’t know how to define basic health care,” he said, because we expect basic care to include coverage for every medical contingency. The panelists agreed that if the expectations of the health care system are going to change, the fundamental assumptions of health policy must also change. Lambrew, for one, is optimistic about the possibility for a positive shift. Pointing to growing calls for health coverage from businesses and encouraging developments on the state level, she said that the time for universal health care as a meaningful political issue “might be sooner than you think.”

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