[The Montana Professor 15.1, Fall 2004 <http://mtprof.msun.edu>]
Lewis Petrinovich
Psychology (Emeritus)
History
U.C.-Riverside
When considering the distribution of human attributes it is obvious that there is an inherent inequality in the natural lottery as a result of the probabilistic interaction of genetic and developmental factors within different environments. While recognizing this basic inherited inequality, I believe the outcomes of the social lottery should foster equality; the basic necessities of life should be available to all and all should have the opportunity to develop to the limit of their abilities. Many philosophers, and most members of developed societies, agree that, in a just society, all similar individuals should be treated similarly. There is a serious problem regarding how to deal with the distribution of resources in light of the large inequalities in abilities combined with a limited supply of available resources.
John Stuart Mill/1/ argued for the paramount importance of meeting peoples' primary needs, and considered it to be a moral crime to bring a child into existence without a fair prospect of being able to provide food, and guarantee freedom from pain. If a parent does not provide these things, a child is harmed, and Mill argued that the State ought to see that these primary obligations are fulfilled. Mill also noted that it is important to have secondary needs satisfied--things such as dignity, love, and respect, as well as idiosyncratic needs that are important to individuals, and which should be available as long as they do not harm others.
These arguments have been developed by John Rawls,/2/ to argue for a concept of Justice, and his ideas have evoked considerable commentary, development, and disagreement. He believes that happiness presupposes the enjoyment of primary human goods, such as food, water, shelter, health care, not being tortured, a certain amount of wealth, and a respected place in a free society. To establish justice, Rawls considers the idea of a social contract to be primary; whenever one accepts benefits and opportunities, in terms of the goods provided by society, there is an obligation to do one's part to see that other members of society are provided for adequately.
To establish basic principles by which to regulate a society Rawls suggested we adopt a difference principle: the position of the better-off is to be improved only if it concomitantly improves the position of the worst-off. Inequalities can be considered to be just only if their persistence results in compensating benefits for everyone and, in particular, for the least advantaged members of society. The difficulty in applying this principle is to decide how to weight the different goods--such as liberty, opportunity, income, wealth, health, and self-respect--in order to decide that there is equality, or at least a reasonable inequality. Such scaling is not impossible; in 1993, Kaplan/3/ outlined methods to do such scaling, and they were used to devise the Oregon Health Plan.
This article is driven by a belief that in the type of just society envisaged by Mill and Rawls all citizens have a moral entitlement to an adequate level of health care; universal health coverage is a moral necessity. The United Nations Universal Declaration of Rights contained the statement that people have a right to guaranteed protection of primary needs, with health-care explicitly included. This is not the forum to discuss the basic concept of Rights; whether they should be based on natural or legal grounds. I have addressed these issues at length in my 1999 book,/4/ and here, I will use Rights in the legal sense.
Major problems exist in the delivery of health care in the U.S., and these problems are becoming seriously worse: Too many people are under- or uninsured; drug, hospital, and insurance costs are excessive; and there are too many layers of bureaucracy in the administration of health benefits.
