Medicare For All - Case Analysis [Class Assignment]

Updated: Dec 31, 2021

Question and Background

The question at hand is whether or not the United States should adopt the policy of Medicare for All. The United States is unique to other developed countries in the manner in which it approaches healthcare. Unlike most developed countries, the United States has widely privatized healthcare, which has, in turn, created a multi-billion dollar insurance industry. During the early 20th century, the healthcare system was unregulated, and health insurance was essentially nonexistent (Moseley, 2010, 3). Often, patients would pay the healthcare costs out of pocket, although these costs were more modest than they are now in 2021. This was a little while before surgery was commonly used for what we would now consider mundane things like tumors or appendicitis. During the 1910s, many European countries began to adopt compulsory national health insurance policies, while the United States did not, largely due to a lack of public enthusiasm and pushback from physicians and commercial insurers. As regulatory bodies were formed for physicians and care facilities alike, the cost of healthcare drastically increased (Moseley, 2010, 12). During the 1930s, physicians began to push back against nationalized health insurance out of a fear that it would lower their wages and prevent them from being able to set their own fees for primary care and local practices. During World War II, the IRS added tax exemptions for employer-provided health insurance, securing this approach for seeking out health insurance in the United States. These few policy changes in the 20th century guaranteed that health insurance would be treated as a private consumable product in the United States rather than a public good, as it is treated in other developed countries. In addition, since the industry now holds so much political power through lobbying and other such things, it almost guarantees that Medicare for All will be difficult to achieve. An estimated 35 million people are uninsured in the United States, which is roughly 11% of the population (Wagner, 2020). During the 21st century, the Affordable Care Act extended health coverage to millions of Americans, expanding Medicaid eligibility, and barring insurance companies from denying care based on a pre-existing condition (Moseley, 2010, 5).


