REVISING THE TEMPLATE FOR MODELING HEALTH CARE
2. NECESSITY FOR CHANGE
Change was necessary to avoid the possibility that health care in the United States would become unaffordable. In retrospect, as some critics have suggested, the transition to a managed care system may have been implemented too quickly and too hastily without allowing sufficient time to think through the process in a detailed manner (Buchanan 1998; Emmanuel and Emmanuel 1996). They contend that the switch to a managed care model took place without:
a) Societal agreement on a workable definition of health and a new appreciation for the status of health care
b) A central government willing to take responsibility for ensuring universal access to health care
c) Societal agreement on an authoritative standard for defining the scope of
entitlements, that is, what the entitlement to health care should include (needs vs.
wants, affordable care vs. all possible care). No authoritative standard has been determined for what constitutes the types and quality of care to which everyone could be said to be entitled.
d) Societal agreement on the distribution of labor between public- and private-sector entities in regard to access and quality (Buchanan 1998) 120
incorporating all the crucial system functions into a single organizational format, the
e) Societal agreement on a unifying paradigm of responsibility applicable to all three levels of accountability in health care: professional, political, and economic or consumerist (Emanuel and Emanuel 1996)
f) Societal agreement on the role of business in general and of health care in particular. A consensus is lacking on the scope of institutional arrangements, or even worse, on the legitimacy of the claim that business entities should even be concerned with entering the debate with such arrangements in place. A political assignment of obligations to private-sector entities in regard to access and quality of care is absent.
g) Societal agreement on the moral relevance to health care of the term personal responsibility
Despite all the commotion about the practices of MCOs, the reality is that the political powers have assigned a more substantive role to managed care in managing and reducing the high costs of health care. In other words, managed care is not only here but it is here to stay for a considerably long time. Past debates about health care reform have shown that there is little political interest in exploring systems other than managed care. In the meantime, a growing number of people have health care coverage through managed care plans. In 2004, managed care plans in the United States were covering about 198 million people: almost 69 million in health maintenance organizations (HMOs) and 109 million in preferred provider organizations (PPOs) (MCOL 2004), including those funded by Medicare, and 20 million in fee-for-service (FFS) plans they paid for themselves (AISHealth.com 2005). A significant number of these participants were enrolled in for-profit managed care plans.
In this chapter, I will explore how revising the philosophical basis of change could contribute to modification of the distribution practice within the managed care model. The changes would result from requirements that the principle of genuine responsibility and the concept of justice as appropriation would impose on redefining the health care system operating in a free-market economic environment.
2.1 Recapitulating the Applied Theoretical Framework
Central to any discussion about the delivery of appropriate health care through managed care is the ethical argument that I set forth in this book, which departs from have a responsibility to join the critical discussion and to look for moral standpoints that could reasonably be maintained in the presence of rational, well-informed, sympathetic participants. They would all accept responsibility and could all be called on to be accountable for any decisions that are made.
As outlined in the previous chapter, acceptance of the principle of genuine responsibility results in agreement on the assumption that an intrinsic value rather than an instrumental value must be attributed to human coexistence. Therefore, distributive choices that must be made for the purpose of realizing personal goals must also be made while observing the requirement that an intrinsic value has been the democratized concept of morality. In fact, I propose that all the participants
placed on the notion of living in community. Appreciation for the intrinsic value of this
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notion is based on an internalized understanding that human beings have the capacity to make distinctions and judgments according to reflectively formulated concepts of means and ends and to act on these capacities in order to achieve long- term goals. In other words, the concept underlying the principle of genuine responsibility produces the generic moral requirement to recognize the legitimacy of the claims of others, and, subsequently, to respond impartially to those claims by including the interests of others in the decision-making process about fair distribution.
The philosophical issue that arises whenever this principle is applied concerns the criteria by which we determine the domain and nature of the limitations imposed on the process of realizing personal goals. As a result, the principle of genuine responsibility proposes to broaden the meaning of the term moral obligation. This broader term would include the actor’s moral obligation to contribute in a positive manner to the collective objective of creating or maintaining optimal conditions for choice. Thus, genuine responsibility imposes an extensive claim on all the participants in the discussion and on the praxis of the distribution of social goods.
The same claim, however, will be placed on all parties with an interest in the distribution of health care: the recipient of care, the provider, economic institutions, and society.
2.2 The Ideological Argument in the Health Care Debate
An assessment of what went wrong in the process of reorganizing health care shows that the problems with managed care should be placed within the context of inadequately addressed socioeconomic interests. That is to say, certain interests have dominated the discussion more for reasons of establishing or maintaining asymmetric positions of power than for the greater good of health care. Ideological arguments have played a more important role in the outcome of discussions about health care than “good reasons” could have justified. The main reason that ideology can have an impact is that the construction, negotiation, and transformation of meaning do not take place in isolation but, rather, occur within a wide variety of within the context of the dominant beliefs, values, and interests of society. The
in the distribution and delivery of health care in the past not only to evaluate the clinical behaviors of health care providers but also to take a critical look at the practical priorities and conduct of health insurers, politicians, and researchers.
The question, then, is not so much how can we change the dominant beliefs and values of society but, instead, how can we redefine current assumptions underlying those dominant beliefs and values in order for the health care system to work in a morally more appropriate fashion? In other words, a contradiction seems to exist between the status of health care and the system in which it is expected to function.
Although health care is considered a social good by many, the health care system operates in a socioeconomic environment that prefers the mechanism of the competitive marketplace to distribute its services and goods. Within that reality, the 122
appropriate reorganization of health care requires analysis of what went wrong
social contexts (Kelly and Koenig 2000). Proposals about reforming the health care
system are thus evaluated
principle of genuine responsibility contributes to the assembly of a system of distribution that is morally more appropriate.
The procedural guidelines set forth by the principle of genuine responsibility transform the process of defining health care and subsequently derive the obligations of society for operationalizing the concept of health care as one of construction, negotiation, and transformation of meaning within a variety of social contexts. This process exemplifies how ethics can assist in arranging and ordering complex social interactions, and how we define the society we want to live in.
As indicated throughout this book, social agreement is noticeably absent on crucial components of the health care system. The following sections will elaborate on each issue from the perspective of the principle of genuine responsibility and will identify how this principle could contribute to the improvement of health care redistribution in the United States.