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MANAGED COMPETITION AND MANAGING COMPETING CLAIMS:
The Political Philosophy of National Health Insurance Policies Mike Ridge, Tufts University 1993 - Health Care Policy: Debating Coverage Cures |
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Why take the perspective of political philosophy? One might wonder why seemingly abstract issues of political philosophy are relevant in the context of policy-oriented debate on health insurance. The short answer is that they establish an overall worldview, or paradigm, from which competing policies can he evaluated. The criteria by which you judge a particular policy would be different from a Rawlsian perspective than from a utilitarian perspective, for example. If you adopt the former perspective you might be willing to forego a greater level of "utility" (happiness, beneficial consequences, etc.) for the wealthy in order to further the interests of those least well off (the poor), while if you take a utilitarian perspective maximizing utility is the critical variable in evaluating competing policies. To take a concrete example, consider a Canadian sort of single payer plan. Arguably, such an approach would make the least well off members of society better off by making sure that they have health insurance. Such a policy would also have serious negative implications for the wealthy and the middle class since they would be taxed more heavily to ensure the coverage of the poor. Indeed, since the number of poor people is considerably smaller than the number of rich and middle class people, the overall or net level of utility (the increases in utility minus the decreases in utility) might be reduced. If you adopt a utilitarian philosophy, such a plan would then have to be rejected, while if you adopt a Rawlsian perspective you would vote affirmative, recognizing the special protection society must afford those least well off, even at the cost of a net reduction in utility. In sum, advocating a particular philosophical perspective provides a way to take the "bottom-line" implications of a given policy and evaluate them in a (hopefully) non-arbitrary way. Political philosophy is particularly relevant on this year's topic because it deals fundamentally with issues of income redistribution. The topic mandates that affirmatives guarantee comprehensive national health insurance to all United States citizens. Not surprisingly, those who currently lack health insurance are frequently either poor, unemployed or both. A core problem that the topic forces the debater to deal with, therefore, is whether there is a duty to tax the more well off members of society (who usually already have health insurance) to fund health insurance for the less well-off members of society (who are much more likely to lack it). As the foregoing discussion of Rawls should have made clear, such issues of income distribution are prominent in political philosophy. This is not to say that these same issues have not been (and will not be) relevant to other debate topics. (Indeed, virtually every debate topic imaginable is rich in issues of political philosophy.) If the topic involves foreign assistance, like last year's college and high school topics, issues of income redistribution could come up - whether Americans should be taxed to provide foreign aid for less well off (on average) citizens of other countries, to name but one example. The foreign policy literature, however, tends to focus more on issues like "the national interest," human rights promotion, and promoting political stability than upon issues of political philosophy. The health care literature, by contrast, is fairly rich in its discussion of competing philosophical worldviews. Since debate, as currently practiced, is so heavily dependent upon evidence, this relative bounty of evidence makes philosophical issues more relevant from a practical perspective. More fundamentally, the word "guarantee" in the topic makes such philosophical issues particularly appropriate. To guarantee something implies certainty that the item in question will in some way be provided. The use of such a strong word implies a notion of entitlement, perhaps a fundamental right, to the item in question, which lends itself to the kind of rights-based analysis found in political philosophy. This notion of entitlement or rights is also implied by the word "all" in the topic; things that the government has a duty to provide to "all" U.S. citizens are usually not mere luxuries but are fundamental rights, like the rights of the accused to legal counsel. Again, however, the uniqueness of this topic should not be overstated; questions of political philosophy are in most ways equally relevant to other topics as they are to this one. Perhaps some of the nuances of this topic merely lead one more naturally to view it from a perspective of political philosophy. Constitutional Rights and National Health Insurance Affirmatives may want to claim that the Constitution mandates a right to health insurance. A thoroughgoing philosophical defense of the entire U.S. Constitution goes well beyond the scope of this paper, although some evidence was included in the section for heuristic and bibliographical reasons (D30 and D52-3) on this issue. Suffice it to say that there is a solid set of literature that argues that upholding the Bill of Rights and all of the various amendments of the Constitution is a bare minimum that any just government must meet, whether for reasons of social contract or natural law, and that there is an opposing literature that