Analysis

When looking at the issue of whether to pass Medicare for All, we should look at it through the lens of utilitarianism. In short, utilitarianism is the concept of passing policies that do the most good for the most people. According to John Stuart Mill (Bentham, 1879), utilitarianism is the principle of promoting right actions as it compares to wrong actions. As defined by Mill, a right action is one that promotes happiness, and a wrong action is one that produces or encourages the opposite of happiness. For his argument of utilitarianism and the concept of utility, Mill defines happiness as pleasure, with the absence of pain (Bentham, 1879). Another philosopher, often regarded as the father of utilitarianism, was Jeremy Bentham. Bentham and Mill share a lot of the same ideas about utility. In fact, Mill was a close follower of Bentham and based many of his ideas about utilitarianism off of Bentham’s original framework. Bentham posits that there is no qualitative difference between pleasures, only quantitative ones. This is one area in which Bentham and Mill disagree. Mill believes that pleasures cannot, in principle be qualitatively the same. For example, Mill holds that the pleasure of drinking a beer in front of the TV is not qualitatively the same pleasure of getting a cancer-free diagnosis from your doctor. Mill believes that Bentham’s assessment of pleasure is too simple for humans, especially in the society in which we find ourselves, when everything often inflicts some degree of pain, no matter how much pleasure it induces. Mill appeals to the intuition and lived experiences of the reader to prove this idea about pleasure and the qualitativeness versus quantitativeness of pleasure. Mill attempts to address concerns about the definition of utility, by positing that everyone desires and seeks out happiness (Bentham, 1879). Mill also argues that the end goal of utilitarianism should be a “general happiness” or a “good to the aggregate of all persons” (Bentham, 1879). This is where we pull the shorthand of “doing the most good for the most people.” For this argument, we are going to use Mill’s definition of utilitarianism and the distinction he makes when talking about pleasure. The reason we will use Mill’s definition is because of the measurable differences between certain health procedures, as we will see later in the analysis. There are many ways to think about utilitarianism and what it means for the people who are not part of that category of “most people.” One example in which policymakers applied a utilitarian principle to the issue of healthcare is the Oregon Health Plan. The policymakers ensured that the policy would do the most good for the most people without sacrificing the livelihoods or the needs of the folks not considered in the “most people” category. The Oregon Health Plan was a successful effort on behalf of the Oregon state legislature to expand Medicaid in the state. At the time of the Oregon Health Plan’s inception, only people below a certain percentage of the poverty line were eligible for Medicaid. Medicaid is subsidized health insurance for low-income Americans. There were many policymakers in the Oregon state legislature that wanted to change this. These policymakers wanted to expand Medicaid so that all people, at or below the poverty line, would be eligible for Medicaid. The policymakers wanted to use the resources that they had at their disposal to do the most good for the most people. There were a couple of hurdles for them to jump through. First, a lot of Medicaid funding comes from the federal government, so they were subject to some restraints. Another hurdle was that, if they were to implement this program, Medicaid wouldn’t cover 100% of medical needs or operations. So in order to make this work, policymakers would have to come up with a comprehensive way to prioritize medical procedures so that all essential items were comprehensively covered and some non-essential needs were also met. The final system for ordering these procedures was the result of a lot of trial and error. At first, the policymakers just applied a cost-benefit approach to the ranking of procedures. This resulted in things like an appendectomy (high cost, high benefit) and a tooth capping (low cost, low benefit) to be ranked relatively the same on the list of items. Policymakers realized this wouldn’t work after public pushback about the ranking of maternal care items, so they went back to the drawing board. In the second method of prioritization, the Oregon state legislature created the Oregon Health Board, the body by which the prioritization list would be created. According to the language in the Oregon Health Plan, legislators couldn’t change the order of care items on the prioritization list, they could only decide at what level to fund the list. Anything above that level would be fully funded under the Medicaid expansion, and anything below it wouldn’t be covered. The Oregon Health Board was created to make this list as comprehensive as possible and ensure the equitable construction of the final items on the prioritization list. The board was made up of healthcare providers, some public officials, and input from stakeholders in the community (i.e. low-income folks who would be eligible for the Oregon Health Plan should it become law). The prioritization method they came up with was much better than the original. This prioritization list would still be put through a cost-benefit analysis, but instead of ending it there, the list would be hand-reviewed line-by-line by the Oregon Health Board to ensure that the final list was accurate and equitable. The Oregon Health Board used the concept of utility to create this list. Using what they knew from the medical field and from the standpoint of utilitarianism, the health board created a list of procedures that would eventually do the most good for the most people, without harming those who were not part of the category “most people.” Because this expansion of Medicaid was not compatible with federal law, a waiver from the president was needed to greenlight the Oregon Health Plan. They did not initially receive the waiver, over worries about the prioritization list and its potential violations of the Americans with Disabilities Act or ADA for short. So, once again, it was back to the drawing board. This time, the health board split its prioritization up into categories, allowing for mental health and other disability care to be covered. This is the final version of the Oregon Health Plan that became law and is still in place today for the most part. The Oregon Health Plan, and the process by which the health board arrived at the prioritization list, is how Medicare for All legislation should be modeled. When utilitarian legislation like Medicare for All is being created, it must be thought out in a way that centers on justice. It is not enough to consider utility and the needs of the “most people.” Instead, the framework of the legislation should prioritize the needs of the “most people'' without sacrificing the needs or the livelihoods of those individuals not a part of that “most people” category. The goal of Medicare for All should be to minimize pain and maximize pleasure for all people, not just some. An example in which Medicare for All could benefit everyone in a utilitarian manner is the availability of maternal care and infant mortality rates in the United States among low-income women. While it may not seem in the interest of utility to care for mothers, it is actually one of the most utilitarian things that can be done. In order to continue the functions of this economy and this country, we need to continue to rear generations that sustain this country and its economy. The United States is also on the verge of having a top-heavy age demographic model. Within the next 20 years, the proportion of elderly people in the United States is going to be very large. Therefore, it is in the best interest of the United States to ensure that all mothers are provided with the adequate care they need to have children. By lowering the infant and mother mortality rate in the United States, we would benefit the society as a whole because the economy would be well supplied with a workforce, and our aging population would have plenty of helping hands to hopefully ease the impact that the aging population will have on the healthcare systems. Another way in which Medicare for All is a utilitarian policy is the way in which Medicare for All is structured. Medicare for All, as defined by the bills introduced by Senator Bernie Sanders (D-VT) and Representative Pramila Jayapal (D-WA) would be a replacement for all private health insurance and the existing Medicare infrastructure, not just another public option like the existing forms of Medicare and Medicaid. In addition to this, it would be tax-financed, although it is important to note that the funding from Medicare for All would come from an amended tax code that heavily taxes the super-wealthy and large corporations, a provision that does not currently exist in the US tax code. Medicare for All would provide lifetime enrollment, with all US citizens being automatically enrolled using the Social Security number they are assigned at birth. The Sen. Sanders and Rep. Jayapal version of Medicare for All would include no premiums and all state-licensed, certified providers who meet the eligibility standards would be able to apply for the Medicare for All program. Medicare for All would establish a similar publicly funded health system as the ones that already exist in places like Canada, the United Kingdom, and Australia. Consistently, the United States has ranked lowest among developed countries for the standard of care, ease of use, and cost of healthcare in the country. Medicare for All would eliminate most of the private and employer-based insurance plans on the market in the United States today. Medicare for All would also expand on what Medicare currently covers, making it a much more expansive and robust system than what currently exists now. Medicare for All, as envisioned by Sen. Sanders and Rep. Jayapal, would enable recipients to have virtually no out-of-pocket costs associated with healthcare. The bill would prohibit deductibles, and surprise medical bills for all the services covered under the Medicare for All umbrella. The benefits of Medicare for All are expansive enough that one likely would not have to pay out of pocket for much since most of the necessary items are covered by Medicare for All. In all likelihood, one would be able to retain the current primary care provider that they have, as Medicare for All would apply to any provider who currently accepts regular Medicare. Although taxes would likely increase in a Medicare for All world, they would only be increased marginally, and any tax increase would be significantly lower than any health insurance premium one is paying right now under the privatized system in the United States. As opposed to private health insurance, Medicare for All would actually give someone more freedom over choosing who their primary care provider is and who does their services. When we think of this bill, this potential policy. It may not seem utilitarian, because of its rise in taxes and its disruption of the current healthcare system, it can seem like a daunting task and one that might not do the most good for the most people. I would challenge this idea. The standard of care in the United States is already one of the worst among developed countries due to the high cost of healthcare and the inaccessibility of vital health services. From a purely utilitarian perspective, the current mass privatization of healthcare does not do the most good for the most people, in fact, it does the opposite. The privatization of healthcare in the United States has only raised the profits of the most wealthy while continuing to make healthcare inaccessible to the vast majority of Americans. Medicare for All is utilitarian, it will preserve existing healthcare networks and allow for the people currently excluded from this system to gain access to quality, affordable care that they need.

