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April 23, 2014

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daily memo: health:

Why some American values are obstacles to insurance system overhaul

Reformers must overcome attachments to individualism, capitalism, experts say

In the frontier days, Nevada’s economy revolved around mining. The resulting abundance of single men and the high rate of transience contributed to a cultural ethic of independence.

“People were expected to look after themselves,” according to a government history of health care in Nevada. “Government was not expected to provide for their assistance.”

About 150 years later Nevada’s demographics have changed, but its libertarian values are still in play. The emphasis on small government is a primary reason Nevada’s funding for Medicaid, the government’s insurance for the poor, is the lowest per patient in the nation.

In a similar manner, the congressional debate over health care reform is being driven by ingrained cultural values that often go unspoken.

An estimated 46 million Americans have no health insurance. Employers are buried under the rising health insurance costs, as is Medicare, the federal government’s insurance for the elderly and disabled. With Congress on vacation this month (the Senate is scheduled to begin its recess Friday; House members have left Washington), the national politicians are back home — debating, ridiculing and supporting the nuts and bolts of various reform proposals: a public health insurance plan; an emphasis on preventive medicine; insurance mandates; looming taxes and more.

But the surface issues don’t strike at the heart of the health care reform debate, according to ethicists and policy experts. Just as Nevada’s libertarian heritage influences the state’s investment in health care for the poor, discussion to change the nation’s health care system is deeply influenced by cultural values.

Two fundamental American values — capitalism and individualism — present obstacles to significant change. American culture embraces commerce, consumption and profit and elevates the rights of the individual over obligations to the community. This makes it easy for some critics to heap disdain on changes that can be painted as limiting free enterprise, cutting into profits or leading to the real boogeyman — socialism.

American cultural values are “incredibly powerful forces” that influence the debate, said Eric Wright, director of the center for health policy at Indiana University-Purdue University Indianapolis. “The problem has been that we’re not making those value distinctions explicit.”

Health care reform advocates are urging a shift in perspective so that medicine moves from a private good, for the benefit of individuals, to a social good for the benefit of all. This raises fears of “rationing,” Wright said, but health care is already rationed — on the basis of a person’s ability to get health insurance.

People don’t talk about the cultural values that influence the debate because “it gets too threatening, it sounds un-American,” Wright said. “It doesn’t matter what you propose, they’ll throw out the ‘s-word’ — socialism.”

Josephine Johnston, a research scholar at The Hastings Center, a bioethics think tank, said there are many examples of health issues where the public good trumps personal autonomy, including seat belts, smoking bans for public spaces and the Medicare and Medicaid systems.

An effective health care overhaul would require a trade-off in values, she said, and sometimes it comes down to how values are emphasized. For example, Americans are individualistic, but they’re also incredibly generous, she said. “People have a sense they need to help the disadvantaged,” she said.

The Hastings Center is pushing the values arguments with its new report: “Connecting American Values with Health Reform.” The report includes essays that show how values such as liberty, justice, fairness and responsibility support the argument that there must be “universal participation” in the health care system.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said the values and ethics of health care are being lost in the current debates muddied by ever-changing proposals. In the 1990s the details of the Clinton plan ran 1,800 pages, he said, but it failed because there was no agreement that health care is a fundamental human right, like food and shelter.

“If you think that health care is a right then everything else gets worked out,” Caplan said.

Ultimately, he said, it comes down to an ethical conviction.

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