Should access to health care, especially in life-threatening situations, depend on whether you can afford it? Absolutely not, says Robert C. Hughes, Wharton professor of legal studies and business ethics, who compared health care systems in the U.K., Canada and Australia. He writes about this question and other issues in a recent paper titled, “Egalitarian Provision of Necessary Medical Treatment.” (The author-accepted version is here.)
Hughes identifies two key features of an egalitarian health care system. First, he argues, it would protect people’s liberty to ensure that access to money does not decide if people get the health care they need. Second, it would promote stability and encourage people to be law abiding. “The central finding of [my research] is that it’s morally necessary to make sure that people’s finances don’t affect their ability to get truly medically necessary treatment,” he notes in an interview with Knowledge at Wharton. (Listen to the podcast at the top of this page.)
Hughes favors universal health care coverage in the U.S. Further, in order to ensure that everybody has access to the medical care they need, he says one option is to eliminate private health insurance for coverage provided under ‘Medicare for All,’ the solution that Democratic presidential candidates Elizabeth Warren and Bernie Sanders have proposed. In this interview, he explores what legislators, the pharmaceutical industry and other health care providers could do to ensure a fair health care system where private parties don’t get to decide who is eligible for what treatments.
An edited transcript of the conversation follows.
Knowledge at Wharton: In your paper, you explore a topic that hits the news headlines regularly these days. It’s the need to provide necessary medical treatment in an egalitarian way to everyone, regardless of their capacity to pay. What inspired you to study this topic?
Robert Hughes: When I started working on this topic, I was a post-doc in the Bioethics Department of The National Institutes of Health. I looked for a topic that would be of interest to philosophers – that is my academic background – to the general public, and to bioethicists. My graduate advisor Seana Shiffrin raised a very interesting question. Suppose we agree that we should have universal health insurance in this country. Should we allow people to top-up [their health coverage] with supplemental insurance or buy private services in other ways? Or should we have the same for everyone? I thought, “This is an important question, and I don’t know the right answer.” I needed to turn to some more abstract principles of moral philosophy and political philosophy in order to find an answer.
Knowledge at Wharton: You write in your paper that different countries, especially Canada, the U.K. and Australia have dealt with this issue in various ways. What are some of the pros and cons to the approaches they have taken?
Hughes: The British model, which is also the Australian model, is to have a public system that covers everybody, but to allow people to buy private supplemental insurance. It works differently in those two countries. In both the U.K. and in Australia, many people buy supplemental private insurance. Canada has ‘Medicare’ for everyone, [as its] national health insurance system is called. Although they haven’t completely outlawed private insurance, there are some obstacles. At the federal level, there are limits on payments doctors can take. Some provinces have prohibited coverage that duplicates coverage [provided by] the public system. That prevents people from using private insurance to skip the queue for things like joint replacements. So, there’s pressure in Canada towards a single-tier system where everyone gets the same quality of care.
What are the pros and cons of these approaches? The big benefit of the U.K. [system] or the Australian system is autonomy. We think that people should be free to spend their money on cars or vacations or big houses; why shouldn’t they be able to spend their money on their health? The Canadian system has mostly been understood in terms of the political pressure to improve care for the less well off. If everyone is getting the same, the wealthier people who have some more political influence are likely to use that influence to make sure that that universal system is a really good system.
My work brings out an advantage to the Canadian approach, broadly speaking, that hasn’t been recognized before. And that is that it addresses a liberty concern. If money controls access to certain expensive but lifesaving or otherwise medically necessary treatments, then for people who don’t have enough money to pay for those treatments, the ability to get it depends on whether they can persuade someone to give them money. The result is that individuals and private organizations with money that they could choose to share end up having power over other people.
“There’s a moral dilemma that people face when they can’t afford health care that they need or their dependents need, and they may face a dilemma about whether to steal in order to get it.”
We see [this] when people on social media in the U.S. sometimes post requests for, “Use my GoFundMe to cover my expensive medical treatments.” (GoFundMe is an online fundraising platform that helps people crowdsource resources to fund medical treatments and other life events.) Whether [or not] they have an appealing presence on social media might affect whether they live or die. If you have an egalitarian health care system, or a single-payer health care system, that kind of dependence and that kind of potential domination doesn’t appear.
Knowledge at Wharton: What other philosophical issues does this bring up? As you said, your background is philosophy.
