Paying for health

A person's income determines his/her access to many things he wants and needs: food, clothing, transportation, housing, entertainment, and the internet, for example. And people who have higher income are able to consume more of all of these categories than people with lower income, if they choose to. More affluent people shop for food at Papa Joe's or Whole Food; live in larger and more luxurious homes; buy their clothing from boutiques rather than Penny's or the thrift shop; and drive multiple handsome cars. Poor people can't afford the luxury end of these forms of consumption. And in some way our culture has judged that these sorts of inequalities of consumption are a legitimate and fair part of a market economy; if you judge that inequalities of income are justifiable (perhaps with some limits on extremes), then you pretty much have to support the idea of inequalities of consumption as well.

But what about goods that have a price but that are essential to living a decent human life? Food certainly falls in this category; if 30% of society could literally not afford to purchase enough calories to provide 2200-2900 calories per day for adults and 1800 calories for children, then we would probably have a different idea about the fairness of a market for food -- the principle that says "to each according to his/her earning capacity" doesn't seem very convincing in circumstances where it leads to malnutrition or starvation. In other words, if the normal workings of a market economy left a significant segment of the population without the ability to purchase enough food for subsistence, we would surely judge that this isn't a fair or socially just way of distributing income and food. And there is an important point to be noted here: there is hunger in America, and the system of producing goods and income isn't fully satisfying the subsistence needs of the whole population. (This is exactly what makes it compelling that our government needs to provide food assistance for the very poor, through food stamps or targeted income supplements.) So there is an important issue about the justice of current actual distributions of such basic goods as food, clothing, or shelter across the U.S. population.

But push a little deeper and consider the "market for health care". Supporting one's current healthy status is a costly effort; repairing the body in times of traumatic injury or serious illness is even more costly; and our society leaves a lot of the allocation of health care services to private purchasing power. Health insurance is the primary vehicle through which many Americans provide financially for their health care needs. Some people have insurance provided or subsidized through their employers; some families purchase health insurance through the private market; and many families lack health insurance entirely. Upwards on 45 million Americans are uninsured, including 20% of adults and 9% of children (CDC link). And this includes a wide range of Americans, from the extremely poor to the working poor to the solidly middle class.

It is clear that access to doctors, hospitals, nurses, and prescription drugs is a critical need that everyone faces at various points in life. It is obvious as well that one's future ability to live and work productively and to enjoy a satisfying life is conditioned by one's ability to gain access to health care when it is needed. It is also clear that uncertainty about the availability of health care is a major source of anxiety for many, many people in U.S. society today. So it is self-evident that decent health care is one of our most basic and unavoidable needs.

So what do people do when they lack health insurance and serious illness or injury occurs? This isn't a mystery anymore; families go into debt to doctors and hospitals, they face bankruptcy, they find some limited sources of free care (free clinics, pro bono doctors' services), and they forego "optional" treatments that may well extend the length or quality of life. And it is evident that this pattern results in very serious harms and limitations for people in these groups. People who have the least access to health care through our basic institutions may be expected to live shorter lives and to suffer more.

And what about people at the high end of the income spectrum? How do they relate to the problems of health? Here too the answers are fairly well known: they are able to seek out the best (and most expensive) specialists, travel to national centers for specialized treatment, and undergo advanced diagnostic tests that are not covered by insurance. (Here is a news story from CNN on boutique health care.) The affluent aren't able to assure their health through expenditure -- but they can certainly improve their odds.

In other words, ability to pay influences the quality and extent of health care that an individual or family is able to gain access to; and the health status of the family is affected by these variations in quality and access. So, to some meaningful extent, our social system places health care in the category of a market good.

But here is the question I'm working around to: what does justice require when it comes to health care? Is it right to look at health care as just another consumption good like shoes -- affluent people wear Gucci and poor people wear Dollar Store, but everyone has his/her feet covered? Or is health care in a special category, too closely linked to living a full human life to allow it to be distributed so unequally?