I was writing a book, Living and Dying Well,/5/ during the time of the Clintons' ill-fated attempt to reform the U.S. health-care system. The situation was dreadful at that time. The Census Bureau reported that, in 1994, 41 million people (15.3%) did not have health insurance. In 1993, the average period people did not have health insurance was 7.1 months, and 9 million had been without insurance for the entire 32 months covered by the report. Partly due to the lack of insurance, infant mortality in the U.S. was 8.9 per 1000 (the 5th highest among 29 western industrialized nations). In the mid '90s the World Health Organization rated the U.S. 37th overall in quality of health, behind virtually all Western European nations, Canada, Colombia, and Morocco. The U.S. ranked 24th in life expectancy--below Japan, Greece, and Iceland. A survey of the net benefits of treatments available for several conditions, including heart attacks, cataracts, and depression led to an estimate that substantial welfare is being lost every year because the benefits of technology are not reaching the uninsured./6/
Since that time the situation has not improved. The Census Bureau reported that the number of uninsured had risen to as many as 44.3 million in 1998,/7/ and nearly twice that many people experienced a period without health insurance in any given two-year span./8/ The Congressional Budget Office estimated that nearly 60 million people lacked health insurance at some point in 2002./9/ Although 80% of the uninsured belong to working families, many employers no longer offer health insurance, more are expected to drop coverage, or are requiring increased employee contributions in the form of premiums and deductibles. During the current economic downturn many workers have been laid off, and those still working often cannot afford to keep the employer's plan, or afford to pay for an open-market plan. Health insurance premiums for active employees increased by 12% in 2001 (5 times the inflation rate), 13% in 2002, and 15% in 2003./10/
The worsening economy has resulted in state budget deficits, leading many states (including Montana) to consider reductions in Medicaid, a program that has surpassed Medicare as the nation's largest health insurance program for the first time./11/ Medicaid provides health insurance for 51 million people: 24 million children, 14 million indigent adults, 13 million disabled or elderly persons, and the costs of two-thirds of all nursing home residents. It has been estimated that as many as 1.7 million Americans could lose coverage under proposals advanced by governors or adopted by state legislative committees this year./12/
Medicare recipients (who are the 40 million aged and disabled in the U.S.) face a 12.4% rise in premiums next year (the largest increase in 11 years). This increase will occur despite the fact that Medicare will cut physicians' fees by 4.2%. The health care needs of America's seniors do not change, however, with the ups and downs of the economy./13/
The Department of Health and Human Services reported that health care spending increased 6.9%, to $1.3 trillion ($4,637 per person) from 1999 to 2000 (the economy as a whole only grew 6.5%). This was the largest one-year percentage increase since Clinton proposed his plan in 1993. It is estimated that national health care costs will reach $3.1 trillion in 2012, growing at a mean annual rate of 7.3% during 2002-2012--a rate that is 2.5% per year greater than the increase in the gross domestic product (GDP)./14/ From 1999 to 2000 costs of hospital care increased by 5.1%, and prescription drugs by 17.3% (the sixth consecutive year of double-digit growth)./15/
In 1999, total health spending per capita in the U.S. was $4,358. Switzerland had the next highest level at $2,853, and was followed closely by Luxembourg, Canada, and Germany./16/ People in Canada, Taiwan, and the U.K. spend much less on health care, enjoy universal coverage, are healthier, and more satisfied with their health care systems than are those in the U.S. In 1999, the % of the GDP spent on health care was 9.2% for Canada ($2,616 U.S. per person), 6% for Taiwan ($686 per person), 7.1% for the U.K ($1,666 per person), and 13.0% for the U.S. ($4,373 per person)./16/,/17/
The acceleration in health care costs will likely continue, and the increasingly sluggish U.S. economy may well mark the end of an era of reasonably affordable growth in health care if current conditions continue. What is affordable on average may not be affordable to all segments of society. A greater portion of the health care bill will be shifted to patients through an increase in deductibles and co-payments, tiered provider networks, and consumer driven health plans, all of which will cause more people to lack health insurance coverage./18/
In 1999, administrative costs in the U.S. contributed 25.8% of all costs (if advertising is included). This is more than three times that for Canada: $1,059 per person in the U.S. and $307 in Canada./19/ The savings that could result if excess administrative costs are eliminated in the U.S. would make it possible to cover all of the uninsured, with money left over for prescription drugs for seniors./20/
Other major costs are due to the expenses and profits of the 1,500 private health insurers, whose overhead was 11.7% in 1999. Private health insurance premiums increased 8.4% between 1999 and 2000, making it one of the fastest growing health care costs. About two-thirds of private insurers' overhead is due to underwriting and marketing--functions that are absent in public programs. Premiums increased primarily because benefit costs rose, especially for prescription drugs./15/
It has been argued that government bureaucracy is inferior and inefficient, but, in 1999, Medicare overhead was only 3.6%, for Medicaid 6.8%, and Canadian Health Plan overhead was only 1.3%, compared to 25.8% for our private system. In 1999, insurance companies collected $401.2 billion in premiums and retained $46.9 billion in profits, marketing, and administrative expenses--almost $50 billion that could have been used to move toward universal health care.