argues that the Constitution is merely a mechanism to entrench the arguably antidemocratic power of certain elite members of society. The more germane issue for the purposes of this essay is the "link" debate--whether the Constitution implies a right to health insurance. One set of evidence (DI -D2) makes the argument that none of the basic rights in the Constitution have any meaning without health insurance. For example, the right to free speech has little meaningful content to the invalid denied health care because she lacks health insurance. Other evidence (D3) argues specifically that health care is needed to exercise the right of assembly. Finally some evidence (D6) argues that since criminals are afforded the right to legal counsel, no American should be denied the "seemingly more fundamental right to basic medical care." The negative has several strategic options with which to attack these sorts of advantages. Perhaps most powerfully, the negative may wish to emphasize what has been called the distinction between positive and negative rights. Negative rights are rights against interference from others, particularly the state; I have a negative right to free speech insofar as it is improper for the state to interfere with my exercise of that right. Positive rights imply not only a governmental duty not to negatively interfere with individuals' attempts to exercise their rights but imposes as well a duty upon government to provide individuals with whatever means are needed to exercise those rights. Unless it can be proven that the government caused someone to get sick (in which case the government would have violated its duty of noninterference and would have to make reparations), it should be rather clear that a theory of negative rights would not recognize a right to health insurance. Certainly the government is not responsible for the majority of health problems in the country, and by no stretch of the imagination is it responsible for all of them. Personal choices about one's lifestyle, diet, etc. and the exigencies of one's genetic heritage, more than any governmental policy, affect one's health status. So if the negative can defend the proposition that the Constitution only recognizes negative, and not positive, rights they will be in an excellent position. Even if the government has a duty to provide health care to those individuals it causes to become ill, it will most certainly not have a duty to provide such care to "all United States citizens." Arguing that the Constitution. only recognizes negative and not positive rights can be done in several different ways. One argument is simply based upon an appeal to authority; you can argue that the Supreme Court has never recognized positive rights stemming from the Constitution and that they are experts on interpreting that document. The affirmative should be quick to point out the incredibly conservative implications of this argument. If we are to unquestioningly to assume the validity of the Supreme Court's pronouncements because they are "the experts" then anything that happens in the status quo that is sanctioned by the Court is legitimate. The negative would be forced into defending the repugnant notion that slavery was legitimate at one point in our history, given the Supreme Court's Dred Scott pronouncement. That example also demonstrates that "the Court" (a phrase that inaccurately implies a monolithic entity)changes its pronouncements over time. Surely fundamental issues of basic rights do not change over time so easily! At best it would seem that this argument can buttress the negative position; in and of itself it seems an inadequate criticism of positive rights. A more promising indictment of positive rights is to simply point out the intuitively absurd implications of such a theory. For example, does the right to free speech imply that I have a right to have a loudspeaker, lectern, and a printing press provided to me by the state upon demand? Does the second amendment imply that the state must provide me with a tank if I can't afford one? The affirmative evidence that various rights outlined in the Constitution will lack meaning for some people without health care may be true to a degree, but that would at best establish a utilitarian basis 1 for providing those services (which could be "outweighed" by other unpleasant consequences). Having a right to something is distinct from needing something for a right to be meaningful. It might be nice of the government to provide everyone with health insurance insofar as it has pleasant consequences in that everyone's rights would be more meaningful, but (this argument would go) the state has no Constitutional obligation to do so. Finally, the argument in favor of libertarianism establish a case for a purely negative conception of rights in terms of what Nozick calls "side constraints." The negative may also be able to point out that the affirmative "link" into the Constitution does not match their "impact" evidence. Many of the good impacts to upholding the Constitution presuppose a negative theory of rights. Evidence that says that without Constitutional checks we will be subjected to a tyrannical government, for example, almost certainly makes such a presupposition. Without the positive rights the affirmative defends we may be vulnerable to a somewhat metaphorical "tyranny of disease," but the negative rights theory provides a sufficient check upon governmental encroachments upon our freedom by precluding the state from interfering in the exercise of our rights. The negative should also not let the affirmative gain