Equal opportunity vs. absolute equality -- Looking at the psychology of American health care reform

America is all about equality -- it's written into the fiber of our being that "all men [and women] are created equal" and are entitled to "life, liberty, and the pursuit of happiness." It is therefore not surprising that equality has remained an unquestioned principle through many a round of health care policy debates. Interestingly, the rhetoric of equality has also been wielded by both conservatives and liberals, by those for universal public health insurance as well as those for privatized, market-driven coverage -- essentially all parties across the spectrum. How is it that such a commonly accepted value can be used with equal effectiveness by opposing arguments?

Perhaps we ought to stop and think about what each side means by "equality." There are those who are interested in creating a publicly funded universal insurance program similar to the Oregon Health Plan, in which services were defined by their degree of necessity and strictly rationed based on patients' medical needs. These people are likely concerned about equality in the sense that everyone obtains the same services in terms of type, quality, and quantity. On the other side of the debate, pundits argue that it is precisely in unrestricted access to whatever medical services people desire or require that the principle of equality will be upheld. Of course, open access necessarily doesn't necessarily mean that everyone will get the latest CT scans, cancer therapies, or boob jobs. The hidden limiting factor here is money; we have an openly accessible system where those with money can buy whatever care they want, while the poor are often barred from even a basic level of service. In the end, we as Americans may actually care less about having the equal level of care than the theoretical equal opportunity to get the level of care we want or need.

But most of us lie somewhere in between. On the one hand, we feel that we've earned our money fair and square. No government should be able to take it away from us to subsidize someone else's care, and gosh darn it, we should be able to get that perfect pair of breasts if we so wished! But we also intrinsically see something wrong with having our health and happiness depend almost entirely on how much green we have in our pockets. In fact, in these troubled economic times, we fear more than ever how one job loss can leave us depending on state-run Medicaid for health insurance. Ai, there lies the rub. You've heard the big scary word before: rationing. Whether you like it or not, baby boomers aren't getting any younger, new diseases are being discovered and therapies being developed for them everyday, medical school is getting more expensive, driving our future doctors to sub-sub-specialize instead of go into primary care, and physicians are being incentivized to provide high quantity, not high quality, care. All of this means there will be more demand for health care services, which further drives up the prices of these services in a techno-philic system that already pays a premium for the latest-and-greatest.

Like it or not, our health care system has long passed the point where people were able to receive as much care as they wanted for a reasonable price, which means rationing has been going on longer than we might perceive. Currently, our system implicitly rations health care based on wealth; depending on your income, you can have pretty much as much of whatever kind of care as you'd like, with almost no upward limits. We don't like to think about this as rationing -- we think of it as the American way, in which there are no glass ceilings to the level of wealth you can achieve, and therefore the level of care you can buy with that wealth. Although most of us live modestly, we would nevertheless like to believe that ordinary people like us, with enough hard work and a sprinkle of luck, can be the one to have it all (see this idea parallelled in this Newsweek article on why we don't hate the rich).


Does our concept of equality (equal opportunity or absolute equality), and thus our idea of what an equal distribution of health care looks like, really come down to what the middle class identifies with the most? In good times, we have the luxury of optimism, to aspire to "having it all," and we don't want that optimism curtailed. But when a downturn like the current one hits, and we begin to prepare for worse-case scenarios that threaten our reality, we believe that we are honest, hard working people who deserve a sturdy safety net (it's why the stimulus bill provides additional funding to bring people into Medicaid). This is the conflict that we're caught in as we try to rectify the inequalities in our health care system; we're torn between the two seemingly opposing cornerstones of our being -- impossible optimism and dogged pragmatism. The ultimate solution looks, again, to be two-tiered. One (say, a government funded basic insurance package) must appease our desire to be guarded against catastrophes outside of our control, while the other (the private market) maintains the hope for unlimited growth and progress. Beneath the surface, however, there is a unifying factor, a redemptive quality - both ideas stem from a deep belief that our efforts can make a difference, that we should be protected against external ills to the extent that they no longer impair our potential for self-made progress. This belief has driven us both towards innovation as well as stagnated debates, towards unparalleled quality of care as well as disparities that rivel those in third world countries. It's what makes health care reform so uniquely difficult.