Academic journal article Law and Contemporary Problems

The Political Economy of Unfairness in U.S. Health Policy

Academic journal article Law and Contemporary Problems

The Political Economy of Unfairness in U.S. Health Policy

Article excerpt



The American health care system presents an intriguing paradox: it is perennially in crisis, yet seemingly impervious to comprehensive reform. Throughout the twentieth century, reformers repeatedly failed to enact national health insurance. (1) The most recent effort at comprehensive reform, the Clinton administration's Health Security Act, ended in political disaster for the administration in 1994, with the Clinton plan failing to muster even the minimum support necessary to bring it to a floor vote in the House or Senate, and with the Republican party subsequently winning majorities in that year's midterm elections in both houses of Congress for the first time in four decades. (2)

The political lesson apparently learned in Washington from the Clinton-plan debacle was that comprehensive health reform was too politically risky to pursue. (3) Since 1994, even as conditions in the health care system have worsened, U.S. heath policymakers have embraced a strategy of inaction and neglect, with only the occasional interruption for incremental reforms. (4) As a result, the United States finds itself coping yet again with the familiar combination of rising health care costs and growing numbers of uninsured. This is not a dilemma that can be fixed by leaving the health care system to its own devices: without policy interventions the problems of rising costs and eroding access to health insurance are likely to worsen substantially in coming years.

Although outrage at the inequities of U.S. health care policy, which leaves more than fifteen percent of the population without guaranteed access to medical care, (5) is nothing new, the focus of outrage in Clark Havighurst and Barak Richman's searing indictment of the health system is different. (6) For Havighurst and Richman, the major source of unfairness in the system is how health care is financed, particularly the regressive burden that health financing arrangements impose on privately insured lower- and middle-income Americans. At the same time, they posit that lower-income Americans are also shortchanged on the receiving end, as well, since utilization of medical care may vary substantially with income. Havighurst and Richman argue that this distributive injustice means ordinary Americans are unknowingly getting a raw deal in health care--paying proportionately more while getting less--to the benefit of their higher-income compatriots and the health care industry. (7)

This article provides both a critical perspective on Havighurst and Richman's argument and a broader commentary on inequality and health care politics. It focuses on the political economy of unfairness in U.S. health policy by first highlighting the moral issues raised by our system of financing medical care and then by analyzing the political dynamics that sustain that system. Part II explores the moral illogic that governs American health care, paying particular attention to the uninsured. Part III discusses the politics of U.S. health policy and explains the difficulties in reforming even strikingly regressive health policies. Part IV discusses the role of the tax subsidy in health politics and the development of comprehensive health insurance. Part V explores Health Savings Accounts (HSAs) and their implications for fairness in American health care. Part VI concludes the article with an explanation of why markets cannot ensure progressive health financing. I argue that although the U.S. health care system is exceptionally regressive, policy solutions now in vogue suggest it could well become even more regressive in the future, and only a move away from market-based health policy can reverse these trends.



Unfairness is inarguably a cornerstone of the U.S. health care system. Whether it is the moral philosophy Americans have consciously chosen or inadvertently stumbled into ultimately matters little to those who suffer the consequences of the unfairness. …

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