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

Rethinking the selfare state 98
this objective of the welfare state in Chapter 1. Fundamental to the liberal model of
individual free choice is a universal guarantee of its necessary conditions. 3 That is, it is
not liberty simpliciter that is the central feature of contemporary liberalism, but equal
liberty to all. Although there will always exist some disparities among individuals that
result from their personal choices, each individual’s initial position should be roughly the
same. 4 Accordingly, those benefits that are central to one’s health must be made available
to all, and those disadvantages that are the result of the poor health of certain individuals 5
(such as physical disabilities, diseases, age, etc.) must be minimized. One must not,
however, assume that equal access to health care services in itself will ensure a fair
allocation of health. Other determinants of health besides health care services include
biological factors, physical environment, lifestyle and social environment. Further-more,
socio-economic status along with access to social welfare services and education may
have a greater impact on health than the consumption of health care services. 6
Individual autonomy
The central importance of health, both to individual well-being and to the possibility of
autonomous choice itself, underscores the importance of assuring the good health of all
citizens. However, not only is a basic level of health a necessary condition for
autonomous choice, its provision should, in turn, be the subject of autonomous choices as
well. Although most patients do not have the information required to make highly
technical decisions about how, precisely, to carry out their treatment, considerations of
value (such as whether or not to proceed with a certain form of treatment at all) must be
left up to patients themselves. Because it is one’s own body and mind that are the subject
of health care decisions, such decisions are necessarily private and personal. However, as
these decisions involve information that is highly technical, it is also crucial that patients
be fully informed of the consequences of their choices. 7
Efficiency
In 1997, per capita spending on health care in the United States equalled $3,925, with
total expenditures representing 13.5 percent of the country’s GDP 8 (twice the amount
spent on education and approximately three times that spent on national defence). 9
Canada spent $2,095 per capita on health care in that year, the total expenditure
representing 9.0 percent of its GDP. 10 By way of comparison, the OECD median per
capita expenditure in 1997 was $1,728 with an average total expenditure representing 7.5
percent of GDP. 11
The percentage of GDP that a country spends in any particular sector is an important
figure to consider for it is suggestive of opportunity costs. That is, if a large proportion of
GDP is spent on health care services, this may “crowd out” resources available for other
goods and services. It is noteworthy that between 1960 and 1997, no OECD country was
able to limit growth of health care spending to growth in GDP. 12 The escalation of total
health care expenditures has been the result of a variety of factors including the
increasing proportion of the elderly in the population and rapidly changing technology
with respect to drugs, equipment and products. 13 For example, by 2002 Ontario’s forecast
health spending per capita was $3,393 (1997 dollars), up from approximately $1,745 in