too much mileage from the analogy to legal counsel. If someone is accused of a crime, they are in jeopardy of being punished by the state, of having their fundamental liberties violated by the state. Providing legal counsel is a necessary step that the state must take to ensure that it does not deprive innocent citizens of their fundamental rights. The main distinction is who is responsible for the harm done to the individual. In the case of providing legal counsel, the accused is at risk of being punished by the state, and so the state has a duty to make sure that such punishment is not imposed on the innocent. Such a duty is consistent with the viewpoint of negative rights -- the state has a duty of noninterference in the basic rights of innocent citizens so they must take every precaution against(for example) imprisoning the innocent. In the case of health care, the ailment (usually) is a result of some natural contingency or lifestyle choice that the state had nothing to do with, and hence from a negative rights based perspective the state has no duty to provide that individual with health care. Another potentially powerful distinction for the negative is the one between health insurance and health care. Even if the state has a duty to provide health care to its citizens, the question of how that care is to be financed is not settled (See D38). This argument could be strengthened with evidence that status quo laws preclude hospitals from turning away patients in need of emergency care because they lack health insurance. Such a law would mean that all citizens have a right to at least some level of health care that is protected by the status quo without all citizens having health insurance. Furthermore, the negative may want to question the notion of a right to comprehensive health insurance, depending upon how that word is interpreted. Most of the affirmative authors only advocate a certain basic minimum of health care to which everyone is entitled. Whether such a basic right would imply comprehensive benefits is an open question. To take an extreme example, most of the affirmative authors would probably agree that citizens have no constitutional right to purely cosmetic plastic surgery (obviously by "purely cosmetic" I mean to exclude cases in which someone has been seriously disfigured, like a bum victim). If the affirmative is forced by topicality arguments to provide "overly" comprehensive benefits the negative might have an excellent strategy in a counterplan to provide the basic minimum of benefits to which citizens are entitled and arguing some disadvantage to the more elective components of the affirmative plan as net benefits. The "rights trivialization" argument is basically a disadvantage included here because the impact would be a case turn against Constitutional rights types of advantages. The argument basically is that by promoting an ever expanding list of Constitutional rights the affirmative risks trivializing the entire Constitution, and the more "core" values it protects. Obviously if you can prove that the right to health insurance is not a trivial right this argument loses much of its force, so that the "case debate" discussed above has serious implications for the link. The physician's autonomy argument that a right to health insurance unfairly burdens the physician's autonomy in treatment decisions is included here even though the evidence is not specific to any Constitutional right to such autonomy. The argument could also be used against most other accounts of a right to health care, like a Rawlsian account, for example. It was included in this section simply because there were not enough cards on it to merit its own section; the decision to include it here instead of the Rawls section is admittedly an arbitrary one. Another negative argument against cases that focus upon a Constitutional right to health care involves the notion of "legislative overrulings" of Supreme Court precedents, and several disadvantages associated with such actions. If the affirmative has Congress pass a law mandating national health insurance for all citizens based upon a Constitutional right to such insurance, then the Congress would be overruling several Supreme Court decisions which clearly state that the Constitution implies no such right. By offering an alternative and contradictory interpretation of the Constitution the affirmative might undermine the Supreme Court's legitimacy. 2 Supreme Court legitimacy was a fairly effective disadvantage on the college privacy topic and could be an effective one again this year. A specific impact that might be persuasive in this context would be "branch-fighting"; since the Court lost its legitimacy because of something the Congress did, relations between the legislative and judicial branches might sour. Finally, some authors have argued that the current Supreme Court is very conservative and will only change its ways when the legislative branch enacts sufficiently progressive legislation that clearly demonstrates that the Court is "out of synch" with the American people. The argument is that by forcing such a dichotomy between the Court's views and the apparent views of the rest of society at large, a "Constitutional Moment" would occur, and the Court would change its ways and become progressive. 