Reforming Health Care Reform

This issue features two distinct levels of debate about health care reform, both of which are set in motion by David DeGrazia in the lead article. DeGrazia assembles an argument for consolidating health insurance in a single payer (or at least for moving us in that direction) while continuing to make the delivery of care private and dispersed. The argument dispenses with broad claims about justice and rights; instead, it starts by identifying four specific goals of health care reform as touchstones for reform: the best reform is the one that looks most likely to achieve these goals.

Three commentaries on DeGrazia's article are mostly about the details of reform. (We sought commentaries because the issue seems to us to have a special importance, so that giving a debate about it an extra push seemed warranted.) Paul Menzel endorses the basic proposal but suggests another way of getting there; Len Nichols endorses the goals of reform but suggests that single-payer insurance with managed competition is no likelier than straight managed competition to get there; Ezekiel Emanuel endorses the goals and asserts that single-payer insurance goes in exactly the wrong direction.

Thus one level of debate is about the details of reform proposals. The other level is about the structure of the argument: how can we best argue for health care reform? DeGrazia dispenses with justice in favor of his four goals of reform because he thinks there is as much disagreement about justice as about health care reform itself. On the facing page, the Center's Mary Crowley responds to his skepticism about justice with a vigorous defense. A rough and ready sense of justice has been the driving force behind other major policy reforms, she argues, and it remains the best bet for pushing health care reform forward.

Elsewhere in this issue—and purely serendipitously—an essay by Charity Scott offers an interesting sidelight on this exchange. Scott draws on recent social science research showing that some people think the world is fundamentally a just place, rewarding good behavior and punishing bad behavior, such that those who are poor probably deserve to be poor. The implication is that disagreement about justice is metaphysical as well as moral: not only do people disagree about what justice tells us about the proper distribution of resources, but they disagree about how the world works. As a result, even supposing agreement on distributive principles, people might still disagree about how to identify cases of injustice. This added disagreement complicates the defense Crowley wants to offer, but does not shut it down. Scott believes that claims about justice can be articulated in ways that get around the disagreement over whether the world is just.

Perhaps a third question is implicit here. We can debate the reform proposals, we can debate the terms of the debate, and we could ask about the very point of debate: are we trying to decide which policies we should enact, or are we trying to enact policies we have already decided on? I think Crowley and Scott assume we might be doing both, and this seems right to me, too. Nor does this reduce philosophy to rhetoric. If we are committed to certain moral positions, then it might seem that we should not change the way we talk about them; we should just describe them as accurately as possible. But if one of our commitments is to bridge gaps and build community, then we will work to find common ground. We will want to frame our moral commitments in common language.