The prominent health-care economist Uwe Reinhardt aptly wrote before his death in 2017 that it is “an unwritten rule that in [the United States] we prefer to debate proposed health reforms mainly in terms of technical parameters,” focusing on things like premiums, out-of-pocket costs, high-risk pools, and uninsured rates (2019, 99). This state of affairs is understandable. Discussions about the technical details of health policy make it seem like our disagreements are less about underlying principles and more about how to manage the economic and health-related outcomes of different policy proposals.
The problem, for Reinhardt, is that the “elephant in the room” in most public debates about health policy is what we collectively owe to our neighbors. We entertain conversations about what economic and health outcomes are relevant in designing new health care systems but neglect how those outcomes matter in protecting equality of each citizen (cf. Field Reference Field2015). Thus, to take a recent example, instead of seeing the Affordable Care Act’s (ACA) premium subsidies as a principled step to provide access to health insurance for lower-income Americans, it has been more convenient—even for the law’s proponents—to debate the impact of subsidies on other premiums and the number of companies participating in insurance “exchanges” (Congressional Budget Office 2018). The moral case for health care reform in the United States has waxed and waned, even in light of the attention that it will likely receive during the 2020 election cycle.
Alex Rajczi’s relatively compact treatment in The Ethics of Universal Health Insurance is valuable for a number of reasons. But the most important of these is his novel answer to the concern raised by Reinhardt. While Rajczi does not deny that underlying moral principles matter in how health-policy debates are framed, he encourages us to see the debate over universal health insurance as one where the technicalities of insurance policy are part of a larger debate about how to effectively provide access to health care, something that he thinks most engaged observers would agree is part the “social minimum” owed to citizens (56). Rajczi holds that an authentic and effective public debate about the future of health policy should focus on the most common objections to universal health insurance. We need to remain open to “real-world” disagreements about the level at which the social minimum should be set and the reasonable grounds upon which serious, well-intended people differ about how to effectively meet that minimum (2).
There are three (related) objections to universal health insurance that occupy most of Rajczi’s time. The first is that policies designed to provide universal health insurance—whether through market regulation or a single-payer system—impose a heavy “personal cost” on citizens, such as loss of existing insurance, substantially new taxes, reduced employment opportunities, or the loss of freedom through mandates to purchase insurance (80). The second objection holds that universal health insurance regimes are not effective in improving overall health of the population, or, if they are, they do so inefficiently or by reducing levels of care for certain populations. Rajczi refers to this as the “efficacy” problem and notes that under this objection are worries about how universal health insurance dampens health-care innovation, produces wait times for services, and otherwise reduces quality of care (166). The third objection levelled against universal health insurance is that the “fiscal” burdens of paying for universal coverage involve substantial tradeoffs with other public endeavors that may make citizens worse off (210). There is a substantial chapter devoted to each of these objections, followed by a discussion in the closing two chapters that develops the case for universal health insurance.
Rajczi is careful in his consideration of each of the above objections. He responds by appealing to multiple data sources, extensive literature in public policy, and comparative evaluations from other national health systems. We learn, for instance, that, contrary to the received wisdom of most critics of national health insurance, an examination of data shows that wait times for elective surgery in the United States are comparable to other countries with policies of universal health insurance, especially once researchers control for the general accessibility of care (198–203). Rajczi reminds us throughout the book that universal health insurance programs have a number of options that can preserve a robust marketplace for private insurers, thereby providing tangible ways to maintain consumer choice and reduce overall health-care spending (30–33). He stresses elsewhere that rigorous studies on the financial burdens of universal health insurance point to the intermediate- and long-term cost savings that result from single-payer systems (44–5). On various cross-national quality measures, health outcomes measured as a function of national expenditures tend to be higher in countries with highly regulated or nationalized health insurance systems (171–6). For anyone interested in a systematic review of these kind of policy insights, The Ethics of Universal Health Insurance will not disappoint.