3 While most of the authors who talk about this are advocating such a Constitutional Moment, there are plenty of authors who argue that a radically liberal Supreme Court would be a bad thing, for reasons ranging from criticisms of affirmative action to indictments of ideas like comparable worth. These disadvantages could even be run against cases that did not specifically put in their plans that they based the entitlement to health insurance on a Constitutional right to health insurance. You could have a pretty persuasive story that even though it isn't specified in the plan, the most likely way it would be passed in Congress would involve at least some Congressperson (probably Senator Wofford - see D6) yapping about how we have to adopt the plan because there is a Constitutional right to health care; if that occurred the perception might still be that the Congress was correcting the Court, and the disadvantages would still link. A Rawlsian Analysis of National Health Insurance John Rawls' A THEORY OF JUSTICE 5 offers the most comprehensive explication of his political philosophy. Any attempt to summarize his overall philosophy here will by nature of the brevity of this article be unduly superficial, so affirmatives interested in making this position a centerpiece of their affirmative would do well to read that work as a starting point. In that work Rawls works out what he calls a theory of "justice as fairness" which he considers a contract theory.6 An important component of Rawls' position is the notion of the "original position." This is the perspective from which he argues we should craft a just political system:
Rawls argues that adopting this veil of ignorance is necessary in the original position to ensure that the principles decided upon there are fair. Lf people knew what their particular attributes were, they would have an incentive to lobby for a set of principles that would give unique advantages to individuals with those attributes. The veil of ignorance serves to ensure that the principles of justice are not set up in such a way that people would be "advantaged or disadvantaged in the choice of principles by the outcome of natural chance or the contingency of social circumstances."' People in the original position are also assumed to be rational and capable of a sense of justice. This assumption of rationality allows the theory of justice to exploit the intuitively appealing idea of rational prudential choice (see D54). Rawls argues that this original position would yield a particular set of principles of justice:
These principles are arranged in what Rawls calls lexical ordering, meaning that the first principle must always take priority over the second. Specifically, the first principle must be satisfied before the second comes into play. 10 In further fleshing out this theory of justice, Rawls goes on to argue that the second principle should read:
This notion that inequalities should be arranged to the greatest benefit of the least advantaged is also called the difference principle and the maximin rule. Rawls argues that people in the original position would opt for such a rule firstly because of the impossibility of probability calculations in such an initial state. For example, if people knew that there was a 99.9% chance that they would be among the elite section of society they might opt for principles of justice which allowed for grotesque inequalities of what Rawls calls primary goods, 12 because the odds are so good that they would not be among the least well off who would be devastated by such inequalities. 'Me veil of ignorance, however, makes such probability calculations impossible. Since such probability calculations are impossible, the person in the original position would be quite cautious about aflowing principles to be chosen which could have grave consequences for the least well off, because there might very well be a high probability that he would be among them (see D55-6). Another reason people in the original position would opt for the difference principle as a principle of justice has to do with the publicity criteria. Rawls argues that a condition of publicity would naturally result in the original position:
Rawls argues that the publicity criteria would also rule out principles that implied inequalities that did not work to the advantage of those who are least well off. Since any such set of principles would make it clear that some people (the least well off) were being forced to "forgo greater life prospects for the sake of others."" Such knowledge, Rawls posits, would seriously undermine the self-esteem of the least advantaged, and the stability of the entire system would be jeopardized (D 187-8). The publicity criteria makes this an intrinsic cost of such principles because the least advantaged will know that their life prospects are explicitly being reduced for the sake of others who are more advantaged. Since people in the original position would not choose a social system that would inevitably collapse, the publicity criteria lends credence to the difference principle. It is not too difficult to see how the validity of this difference principle can impact the health care debate. The least advantaged members of society are most likely to be without health insurance, simply because they can't afford it. In this way Rawls' theory d creates a societal obligation to provide health insurance for those least advantaged members of society. To my knowledge, none of Rawls' published writings deals with health insurance per se. It is not clear whether health insurance in and of itself would be a primary good .15 The most comprehensive analysis to date of health care from a Rawlsian perspective is probably Norman Daniels' JUST HEALTH CARE. He argues that disease and disability epitomize the arbitrary result of what Rawls calls the "natural lottery" and therefore society has