Now that it has been established that the policy has utility and is utilitarian, the question then becomes, why utilitarianism? Why are we looking at the policy from this specific ethical perspective? The answer to that is quite simple actually, when considering big social policies like this that have consequences for every single member of a community, it is imperative that we analyze the issue through the lens of utility. If we are to administer justice, what is the point of a large social policy if it doesn’t do the most good for the most people? A sweeping policy like this must fit within the confines of utility in order to be considered just. If this policy does not do the most good for the most people, it should not be a large sweeping social policy that affects most people in the United States.


Recommendations

My recommendation is that Medicare for All should be adopted in the United States. First, it fits into Mill’s definition of utility and what it means to maximize pleasure and minimize pain (Bentham, 1879). Second, if it is executed in a manner similar to that of the Oregon Health Plan, by doing the most good for the most people without sacrificing the pleasure of those not included in the “most people” category, it will be a success. Lastly, it should be adopted because it lowers the cost of healthcare for all people, further providing utility and maximizing pleasure.


References

Wagner, S. L. (2020). The united states healthcare system: Overview, driving forces, and outlook for the future. Health Administration Press.


Bentham, J. (1879). Introduction to the principles of morals and legislation. Oxford, The Clarendon Press.


The Affordable Care Act: A Brief Summary - March 2011. (2011, March). National Conference of State Legislatures. https://www.ncsl.org/research/health/the-affordable-care-act-brief-summary.aspx


Guttman, A., & Thompson, D. (2006). Rationing in public: The Oregon health plan. Ethics and Politics, 4, 28. https://ares.lib.unc.edu/ares/ares.dll?Action=10&Type=10&Value=109158398


The history of the US healthcare system. (2016). Jones & Bartlett, 22. http://samples.jbpub.com/9781284108163/Chapter_1.pdf


Levitt, L. (2019, July 2). Medicare for all or medicare for more? The JAMA Forum, 2. 10.1001/jama.2019.8268


Moseley, G. B. (2010). The US health care non-system, 1908-2008. AMA Journal of Ethics. 10.1001/virtualmentor.2008.10.5.mhst1-0805

Recent Posts