Growth in hospital spending is now the key driver of growth in total health care spending. Between 2001 and 2002 the fastest-growing component of total spending was for outpatient services (14.6% increase), and the second was for prescription drugs (13.2% increase)--compared to a 2.7% increase in GDP during that period./10/
The excessive cost of pharmaceuticals has contributed the most to the rise in costs. The industry argues that these costs are necessary to promote Research & Development (R&D), reporting $10 billion in R&D expenditures. They spent another $11 billion on promotion, marketing, and advertising, much of which was for increased direct-to-consumer advertising ($2.5 billion for direct-to-consumer advertising in 2000; a seven-fold increase between 1996 and 2000/21/), a shift in payment for drugs from consumers to private health insurance companies, the adoption of newer therapies, and shifts in consumption toward newer, higher-priced drugs./15/ Retail sales of prescription drugs amounted to $30.6 billion in 1998, $140.6 billion in 2000, and are projected to reach $445.9 billion by 2012./14/ Private companies are responsible to their stockholders--not to patients, and they serve those corporate interests admirably.
It has been argued that the U.S. health care system is a private one, not dependent on government tax-supported handouts. Yet, the government's share of health spending in the U.S. was 45.3% in 1999. Americans now pay higher taxes per capita to finance health care than do any other nation's citizens. U.S. health spending is regressive; although highly visible Medicaid spending benefits the poor, tax subsidies benefit the affluent, who are most likely to have employer-paid coverage, and whose higher marginal tax rates translate into greater tax savings. When direct government payments, public employees' benefit costs, and tax subsidies for the purchase of health insurance and health care are included, Americans pay the world's highest taxes to finance health care, yet do not have universal coverage./20/
The Director of the Congressional Budget Office estimated that, under current law, Medicare spending is expected to quadruple from 2.5% to more than 9% of the GDP by 2075./22/ The current system is highly politicized and strongly influenced by industry groups. The political and economic forces at play are powerful, making it likely that costs will grow, and the number of uninsured will continue to increase.
Even this cursory examination of problems facing U.S. health care indicates that the situation has increasingly worsened. Of course, we could take what could be considered a Social Darwinist approach, and say that those who cannot afford health care should be allowed to fall by the wayside--survival of the richest and luckiest. However, some of us prefer to live in a just society in which the basic needs of all people are provided.
Medicine today operates under a condition of scarcity, and a major question is how much of our resources should be used for health care, and what medical services should be guaranteed to all. If it is not possible to provide all services to everyone, it will be necessary to develop a rationing plan to rank patients and treatments using explicit selection criteria. Health care should be viewed as a service that is a human entitlement in a just, free, and humane world--not as a commodity served up for profit. With products I can decide whether to buy a new car, depending on my financial condition and the desirability of meeting other concerns, or enjoying certain luxuries. With health care, however, I cannot decide to postpone a serious accident, or to have cancer some other year.
Mayo Clinic, Rochester, MN. Photo by Hayden Ausland.
Price competition in the medical realm should be minimized because a market economy always drives medical prices higher, given the peculiar nature of the sick--who are captive buyers. Glazer/23/ argued that health care involves so many weak, dependent, and poor people that it cannot be a system geared to conventional consumer markets, but requires redistributive financing. He believes, and I agree, that we should abolish private insurance as an integral part of the national health care system. Such abolition would diminish (if not eliminate) a large and politically powerful industry, and the industry's lobbying against such a possibility will be massive, although such a move would make it possible to have universal health coverage.