Hughes: Another philosophical issue this brings up is stability. [This is] not so much the empirical question about what policies lead to stable societies, but, as a moral matter, when should people have complete fidelity to the law? There’s a moral dilemma that people face when they can’t afford health care that they need or their dependents need, and they may face a dilemma about whether to steal in order to get it.
There’s a famous psychological experiment where people are asked about what’s called the Heinz Dilemma. Heinz is a man whose wife is dying and there’s only one drug that can save her. And there’s only one druggist who sells that drug. This is hypothetical, of course. And the druggist is charging 10 times what it costs to make the drug, and he’s the one who makes the drug, so it’s 10 times what it cost him. Heinz goes to the druggist and says, “I’ll pay you half now, and can I owe you the rest? I will pay you [the rest later].” And the druggist says, “No, I want the money now.”
Well, now there’s only one way to save his wife. It’s called The Heinz Dilemma [because] reasonable people disagree about what Heinz should do in this situation. The Heinz Dilemma is gone if money doesn’t control access to genuinely lifesaving medical care. There’s a way in which the moral duty to respect others’ property and the moral duty to obey the law generally are strengthened if we have egalitarian access to medical care.
Knowledge at Wharton: Could you highlight some of the major takeaways from your research? Also, how do your findings relate to the current debate in the U.S. on ‘Medicare for All’ in the run-up to the presidential election next year?
Hughes: The central finding of this [paper] is that it’s morally necessary to make sure that people’s finances don’t affect their ability to get truly medically necessary treatment. That means things that prolong life significantly, address serious disabilities, and address serious forms of suffering.
What are the implications of this? First, we should have universal health care coverage. We don’t have that yet in this country. Second, if we can’t afford to pay for a medically necessary treatment for everybody who needs it, then we might need to take some very expensive medically necessary treatments off the market to prevent this kind of private dependence from happening.
What are some ways of achieving this? One way is to abolish private insurance and institute Medicare for All. That is one of the policy positions being considered in the current Democratic party primaries. I should clarify: The debate is whether to abolish private insurance for things that Medicare for All would cover.
Another possibility would be to have a system of subsidized private health insurance, where health insurance is available to everybody. [Here], the government makes sure that everyone can afford it, and the insurance companies compete on price and convenience, or on [aspects like] whether they cover private hospital rooms, but not on what [essential medical] services are offered, or on whether they cover lifesaving [treatments].
Knowledge at Wharton: What are the implications of your research for government regulators? What role could they play in ensuring that private citizens don’t have the power to make life-and-death or sickness-and-health decisions for people who can’t afford to pay for it?
Hughes: The change needs to happen at a legislative level. There are two main approaches that could be taken. One would be to have a single-payer system. A second option is to have subsidized private insurance where there’s not a single payer, but multiple payers. A third [option] would be to just have a National Health Service. I doubt that’s what we want in this country. I think the first two of those options seem to fit more with American culture.
Knowledge at Wharton: Do you believe if the state does provide public insurance that some people should be allowed to opt out or to buy supplementary insurance, or to pay for some services out of pocket?
“There’s a way in which the moral duty to respect others’ property, and the moral duty to obey the law generally, are strengthened if we have egalitarian access to medical care.”
Hughes: No. That’s the main conclusion of the research. In order to prevent this kind of private dependence, we need to make sure that necessary care is provided to everyone without the ability to pay. If we had a public option and a private health insurance option and they covered the same services, and everyone could afford whichever one they wanted, and we said, “Do you want public insurance? Do you want private insurance?” and we let people choose, that sounds great. But it is a problem if there’s a lifesaving treatment that you can only get by paying for it with private money.
Knowledge at Wharton: Is that because it would not be equitable if it were done that way?
Hughes: I don’t want to think of it in terms of equity, I want to think of it in terms of power. People who can’t afford the expensive lifesaving things are dependent on whether they can get the charity from a relative, from strangers on social media, from a wealthy individual or from a charitable organization. There are probably multiple problems with that dependence.
Knowledge at Wharton: I’d like to come back to the question of power, which is fascinating, but before that, could we discuss the implications of your research for other stakeholders in health care such as private insurance firms, health care providers, or the pharma companies? What do you think leaders in these industries could do to support egalitarian provision of health care for necessary medical treatment?