These policy-related responses to the personal cost, efficacy, and fiscal risk objections are buttressed by important philosophical lessons. In the chapter addressing the personal costs of universal health insurance, for example, the reader is reminded that evaluations of whether a policy has disproportionate personal costs is a function of how we categorize those personal costs and how those costs undermine an individual’s goals, interests, and other legitimate pursuits. At one moment Rajczi questions how personal costs are accounted for among critics. He argues that whether someone is personally worse off under a new social welfare policy cannot simply be a function of that person’s subjective evaluation of their own well-being. A person may have to pay taxes to support a new health insurance policy. Such taxes may reduce her ability to pursue a cherished hobby. But there are certain goods—like economic opportunity, physical health, and civic participation—that form the basis of a good life, regardless of one’s subjective pursuits. Rajczi thereby casts doubt on whether perceived personal costs—in this case, to the pursuit of a hobby—should necessarily outweigh the more expansive goods that social welfare taxes enhance (144). Or, in a similarly instructive move, he notes that the subjective personal costs that may result from the imposition of a social welfare policy are outweighed by new opportunities (146). So while it may be that a universal health insurance policy reduces some options for personal choice in the insurance market, it may also open doors to better coverage of important health-related services.
Another example of an instructive philosophical moment comes in Rajczi’s treatment of the efficacy objection. One commonly cited problem among critics of universal health insurance is that such policies dampen health-care innovation, thereby inhibiting improvements to quality medical practice. Rajczi—in his characteristically pragmatic tone—is open to the possibility of this concern. But after examining the data about innovation in countries with universal health insurance, as well as explorations of how innovation can be enhanced through public policy, he argues that the central problem with critics’ position is moral rather than empirical. Even if critics are correct that universal health insurance will reduce innovations in, say, technology or medical practice, it is mistaken to prioritize innovation-led quality of care over the access to a social minimum of care. Through an excursus of how competing, seemingly incommensurate welfare concerns can be reconciled, Rajczi reasons that innovations producing improvements to care, while important, are constrained by the considered judgment in “reflective equilibrium” that a minimum of care for all citizens has priority over other concerns (192). As long as there are real-world tradeoffs between innovation, quality, and access—something efficacy objections implicitly concede—then there is a reason to prefer universal health insurance arrangements that can, first, assure access to care while still allowing, second, private and public mechanisms to make up for a deficit in innovation (cf. Mechanic and Altman Reference Mechanic and Altman2010).
It should be stressed that the philosophical importance of Rajczi’s book lies not just in these insights. The unique contribution of the book is Rajczi’s admission that there continues to be reasonable disagreement among individuals on the merits of various arguments in favor of universal health insurance. This premise gives rise to Rajczi’s overarching methodology, which he terms “other-oriented philosophy.” He maintains that his goal “is to offer arguments which [would] be accepted by [an] audience, were the audience to react rationally to the evidence presented” (103). Other-oriented philosophical argumentation seeks to provide reasons that should convince a reasonable audience. Rajczi is constantly crafting his arguments—both empirical and normative—to be appealing to a broad audience of engaged, reasonable individuals who may not see eye to eye on the underlying norms or social scientific claims supporting universal health insurance.
Some readers may find this unexpected, if disappointing. A book with the terms “ethics” and “universal health insurance” in the title might suggest that it aims to lay bare the normative grounds for universal health insurance. In a sense, of course, this is done; however, Rajczi’s other-oriented methodology embraces at least two important assumptions that may help explain his aversion to a thoroughgoing philosophical defense of universal health insurance. First, there are inferential gaps between the evidence and data (economic or otherwise) used by advocates of social welfare policy and the conclusions that they hope we accept. The same holds true for the positions defended by critics of social welfare policy. Second, part of generating stability and social consensus around public policy is that reasonable people, who sometimes disagree about principles of justice, can nonetheless find agreement when there are avenues of discourse open between reasonable people. We are better served, for Rajczi, by finding more concrete moral grounds upon which a defense of public policy can emerge.
Rajczi therefore stresses that the public philosopher need not subscribe to, or advocate for, a comprehensive normative theory in order to adequately defend universal health insurance; rather, as Rajczi himself does throughout the book, the public philosopher should appeal to midlevel, intermediate principles and considered judgments that a broad audience can find plausible (283). It will be interesting to see whether conservative and progressive voices in the health insurance debate will take note of this methodological posture. But, if they do, Rajczi’s insights will not only help bring an honest consideration of the facts to the fore, but will also help us remain faithful to Reinhardt’s call to engage the moral dimension of health-care policy without presuming that we need to agree on a “deep theory” of justice (283).