Another question concerns whether we should develop and use new and costly diagnostic and treatment technologies. For example, should we save the lives of those doomed to die soon, despite heroic medical efforts, or would it be better to use the resources to guarantee basic, less costly care to everyone? Basic care would include such things as preventive medicine, routine physical examinations, vaccination programs, prenatal care, and nutritional programs. I am convinced that trade-offs must be made, and that universal basic care should have the highest priority.
The Clintons attempted to revise the U.S. Health care system in 1993 in order to avoid the terrible problems we have now encountered. Unfortunately, their attempt failed for a variety of political reasons. The 103rd Congress debated the plan, but no solutions were reached. I predicted/5/ that the issues would undoubtedly be with us for some time to come--and they are. I argued then, and still believe, that a massive overhaul must take place in order to avoid moving toward what I have characterized as a Social Darwinist society. The strong get stronger, inequalities in income and services become greater, and might (money) makes right.
A single payer plan could provide federally mandated and funded universal coverage, administered largely at the state and local level. Before describing such a system, I'll consider some of the stated objections (mainly slogans) that have been used to argue against any single payer universal health care plan. The most common one is that it is Socialized Medicine, and that a single payer plan will lead us down the slippery slope to complete socialism. Sweden has a socialistic government and universal health care, but is hardly a monolithic tyrannical society. Canada has a democratic government and universal health care that has worked well in the capitalist mode. The socialistic British health care system has been nationalized for years, and Britain has both privatized and socialized aspects, with a parliamentary system of government, responsive to the parliament and the voters. Taiwan has a universal health insurance (NHI) plan and a democratic government./17/ Minnesota has a universal insurance system in place,/24/ and Oregon has a rationing system that was rationally devised./25/ In all these instances there is no support for the argument that moving to a single payer health plan will place us on a slippery slope leading inevitably to Socialism.
Another objection made by drug companies and physician organizations is that if the government is involved, we will have long waiting lines for services and loss of personal choice of doctors and drugs--governmental collectivization and cattle-car-care. If you want cattle-car-care, be without private health care insurance, have an accident or an unexpected serious medical problem, making it necessary to go to the emergency room of a large metropolitan hospital, if it is still in operation. You will endure a long uncomfortable wait in dismal and crowded conditions.
Currently we lack free choice of specialists; it is necessary to obtain a recommendation from a primary physician to the HMO referral desk, then to the insurer's referral officer for approval, followed by a considerable wait for an appointment with the specialist (who must be a member of the HMO panel).
Another complaint is that governmental bureaucracy always is inefficient and expensive. However, the government run Canadian Health Care system is more economical than the insurance driven U.S. system./19/ In 1999, Hospital administration in Canada was $103 per capita, while in the U.S. it was $315; Canadian nursing home administration was $29 per capita, in the U.S. $62; Canadian physician's billing costs were $107 per capita, in the U.S. $324. In Taiwan the administrative costs in 2001 for the HNI was only 2.2% of the total NHI budget, about the same as the under 2% for the single payer U.S. Medicare program. Some of the low costs in Taiwan have been attributed to the fact that 99% of all NHI claims are processed electronically./17/ Transaction costs for insurance companies in the U.S. amount to more than 20% of premium revenues. This pattern hardly supports the notion that governmental bureaucracy is inefficient.
In 1990, the number of people employed by the U.S. Government in all legislative, judicial, and non-defense agencies (including the Postal Service and 111,000 temporary Census workers) was 2.173 million. The number of people employed by private insurance carriers and insurance agents in the U.S. was 2.389 million. This employment picture, along with the costs of administration, give the lie to the claim that government-administered health programs necessarily are more cumbersome and expensive than those in the private sector.
