On April 1st 2012, my book,”Dagbok från USA”, came out in Sweden. It will also soon be published in English (as an e-book for Kindle and for other readers) with the title: “Diary from the United States – Notes on a society in crisis“. As an appetizer for English speaking readers, I will the coming weeks publish some excerpts from the book.

Of course, values affect what kind of health care system we choose in a society

More than 46 million Americans, 15% of the population, lack health insurance. It thus becomes meaningless seen with European eyes to talk about the American health care system being equitable or fair. Europeans mean something quite different by justice and fairness in this context.

At the same time, it would be a mistake to simply dismiss the U.S. health care model as less developed. In some respects it’s superior to the European universal health care model. For example, the resources used for health care in the U.S. measured in relation to GDP are substantially larger than in Sweden, although that it’s to some extent due to much higher administrative costs. The American health care sector is also more research-intensive and provides a lot of space for health care entrepreneurs, more than in Europe. Furthermore, it’s not true that the poor, elderly, and disabled make up most of the more than 46 million Americans who are uninsured. About a quarter of the uninsured qualify for public health services (e.g., through Medicaid) but for some reason choose not to enroll in the system. There is also a large group of uninsured working-age people with moderate incomes who are hoping that they will not get sick or injured, who just have other priorities than health insurance. From a European perspective, this is an unfair system. At the same time, one must note that a large proportion of these people make a conscious choice not to insure themselves.

There are also insightful Americans, such as Harvard professor Michael E. Porter, author of Redefining Health Care, who clearly see the shortcomings of the U.S. system, including the fact that so many people end up outside the protective net, but still argue against a single-payer, universal health care system like in for example the U.K.. Porter argues that such a system costs too much in terms of lowered capacity for innovation and vitality in the health care industry. What is needed, Porter argues, is more competition, especially competition on the clinical level, not less.

There are in theory two ways of organizing health care: the way that most citizens in Sweden, and indeed in Europe as a whole, think is right and the way that a majority of Americans believe is right. In Sweden, as in many other European countries, the focus is on justice, on a fair provision of health care to all citizens. Americans emphasize the individual’s free choice and dynamism and entrepreneurship in the health care sector. In both cases, it’s a balancing act between the two theoretical extremes of complete justice and complete freedom. The American model puts the balance point on the freedom side while Sweden and Europe in general put it on the justice side. Both pay a price for their choice.

It ultimately comes down to two philosophical views of what constitutes a just society. The first approach, the one most people in Europe, at least in Northern Europe, subscribe to, gives society, primarily through the state, the right to reallocate resources. The main objective is to create a more just society. It’s a moral position; the majority wants and stands for a more equitable society. Of course, there are no rational decision criteria that will help us determine what’s fair and what’s not. Consequently, politicians have a lot to say in this model. The American philosopher John Rawls is the most famous representative of this view. He also offers a fascinating algorithm, the model with the so-called “veil of ignorance”, with which one can determine a level of society’s redistributive intervention that most citizens probably would accept.

According to the second approach, at least in its most extreme form, the distribution of resources among the citizens at any given time is also the fair distribution. The argument is simple. Provided we have obtained the current distribution through voluntary choices and exchanges, the income and wealth distribution we have right now is fair. Applying this approach in its pure form, as the passionate libertarians are doing, leaves almost no room for politicians to reallocate resources to create a more equitable society, for example, to provide medical services free or at a low cost, to those groups in society that are unable to pay the insurance premiums required (because a taxpayer-funded health care is not feasible in a libertarian world). Robert Nozick, also an American philosopher, is often associated with this conception of justice. It’s said that when Bernard Williams, another philosopher, argued that the only reasonable criterion for allocating health care is the medical need, Robert Nozick posed as a counterargument, why isn’t “the only reasonable criterion for the distribution of hair care the need to visit a hairdresser”?

The purpose of this article has been to show that there are at least two ways of looking at what we mean by justice and fairness. In other words, which health care model to choose is ultimately a political and moral question. It must be recognized that only concerned citizens can – through a democratic process – make this choice in our type of highly developed society.

The New England Journal of Medicine had an editorial a few months ago (30 July 2009) that discussed whether the American libertarian values have had an impact on the U.S. health care system. Or have not, which was the editorial’s main message.

For my part, I would argue that values have had a great impact on the U.S. health care system. Apparently many Americans believe that it’s up to each and every member of society, at least everyone who is healthy and working, to arrange their own health insurance. The state shall not interfere in such matters. For a European it’s more than clear that this position is grounded in these libertarian values, and that these values will affect the ongoing reform of the U.S. health care system is already quite obvious.

Literature:

Nozick, R., 1978, Anarchy, State and Utopia, Blackwell, Oxford;

Rawls, J., 2005, A Theory of Justice, Harvard University Press, Boston;

Kay, J., 2004, Culture and Prosperity – Why Sometime Nations are Rich but Most Remain Poor, Harper Business, New York;

Porter, ME, & Olmsted Teisberg, E., 2006, Redefining Health Care, Harvard Business School Press, Boston;

First published (in Swedish): December 7, 2009