Hughes: There’s one very important thing that they can do. This goes for corporate leaders, it goes for leaders in the nonprofit sector, and it goes for leaders in unions. And that is to support a good public policy. As we’ve discussed, there are multiple options for good public policy, so there’s certainly room for a lot of disagreement. But it’s very important that leaders in all these sectors not stand in the way of universal health care, that they not advocate for a tiered system, and that they instead advocate for one of the different [egalitarian] options. There are several options that would make sure that everyone is getting the same care, at least where it comes to lifesaving and other [treatments] that are genuinely and seriously necessary.
I don’t think that private action alone can solve this problem, because the problem is with private individuals and private organizations having the discretion to decide who gets which things they need to survive. Certainly, there are important ethical questions in the system we have about what to do with that power when you have it. Of course, charity is great. Of course, it’s desirable for pharmaceutical companies to make thoughtful decisions about how they price their medications. But ultimately, the government is going to have to be involved. Public advocacy [would help, too, and it] is an important part of our system.
Knowledge at Wharton: Coming back to the question of power, to the degree that egalitarian access to medical treatment is a matter of power, do you believe that a bottom-up approach involving local communities and unions, et cetera, would provide better social outcomes than a top-down approach?
Hughes: There are two issues here. One of them is how care is provided. The other is who decides what’s covered for everybody and how that decision is made. It might work very well to have local organizations of all sorts involved in the provision of treatment. But the decisions about what care gets provided to everybody – at least where we’re talking about necessary things – need to be made at a national level.
“The problem is private individuals and private organizations having the discretion to decide who gets which things they need to survive.”
Let’s imagine that this was instead made at a local government level. So Philadelphia, New York, Scranton, might all have a different list of things that they cover. Then whether you get to move to New York, Philadelphia, or Scranton might affect whether you get what your health needs. Since money affects what city you can live in, the problem of private dependence just reappears at a different level. It’s [about] whether someone will let you move in with them, whether you’ve got a relative, or whether you can get a donation. You could have a GoFundMe [campaign] for “Let me move to New York and get on their wonderful local health plan.” The same problem arises. So, we really need this to be at a national level where we make decisions [about] the medically necessary treatments that everyone can get.
Knowledge at Wharton: You write in your paper that some people, especially those who have good private insurance, may be uncomfortable with your research and its findings. What could you say to make them a little more comfortable with your argument?
Hughes: Two things — and I would say this mainly to people in the U.S. Think about what the effects would be of instituting universal egalitarian health care in the U.S. [Is it] going to make your health care different? It might, depending on how we institute it. Could it be disruptive? Sure, it could be disruptive. But is it likely to reduce the quality? Probably not very much, if at all. We can certainly afford, in this country, to provide a good level of health care to everybody.
A second point has to do with social stability. Think back to the Heinz Dilemma and the fact that, right now, there are people for whom this isn’t hypothetical. They actually do face a choice of getting money in some illegal way, whether is stealing or something else, and doing without health care for themselves, for their children, for their spouses. Of course, the threat of the criminal legal system is a deterrent. But we would have more social stability if people didn’t face that choice, if everybody got necessary medical care on an equal basis. It’s a lot easier to have respect for law when we don’t face such dilemmas.
Knowledge at Wharton: What future questions or study do you have in mind to build upon this research?
Hughes: One project I’m working on is on pricing in the pharmaceutical industry. As we all know, there have been, recently, some pharmaceutical companies that have raised prices on certain drugs and devices in spectacular ways that created some scandal in the media. I’m trying to develop an account of fair pharmaceutical pricing that, on the one hand, acknowledges the outrage and recognizes that the outrage is, in many cases, valid, but also recognizes that pharmaceutical companies spend a lot of money on drug development. It’s an extremely risky activity. It’s necessary to try dozens of candidate drugs in order to get one that works and is sellable. Companies need to [earn] back their research costs, and they may need to make a fair profit. How do we reconcile these issues?
There’s an ethical question, which is the main thing that I’m struggling with right now. But the account of just health care that I’ve already developed has implications for how the government should respond. There are two possible responses. One is to regulate drug pricing so that whether people can get what they need doesn’t depend on the discretionary decisions of pharmaceutical executives. The other would be to subsidize the purchase of medically necessary pharmaceuticals, and then that wouldn’t necessarily involve direct regulation of pricing. It might. But that would be another way of making sure that people get what they need regardless of what decisions individual companies’ executives make.