Those opposed to a single payer plan continue to assert that Canadians are so dissatisfied with their system they flock to the U.S. to use our superior medical facilities. The popular perception is that Canada's methods of rationing have led to facility shortages and waiting lists for services, resulting in "refugees" coming across the border for necessary medical care not available at home because of either lack of resources or prohibitively long queues. This story is more myth than reality; the number of Canadians routinely coming across the border seeking health care is infinitesimal when compared with the amount of care provided by their own system. The evidence is that U.S. citizens cross into Canada to obtain health care far more than Canadians cross into the U.S. A study of three heavily populated U.S. urban corridors bordering Canada (Buffalo, Detroit, and Seattle) found no evidence that Canadian patients were flocking to the U.S./26/
It is also stated that Canadians flock to use our advanced CT and MRI facilities. However, all but one such facility reported seeing fewer than 10 Canadian patients in the prior year, and that one had seen only 25. The Canadian National Public Health Survey found that only 90 of 18,000 respondents indicated they had received health care in the U.S., and most of these were under formal contracts between Canada and the U.S. hospitals while Canadian facilities were being constructed. This marketing of facilities makes sense given that the U.S. has capacity not being used. Existing contracts between Canada and the U.S. do not represent a "failure" of the Canadian system, rather it is a "prudent purchaser", taking advantage of the opportunity to "buy" more cheaply than it could "make."
The vast majority of treatments provided to Canadians was for emergency or urgent care while traveling in the U.S. for other purposes, and were unrelated either to advanced technologies or to waiting times north of the border. Because the prices for our health care services are extraordinarily high compared with those in all other countries, Canadians do not come here unless it is forced by necessity.
Canada./27/ The system mandates universal coverage for all medically necessary physician and hospital services, with treatment apportioned according to medical need rather than income. There is a penalty if providers charge in excess of the amount covered by the National Health Plan. People can buy supplemental home and nursing home health care, outpatient pharmaceuticals, and vision and dental care. Drug coverage is limited mostly to elderly and poor people, and the provinces are not required to include nursing-home care.
The Canadian health financing system can be represented as a set of concentric circles. At the core is a realm of universal and exclusive public financing. In an intermediate circle are public programs with co-payments, and an eligibility requirement, or both (e.g., for home care and prescription drugs). In an outer ring are services that have no public coverage. When changes are considered they are in terms of rethinking what belongs in each of the concentric circles. Usually changes involve movement between the central and intermediate ring, and relatively few services (cosmetic and reproductive) have been moved to the outer ring.
The total cost of the Canadian system, in 2000, was $68 billion Canadian./26/ Thirty-eight percent of the costs are generated through personal income, corporate, and other taxes. Most of the costs are paid by direct taxation at the Provinces--primarily provincial income taxes.
There is a single financial source for all revenues paid to hospitals and physicians. The national government regulates expenditures, and monitors the quality and composition of health care providers. Controls are exercised through bilateral negotiation between a universal financing agency and independently owned hospitals, as well as with physicians, nurses, and other health workers. Because pharmaceuticals are the most rapidly escalating driver of health costs the provinces agreed to establish a common review process for drugs to be added to provincial formularies./27/ Capital funds for construction are set in advance as a proportion of the total budget, and are allocated through competitive proposals.
Taiwan./17/ After a seven-year study of national health care systems, Taiwan established its NHI program, which resembles the government-run U.S. Medicare program and the Canadian single payer program. The NHI is a government run, single payer health insurance scheme financed through a mix of premiums and taxes. There is a mixed public and private delivery system predominantly on a fee-for-service basis. NHI enrollment is mandatory and more than 97% of Taiwan's population is now enrolled. NHI benefits are comprehensive, including preventive and medical services, prescription and over-the-counter drugs, traditional Chinese medicine, home nurse visits, treatment for HIV/AIDS, and organ transplants--a package that is much broader than that of the U.S. Medicare program. There is complete freedom of choice among providers and therapies, and no rationing of, or queues for, care.
The program reached the goal of removing financial barriers to health care almost immediately./17/ There are co-payments levied on each component of a treatment, with exceptions for major illness or injury, deliveries, certain preventive services, medical services delivered in mountainous and remote areas, services to low-income households, and veterans and their survivors. In 2000, 32% of the NHI total premium revenue came from employers, 38% from individuals, and 30% from the government. As indicated earlier, the spending for health care in Taiwan is extremely low in terms both of % of GDP (6% vs 13% for U.S.) and in absolute amounts ($686 U.S. vs $4,373 for U.S.).