It seems a bitter but unavoidable truth that there are very substantial inequalities in the provision of health care in our society. One person's likelihood of surviving a devastating cancer may be significantly less than another person's chances, simply based on the second person's ability to pay for premium health care services. Further, it seems unavoidable that these inequalities are flatly unjust in any society that believes in the equal worth of all human beings. And where this seems to lead is to the conclusion that some system of universal health insurance is a fundamental requirement of justice.

Consumption and environmental collapse

Today the Dalai Lama presented a lecture on global environmental sustainability at the University of Michigan. One of his central points had to do with personal consumption and personal happiness: the fact that the planet simply cannot sustain the level of material consumption characteristic of affluent countries, in support of the world's population of over 6.5 billion people. He expressed his hope that we will come to think differently about happiness, fulfillment, and material consumption.

This message made me think of the very powerful analysis that is conveyed in an important recent book by James Gustave Speth, The Bridge at the Edge of the World: Capitalism, the Environment, and Crossing from Crisis to Sustainability. Speth has been an environmental scientist and policy expert for decades -- he is currently the dean of Yale's School of Forestry and Environmental Studies -- and he has an understanding of the crisis that our global society faces that is just as powerful and fact-based as any I have read.

Speth opens his argument with a set of sixteen graphs over a time scale of 1750-2000. And they all have roughly the same shape: beginning at moderate levels in 1750, each of the variables show exponential growth that begins to accelerate in roughly 1900-1950. The variables? Population, total real GDP, foreign direct investment, damming of rivers, water use, fertilizer consumption, paper consumption, motor vehicles, CO2 consumption, ozone depletion, average surface temperature, great floods, ocean ecosystems, coastal biogeochemistry, loss of rain forest, global biodiversity. These graphs tell a powerful story in the aggregate: these are trends that cannot be sustained.

Or consider the second paragraph of the book:

Half of the world's tropical and temperate forests are now gone. The rate of deforestation in the tropics continues at about an acre a second. About half the wetlands and a third of the mangroves are gone. An estimated 90 percent of the large predator fish are gone, and 75 percent of marine fisheries are now overfished or fished to capacity. Twenty percent of the corals are gone, and another 20 percent severely threatened. Species are disappearing at rates about a thousand times faster than normal. The planet has not seen such a spasm of extinction in sixty-five million years, since the dinosaurs disappeared. Over half the agricultural land in drier regions suffers from some degree of deterioration and desertification. Persistent toxic chemicals can now be found by the dozens in essentially each and every one of us. (1-2)

This is the "edge of the world" to which the title refers.

Speth correctly notes that these environmental crisis lines all derive from the economic realities of accelerating economic growth since 1900. Economic activity consumes resources, produces waste products, and clears land for development. Moreover, he observes that the economies that we have created in the modern world place growth at the value center: the central goal of economic activity is to accumulate and grow. And yet he notes as well that often this growth is counter-productive; for example, he quotes the UNDP Human Development Report 1996 and its findings of jobless growth, ruthless growth, voiceless growth, rootless growth, and futureless growth. And he reviews some of the survey data about "personal happiness" that seems to support the point as well: past a certain threshold point, greater income doesn't bring greater happiness.

So if there is a bridge at the edge of the world -- what is it made of? What kind of transformation of the world's activity can slow and eventually reverse these catastrophic environmental trends?

Speth provides a hard but achievable prescription, and it is very much like that expressed by the Dalai Lama today in Ann Arbor: we must re-evaluate the meaning of life, we must change the way we think about material consumption, we must find happiness in activities that are not resource intensive, and we must tame our growth engines in the economic structures in which we live. Nothing less than a fundamental change in our personal philosophies and our economic structures will save the planet's welfare -- from rain forest to Great Lakes to fisheries to the air we breath and the water we drink.

Can we do it? It seems most unlikely. But it's probably the only way out.