a duty to provide health care to all of its citizens (D59). He also discusses health care's "strategic importance" (D61) - since without health citizens would find it uniquely difficult to pursue their notions of the good and exercise their political rights, health care is a special good, one that it is particularly important to provide to the least advantaged. Daniels also discusses health care as being needed for "normal species functioning" which we all need for a reasonable expectation of pursuing our notions of the good(D645). Perhaps most interestingly, Daniels argues that a system of rationing health care is somewhat "invisible" insofar as it is done without a clear, publicly enunciated set of criteria for who will be denied and given access to particular treatments (D69) and that this invisibility violates the publicity criteria. Daniels is specifically indicting the British system for rationing dialysis in this passage, but given some of the affirmative evidence in the rationing section about how the status quo arbitrarily and invisibly rations health care, this argument could be brought to bear against the current American system as well. Some of the negative arguments mentioned in the previous section are applicable tools for the negative in this context as well. Particularly, the distinction between health care and health insurance is a relevant one - Daniels' book is entitled JUST HEALTH CARE, not JUST HEALTH INSURANCE. A counterplan or defense of the status quo as providing sufficient health care to satisfy the Rawlsian principles without using health insurance per se might be an effective way to minimize or eliminate the case advantage. A good counterplan might also be to do some more basic kind of income redistribution with cash transfers and argue that the least advantaged should be able to choose whether to spend their money on health insurance or some other commodity they might value more. As long as the least advantaged have enough cash that they could afford the insurance package that the affirmative guarantees with as much cash left over as they would have with the affirmative, the counterplan meets the Rawlsian criteria of justice as well as the plan because the least advantaged have the affirmative's insurance package available as an option to the same degree that they would under the plan. Indeed, since enhancing the autonomy of the least advantaged is an additional advantage that only the counterplan can reap, the counterplan arguably satisfies the Rawlsian criteria better than the plan (see D116-7 for evidence on this kind of counterplan). Of course doing both would help the least advantaged even more, but that would involve a gargantuan amount of income redistribution, so you should be able to find plenty of (Linear) disadvantages to such a costly permutation. Furthermore, if the 1AC advantage's claim that the plan is sufficient to meet the demands of Rawlsian justice then the permutation is "going above and beyond the call of (Rawlsian) duty"! The same play on the word comprehensive discussed in the Constitutional rights section is available as well; it is not clear that a person needs "comprehensive" health insurance for "normal species-functioning," for example. Another interesting way to answer this sort of advantage is to point out that comprehensive coverage implies an uncontrollable spiral of technology, in which the least advantaged would leech huge amounts of societal resources with minimal results (D84-6). This is particularly relevant given the huge debate about cost control right now, and you should probably cross-reference that section in this context. Furthermore, Daniels' account does not account for a systematic way to balance resources between health care and other primary goods, which any complete theory would have to do (D87), given this huge drain of societal resources. Other powerful negative arguments can be generated by criticizing Rawls' basic theory. A discussion of such issues would go beyond the scope of this article; however, the section does contain a fair amount of evidence on these kinds of arguments (D91-105) and the outline combined with the evidence on these issues is fairly self-explanatory. For more bibliographical assistance in crafting a strategy against Rawls' theory in general, try to find a copy of the poverty DRG, as it had a good section on Rawlsian justice. A Libertarian Analysis of National Health Insurance Libertarianism's most powerful contemporary defense can be found in Robert Nozick's ANARCHY STATE AND LJTOPLA 16 , although since the writing of that work Nozick has ultimately come to reject libertarianism (see D165-6). Nozick argues for what he calls "side constraints" (D128-9) against aggression which stems from the separateness of persons. Once we realize that we are separate people with separate existences, Nozick believes it will become clear that there can be no "greater social good" which can justify a violation of these side constraints. This idea is captured in the adage, "I feel like he used me." When someone says that, they are conveying the idea that it is wrong for someone else to treat them like a tool, even if the benefit for the "user" is greater than the cost the person who is used. This demonstrates the absolutism of moral side constraints - it is deontologically wrong for someone to use another person. Nozick uses this notion of moral side constraints to indict patterned principles of distributive justice. Distributive justice inevitably involves taxation, which Nozick argues violates moral side constraints. In fact, Nozick argues