The success of this plan led to the conclusion that "...while the free market can often produce products and goods efficiently, it is incapable of distributing the goods equitably because the income and wealth of households are not distributed equitably.... When a society is seriously concerned about its people having equitable access to care...the free Market is not a good choice" (86)./17/
Significant progress toward universal health care has been made in Oregon and Minnesota.
Oregon./25/ The citizens of Oregon decided explicitly to ration health care in terms of the quality of health produced. The conditions covered included preventive medical care, visits to physicians for diagnosis, treatment of most conditions (including hospitalization), treatment for drug and alcohol abuse, gynecological care, non-cosmetic surgery, physical and occupational therapy, dental services, prescription drugs, and hospice care. Conditions not covered were those in which treatment is ineffective and the condition will run its course, a home remedy is as effective, the treatment is cosmetic, or is futile.
The number of uninsured children fell from 21% in 1994 to 8% in 2002, and hospital charity care dropped 30-50%. The plan was financed by a tobacco tax and an increase in general state revenues allocated to Medicaid. In 1999, satisfaction with the plan was expressed by 88% of Oregonians.
The general economic downturn has been severe in Oregon, with extremely high unemployment. There has been a rise in the number of uninsured residents, rising costs for long term care, and commercial HMOs withdrawing from the Medicaid market. There will be a budget crisis unless action is taken quickly, although there was a projection (made in 2001) that current revenues would support a universal single payer system in 2005. However, the proposed single payer plan was defeated in the November 2002 state election--73% no, 27% yes.
Minnesota./24/ In 2001, Minnesota had the highest rate of health insurance coverage in the U.S.: 95% of the non-elderly population. The state is unusual in its overarching commitment to extending health insurance coverage. Universal coverage was achieved by starting programs modestly, expanding them as they demonstrate their value, and applying them to all populations in need, regardless of income. There are several programs: Medical Assistance (MA), which is the largest, and targets low-income children and families, the elderly, and the disabled; General Assistance Medical Care aids adults without children; and MinnesotaCare, which requires premiums and cost-sharing, and assists families and adults with modest incomes. The MA program provides a comprehensive core of benefits with no enrollee cost-sharing. The benefits include inpatient and outpatient hospital care, ambulatory care, laboratory and X-ray services, prescription drugs, mental health care, alcohol and drug treatment, dental care, vision and hearing care, home health care, hospice care, private-duty nursing, chiropractic services, and transportation. Payments in 2000 for covered services totaled nearly $3.3 billion, and were financed from the state's General Fund with federal matching funds covering about 51.5% of medical outlays. State law requires all HMOs to contract in good faith with health care programs. The uninsured mainly are ethnic minorities--26% of blacks, 17% of Hispanics, and 16% of Native Americans.
Minnesota benefits from high market penetration of not-for-profit managed care, which has resulted in relatively low health care costs. This promotes relatively high rates of employer-based and individually purchased coverage. There is an enduring public commitment to extend health insurance coverage to everyone. There have been a number of legislative champions for broader health insurance coverage, one public official commenting "Minnesotans thought it was a function of government to provide health care for everyone." Minnesota ranked 14th in the nation in fiscal capacity in 1997, and allocated a relatively small proportion of its general revenues to its Medicaid program (44th in the nation). It was concluded that many other states could probably achieve Minnesota's high rate of insurance coverage given a similar, sustained level of public commitment to achieving that goal.
