Rethinking the Welfare State: The prospects for ... - e-Library

6
Health care
Introduction
Health care—like primary and secondary education—is vital to human flourishing. This
notion underlies the World Health Organisation’s definition of health as “a state of
complete physical, mental and social well-being and not merely the absence of disease or
infirmity.” 1 That is, health is not simply a consideration that surfaces only when we are
stricken by illness or injury; rather, health is a state that pervades every aspect of our
lives. It is fundamental to our ability to work effectively, to participate in the life of our
families and community, and to enjoy our leisure time. Moreover, to suffer ill-health is
not merely to experience an immediate disutility (such as physical pain), but also to be
deprived of the very grounds for the effective exercise of autonomy itself. In this light,
health care cannot be viewed as a benefit that can be straightforwardly allocated in
accordance with an individual’s preferences (as reflected by his or her willingness to pay
for it). Instead, it must be conceived of as a necessary condition for human fulfilment in
all aspects of life and hence a Rawlsian primary good. 2
Because good health has generally been recognized as essential to our overall wellbeing
and autonomy, most Western countries have elected to regulate the provision of
health care services and concomitant health care insurance in order to guarantee at least a
minimum level of this necessary good to all. In part this reflects precepts of distributive
justice and in part concerns about limitations of private insurance markets that are likely
to screen out the highest risk or sickest individuals from coverage. Removing the
provision of such services from the discipline of the market, however, introduces a
number of perverse incentives for both providers and purchasers and, as will be
demonstrated through a discussion of three different models of health care reform, these
perverse incentives are not easily addressed. We will argue that a universal but limited
voucher system may be the most appropriate means of resolving this tension. In such a
system, the government would provide every citizen with a voucher with which health
care services could be purchased in the health care market. Essentially, a market in health
care would be created with government funding. As we shall see again, however, striking
the right balance between efficiency and equity is an extremely difficult enterprise.
The goals of health care policy
Distributive justice
Because good health is vital to one’s autonomy and general well-being, it is a central
concern for distributive justice or the equitable distribution of resources, as we articulate