that taxation is forced labor (Dl3O). The idea is that the state, by taking the fruits of someone's labor is taking time from her and directing her to do particular activities. Since other people are forcing her to do unrewarded work, and making the decisions about what is to be done with the fruits of that labor, those people have a property right in her. Another criticism Nozick levels at patterned principles of distributive justice is that they take an ahistorical approach to justice. By only looking at a "current time-slice" and determining whether it contains a just distribution of resources, this approach ignores the concept of desert. Property does not just pop into existence; it is produced by the labor of particular individuals. By ignoring that particular individuals either by virtue of their labor or free exchange with other particular individuals come to deserve their property, distributivejustice ignores intuitive notions of fairness (Dl33-5). Obviously, virtually all proposals for national health insurance involve some level of taxation, usually a substantial one. Since taxation violates libertarian side constraints, the negative would argue the plan is deontologically wrong and should be rejected a priori. You can either argue the position as a counterplan (see D107 for ideas on a text) or a kritik. One good tactic for the affirmative is to argue that even if some forms of redistribution are illegitimate, health care is a unique good. One argument in this vein is that health insurance aims to remove physical inequalities which libertarian side constraints ignore (Dl52). Another interesting argument is that decisions in the status quo as to whether to buy health insurance are often made for spouses and children by the "head of the household," which undermines the strong notion of individualism libertarianism is trying to protect (Dl54). Another affirmative argument is that health insurance is actually compensation, not redistribution, a distinction Nozick must concede to justify even the minimal state rather than total anarchy. Since the state is responsible for environmental pollution-induced illnesses and other kinds of illnesses, it has a responsibility to compensate its citizens. Naturally such an argument is vulnerable because most diseases are not caused by the state and comprehensive national health insurance would go far beyond merely compensating those individuals who suffered because of the state's actions. Again, some of the strongest affirmative arguments involve criticizing the basic libertarian theory, and generous amounts of evidence have been included in that vein (Dl54-86). A discussion of those points would go beyond the scope of this article and would probably be redundant with the section anyway. Utilitarianism Since utilitarianism seems to be the "default" philosophy of debaters, a discussion of its basic intuitive appeal seems superfluous. Obviously the idea that we should just "weigh" the increment of utility a plan promotes versus the amount of utility it sacrifices has great intuitive appeal. The most interesting issue for the purpose of the section presented here involves the separateness of persons. Both Rawls and Nozick agree that utilitarianism goes wrong by ignoring the separateness of persons. All of the distinct members of society are lost into a big melting pot of social utility. The most interesting evidence for the utilitarian critiques this assumption of the separateness of persons. One argument in this vein is a defense of the intersubjective definition of self. The idea is that the "self' is really constituted by what are commonly considered relations "between" individuals. (Me inadequacy of everyday linguistics to convey this concept is apparent.) According to this argument, people would have no, or only an extremely weak, sense of who they are apart from their relationships with "others" (D214). Against this argument and others like it, Rawls argues that the theory of justice is a political, and not a metaphysical theory. The basic idea is that people have argued for centuries over difficult metaphysical issues like the separateness of persons. To include a controversial, particular notion of the good in a theory of justice is inappropriate. People are still free in their moral lives to accept principles based upon intersubjective notions of self, but that idea should not be included in the principles of justice, which only is supposed to serve to ensure that everyone has a fair chance to pursue his or her own particular notion of the good. Those people who disagree with the intersubjective definition of self should be allowed to live accordingly, insofar as their beliefs are consistent with the theory of justice. Indeed, Rawls points out that previous attempts to impose particular teleological conceptions of the good have caused religious wars and are no longer a plausible option (D201). Summary The primary goal of this article is to help you understand how to use the evidence included in the philosophical section of the book, and to get your creative juices flowing. This essay has just scratched the surface on these issues, and there are other competing political philosophies that were not discussed at all, such as Marxism and anarchy. 'Me key to success with these arguments, like any debate argument, is a good mixture of creativity and intensive research. The ideas discussed here should be used as a spring board for further brainstorming and research rather than a complete explication. Good luck and happy researching!
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