Although individual states have had varying degrees of success in providing adequate health coverage, it is unlikely that universal health care will prevail if the present piecemeal approach continues. One problem, encountered in both Oregon and Minnesota, is that the federal government has not been flexible to accommodate changes in state policies. Only 3 of the 50 states had a budget surplus in 2003. The governors of all 50 states noted that with health care costs growing at such a fast rate the states are on a collision course with essential services, such as education. It was suggested that the federal government should cover the costs for all citizens who are over 65./28/ Both Republican and Democrat governors expressed concern over the president's proposal to set firm limits on federal Medicaid spending in each state over the next decade. They were concerned that the proposal does not protect states against unforeseen costs that might result from changes in the economy, natural disasters, outbreaks of disease, or the development of new drugs and expensive treatments./29/
The issues involved in health-care reform are complex. There must be reform of the health-care system to provide universal health coverage, whether it is some form of rationing, managed competition, or single payer coverage. Morally, it is demanded that such reform occur if we are to have a just society, even though there are difficult decisions that may impose costs to the few to produce benefits to the many. A large number of experts--medical professionals and economists--agree that private insurance companies are unable to provide a safety net for the needy. Currently, the needy are left behind as insurance companies cherry pick the healthy and dump the needy on the government roles. A single payer health plan, similar to the Health Plans in Canada and Taiwan, should be the immediate goal for the U.S. in order to provide for the basic health needs of the American public.
A comprehensive proposal has been developed by a committee of physicians, and endorsed by an additional 7784 physicians and medical students./30/ Space will not permit a detailed discussion of the comprehensive proposal, but I highly recommend its careful study. The program would save at least $200 billion annually (more than enough to cover all the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry, reducing spending for marketing and advertising, and developing a single, automated billing procedure.
While both the moral and economic issues are straightforward, the political one is complex, due to the web of special interests with powerful financial and political influence. It is difficult to overhaul the health care system given the strong political opposition by interest groups with powerful lobbying power. Perhaps only grassroots action can be successful, although this is difficult because of the financially driven misinformation that is always launched by special interests, and transmitted by the media. The moral issues must be kept in the forefront, the dismal reality of our health care system must be emphasized, and change demanded by the public. Progress can probably only be achieved if we elect representatives who are committed to system reform, and if we pressure our elected and appointed officials to implement such changes.
Notes
John Stuart Mill, On Liberty (London, 1859), 239,138; reprinted in M. Warnock, John Stuart Mill (New York: Meridian Press, 1947).[Back]
John Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971).[Back]
Robert M. Kaplan, "Application of a general health policy model in the American health care Crisis," Journal of the Royal Society of Medicine 86 (n.d.): 277-81.[Back]
Lewis Petrinovich, Darwinian Dominion: Animal Welfare and Human Interests (Cambridge, MA: MIT Press, 1999).[Back]
Lewis Petrinovich, Living and Dying Well (New York: Plenum Press, 1996; pb. ed. MIT Press, 1998). See for any references prior to 1995.[Back]
Sherry Glied and Sarah E. Little, "The uninsured and the benefits of medical progress," Health Affairs 22 (2003): 210-19.[Back]
Robert Pear, "More Americans were uninsured in 1998, U.S. says," New York Times, 4 October 1999, A1.[Back]
Kevin Grumbach and Philip R. Lee, "The long road to a national health plan," San Francisco Chronicle, 27 April 2003, D3.[Back]
