Clark C. Havighurst and Barak D. Richman (Duke University School of Law and Duke University School of Law) have posted Distributive Injustice(S) in American Health Care (Law and Contemporary Problems, Vol. 69, No. 4, 2006) on SSRN. Here is the abstract:
This article explores the hypothesis that the U.S. health care system operates more like a robber baron than like Robin Hood, burdening ordinary payers of health insurance premiums disproportionately for the benefit of industry interests and higher-income consumer-taxpayers. Thus, lower- and middle-income Americans with health coverage pay not only for their own families' health care but also to support a vast health care enterprise that primarily benefits others, including many far more affluent than themselves. The system is able to finance itself in part because U.S.-style health insurance greatly amplifies price-gouging opportunities for health care firms with market power, creating a cost burden that falls ultimately on all premium payers equally, like a severely regressive "head tax." Moreover, these same consumers also bear excessive costs for their own health care because, not seeing the costs they bear with any clarity (since the tax system makes those costs appear to fall on their employers rather than themselves), they demand unnecessarily costly coverage and resist efforts to economize - all to the benefit of the health care industry and others with reasons to value high-cost medicine. Lower-income insureds also appear, for several reasons, to get less out of their employers' health plans than their higher-income coworkers, despite paying the same premiums. Finally, insured individuals' lack of cost-consciousness also affects their attitudes and behavior as citizens and as voters, enabling politicians as well as industry interests to make choices on their behalf that systematically raise costs and foreclose economizing possibilities. The burden of excess health care costs and how it is distributed is rarely recognized as the fundamental issue of social justice it is. The purpose of this article is to make the question who pays and who benefits a principal concern of health policymakers.
And from the conclusion of the article:
Some readers may think that, in purporting to discern unfairness in the form of “distributive injustice” in American health care, we have entered the domain of philosophy and must prove, rather than simply assume, that one particular distribution of wealth is definitively less just than another. But there should be little disagreement, philosophical or otherwise, with the two main premises of this article: (1) that the burden of paying for public goods such as health care for the uninsured, medical education, and pharmaceutical research should not fall disproportionately on those with less ability to pay and (2) that persons with lower incomes should not be compelled to pay, as part of the price of having any health insurance at all, either for coverage designed by and for elite interests or for health care that is consumed disproportionately by the well-todo. This article has observed many ways in which, under these premises, the U.S. health care system unfairly exploits ordinary payers of health insurance premiums.
Recommended! The question whether the distributive justice issues would encounter "little disagreement" is, I should think, much more complex than the above paragraph suggests. On most accounts distributive justice should be assessed on the relevant criterion holistically (i.e. the division of all the relevant the benefits and burdens of social cooperation should be assessed over whole lives). Only after we have a theory of distributive justice and then assess distributive justice for the system as a whole, could we assess whether the net impact of health care costs and benefits move the system toward or away from the desired state.
