Book Review

Benchmarks of Fairness for Health Care Reform

N Engl J Med 1997; 336:447February 6, 1997

Article

Benchmarks of Fairness for Health Care Reform
By Norman Daniels, Donald W. Light, and Ronald L. Caplan. 198 pp. New York, Oxford University Press, 1996. $29.95. ISBN: 0-19-510237-1

The failure of the 103rd Congress to pass any kind of health care–reform bill in 1994 was stunning and depressing. Stunning, because no one thought such an outcome was even remotely possible, and depressing, because it induced dark thoughts about the American commitment to justice. The fact that there were then an estimated 37 million uninsured people (there are now as many as 41 million) was widely acknowledged to be unfair, yet no reform measure was passed. The lingering questions are whether Congress might someday be willing to pass a bill characterized by fairness and what such a bill might look like.

Norman Daniels and his colleagues take up those questions. They begin by asking whether Americans are indifferent to fairness, and their answer is no. That's what the public-opinion polls said (and still say). They then ask how a strong case for justice in health care — based on a right to such care — can be made and specify 10 benchmarks to serve as criteria for fairness. These include universal access, comprehensive and uniform benefits, clinical efficacy and financial efficiency, and consumer choice. It is a bracing and impressive list.

At that point the authors make an interesting move. Instead of applying their benchmarks to some hypothetical legislation, they apply them to four of the actual bills that were before the 103rd Congress. The approaches of those bills ran the gamut from single payer to market-based. The authors use a scoring system to determine how well the different approaches measured up to their fairness criteria. Not surprisingly, the single-payer bill (McDermott–Wellstone) wins handily. Its avowed purpose was fairness, whereas the other bills had other aims as well. Although the authors note that the other bills could all have been more fair, it is not clear to me just how much that would have been possible without compromising their other goals (e.g., strong market competition).

Daniels and his co-authors also use their benchmarks to test a number of current trends in health care. These include cost-cutting measures, managed care, and the corporatization of medicine. None score well, which is about what one might expect: none have fairness as their explicit (or even implicit) goal.

The authors work hard to end on a happy note — not an easy task these days for those committed to fairness. Is it not possible, they ask, that managed care itself, now full of problems, might set the stage for an eventual universal health care policy? It is not an implausible idea, and stranger things have happened in this world.

I wish I could share the authors' optimism about the public's commitment to fairness. No doubt it exists, but how much are people willing to sacrifice to achieve it? Not much, the polls have indicated. Nor, given the antigovernment virus that abounds, is there much indication that the public would accept the institutional structures needed to ensure fairness. Even so, this book makes a most helpful and lucid contribution to our self-understanding, and that is a valuable way to begin the hard work that lies ahead.

Daniel Callahan, Ph.D.
Hastings Center, Briarcliff Manor, NY 10510