Robert Pear, "New study finds 60 million uninsured during a year," New York Times, 13 May 2003, A20.[Back]
Bradley C. Strunk and Paul B. Ginsburg, "Tracking health care costs: Trends stabilize but remain high in 2002," Health Affairs Web Exclusive, 11 June, 2003, 266-74 [journal online]; available at http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.266v1/DC1.[Back]
John K. Iglehart, "The dilemma of Medicaid," New England Journal of Medicine 348 (2003): 2140-48.[Back]
Robin Toner and Robert Pear, "Cutbacks imperil health coverage for states' poor," New York Times, 28 April 2003, A1.[Back]
Robert Pear, "Medicare recipients face 12.4% rise in premiums," New York Times, 26 March 2003, A12.[Back]
Stephen Heffler, Sheila Smith, Greg Won, M. Kent Clemens, Sean Keehan, and Mark Zezza, "Health spending projections for 2002-2012," Health Affairs Web Exclusive, 7 February 2003, 54-65 [journal online]; available at http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.54v1/DC1.[Back]
Katharine Levit, Cynthia Smith, Cathy Cowan, Helen Lazenby, and Anne Martin, "Inflation spurs health spending in 2000," Health Affairs 21.1 (2002): 172-81.[Back]
Uwe E. Reinhardt, Peter S. Hussey, and Gerard F. Anderson, "Cross-national comparisons of health systems using OECD data, 1999," Health Affairs 21 (2002): 169-81.[Back]
Tsung-Mei Cheng, "Taiwan's new national health insurance program: Genesis and experience so far," Health Affairs 22 (2003): 61-76; Jui-Fen Rachel Lu and William C. Hsiao, "Does universal health insurance make health care unaffordable? Lessons from Taiwan," Health Affairs 22 (2003): 77-88.[Back]
Michael E. Chernew, Richard A. Hirth, and David M. Cutler, "Increased spending on health care: How much can the United States afford?" Health Affairs 22.4 (2003): 15-25.[Back]
Steffie Woolhandler, Terry Campbell, and David U. Himmelstein, "Costs of health care administration in the United States and Canada," New England Journal of Medicine 349 (2003): 768-75.[Back]
Steffie Woolhandler and David U. Himmelstein, "Paying for national health insurance--And not getting it," Health Affairs 21 (2002): 88-100.[Back]
Meredith B. Rosenthal, Ernst R. Berndt, Julie M. Donohue, Richard G. Frank, and Arnold M. Epstein, "Promotion of prescription drugs to consumers," The New England Journal of Medicine 346 (2002): 498-505.[Back]
Robin Toner, "Medicare caught up in politics," New York Times, 14 April 2003, A15.[Back]
W.A. Glaser, "The United States needs a health system like other countries," Journal of the American Medical Association 270 (1993): 980-84.[Back]
Deborah Chollet and Lori Achman, "Approaching universal coverage: Minnesota's health insurance programs," Field Report, The Commonwealth Fund, February 2003 [journal online]; available at http://www.cmwf.org/publications/publications_show.htm?doc_id=221309.[Back]
John A. Kitzhaber, The national health policy conference, Washington, D.C., 16 January, 2002. Michael S. Sparer, "Health policy for low income people in Oregon," 24 September 1999 [Web site, Urban Institute]; available at http://www.urban.org/template.cfm?Template=/TaggedContent/ViewPublication.cfm&PublicationID=6409&NavMenuID=95. Sharon Silow-Carroll, Emily K. Waldman, Jack A. Meyer, Claudia Williams, Kimberley Fox, and Joel C. Cantor, "Assessing state strategies for health coverage expansion: Case studies of Oregon, Rhode Island, New Jersey, and Georgia," Field Report, The Commonwealth Fund, November 2002 [journal online]; available at http://www.cmwf.org/publications/publications_show.htm?doc_id=229421.[Back]
Steven J. Katz, Karen Cardiff, Marina Pascall, Morris L. Barer, and Robert G. Evans, "Phantoms in the snow: Canadians' use of health care services in the United States", Health Affairs 21 (2002): 19-31.[Back]
Carolyn Hughes Tuohy, "The costs of constraint and prospects for health care reform in Canada," Health Affairs 21 (2002): 12-46.[Back]
Robert Pear, "Bush, governors at odds on cuts in Medicaid costs," San Francisco Chronicle, 25 May 2003, A5.[Back]
Michael Janofsky, "Governors unite in concern over burdens of Medicaid," New York Times, 18 August 2003, A10.[Back]
"Proposal of the physicians' working group for single-payer national health insurance," Journal of the American Medical Association 290 (2003): 798-805.[Back]
[The Montana Professor 15.1, Fall 2004 <http://mtprof.msun.edu>]