What makes reducing the ranks of the uninsured important?

The debate about whether health insurance improves health has been ushered into prominence by the need of proponents and detractors of the ACA to make their case against the other side. It is an important discussion, regardless of why it has popped up (examples of good debate: one | two). Much of the best debate has been technical in nature, hinging on issues of research design, internal versus external validity, statistical power and the choice of measures. The latest round of skirmishes has ventured into the area of whether the benefits outweigh the costs, always a fair question in public policy as is seeking to fully identify the costs and benefits.

This morning I did something I may not have done since I graduated with my PhD 19 Mays ago–I read some of my dissertation “Alternative Measures of Medical Underservice: A Proposal and Assessment.”

Most of it is quite technical–it developed a more precise statistical means of allocating finite remedial resources such as funds for Community Health Centers and the National Health Service Corps using a system of structural equations, and tested the sensitivity and specificity of different measures using geo-coded data from the NHIS. I even proposed the Taylor Index of Medical Underservice (TIMU). And since you have never heard of TIMU, you get a sense of how that went.

However, leafing through my dissertation and reading through the dust, my attention stopped on section 1.4: Social Meaning of Medical Underservice, the beginning of a short section where I focused on why it was important to undertake policy to address medical underservice, essentially justifying the next 350 pages (~6 page pdf scanSocialMeaning). My reasoning was heavily influenced by Michael Walzer’s book Spheres of Justice: A Defense of Pluralism and Equality (1983; Basic Books). The essence of his argument is that the importance of a given good differs across cultures and time, as does the just distribution principle of a good, with this being determined based on the importance that members of a given society assign to a particular good. I think my thesis on why medical underservice deserved to be addressed is found in the middle of page 20 (scanSocialMeaning)

In this research, need is seen as the proper means of distributing health care services, not because it is absolutely clear that improved access will necessarily improve health, but because society as a whole is convinced that it will. Because of its importance in our culture, and the vast public expenditures to support the health infrastructure, access to the health care system should be provided to all members of this society on the basis of need “as a basic token of citizenship.” (Beauchamp, 1988, p. 4). [emphasis was in the original]

I spent very little time on the technical issue of whether you could prove increasing access to care would make people healthier, and I reviewed the uncertainties about this and noted that the evidence was mixed, though I think it tilts toward improved access being positive for health. (I even cited Ivan Illich’s book Medical Nemesis which can be briefly described as an invitation to run from modern medicine).

As I sit on my deck and think of the past 5 years, I am again reminded that one of the things that advocates of health reform learned to do was to make the case for reform in “business case” types of language (triple aim, reduction of cost shifting, transform toward sustainability, and the like). However, we seem to have buried or lost the ability or the willingness to make arguments like the one above, that the 19-year-ago-me would have started with.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

3 Responses to What makes reducing the ranks of the uninsured important?

  1. Brad F says:

    Somewhere today, a 25 yo doctoral candidate writes a similar passage, except not on health care, but climate change. In 2033 he will revisit this thesis and think the same you thing you do now. He or she will say what if….

    You can finish the thought.

    Brad

  2. Matt says:

    A good reminder. Though as a current phd student working on a dissertation, I was struck at “the next 350 pages”…

  3. Pingback: Benefits of health insurance + Indiana Medicaid reform | freeforall

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