Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Political Philosophy of Health: Chad Horne
33 Plays2 months ago
Dr. Chad Horne is a political philosopher of health at Northwestern University. Listen to Chad discuss the purpose of health insurance, the Affordable Care Act and the egalitarian and market failures approaches to justice in health.
Recommended
Transcript
Introduction
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, Jon Neary.
00:00:21
Speaker
My guest today is Dr. Chad Horn.
Meet Dr. Chad Horn
00:00:23
Speaker
Dr. Horn is an associate professor of instruction in the Department of Philosophy at Northwestern University. He is published primarily on the political philosophy of health and health care, where he defends a theory of justice in health care based in the public choice tradition. In 2022, he authored a paper with Dr. Joseph Heath titled, A Market Failure's Approach to Justice in Health. Dr. Chad Horn, welcome to the wound dresser. Hey, thank you for having me.
Core Questions in Political Philosophy of Healthcare
00:00:51
Speaker
um So you're a political philosopher of health, which, as I understand, is ah it's it' a very distinct ah kind of field and within itself. Can you talk about ah some of the issues that ah political philosophers of health explore? Yeah, sure. ah So ah back at the University of Toronto, when I was a graduate student, there was a professor there by the name of Arthur Ripstein, who liked to say that the the two classic questions of political philosophy are questions that are ah understandable to anyone who's ever been an angry teenager, ah which is number one, ah why do you get to make the rules? And number two, ah how is that fair? ah So the first, you know, why do you get to make the rules is the question of legitimate political authority.
00:01:36
Speaker
What, if anything, gives the state the right to make laws and force us to comply with them? And and do we have an obligation to obey the law? Those kinds of questions. ah Under the second question, how is that fair? ah That's the question of distributive justice. Our political system, our economic system, distributes all kinds of things, ah income and wealth and rights and liberties and opportunities.
00:02:00
Speaker
ah and ah you know and and also things like education and healthcare and other specific goods. ah And political philosophers under that kind of second question are interested in what makes for a fair distribution of of those goods, right? How do we know when the the the benefits and burdens of social cooperation are being ah distributed in ah in a fair way?
Healthcare Inequalities
00:02:25
Speaker
I think that even people who are pretty tolerant of significant inequalities in income and in wealth and in a lot of the goods that those things can buy ah still find themselves troubled for by significant inequalities in access to health care. or for that matter in health outcomes, in in in you know ah life expectancy and morbidity and and things like that. ah you know If you tell someone that the rich have nicer cars or bigger TVs than the poor, you know that's is that troubling? it it It may be, it may not be. ah But again, when you tell people that the rich live longer, that the rich live healthier lives, that the rich have, again, you know better access to essential healthcare care services, I think you know ah a lot of a lot of people are are troubled by that.
Right to Healthcare and Fairness
00:03:13
Speaker
ah So, ah within the political philosophy of healthcare, I think there are kind of two too big questions. ah Most obviously, we argue about and discuss whether there's a right to healthcare. care ah whether you know all citizens should have access to some kind of health care package, whether that is a strictly equal health care package with everybody else, or whether that is ah what philosophers sometimes call ah like a decent minimum of health care. And then more recently, as philosophers have become more interested in the literature around what's called the social determinants of health, and more interested in
00:03:51
Speaker
ah the sort of non-healthcare factors that influence people's health and people's well-being. Philosophers have started to be interested in what constitutes a fair distribution, not of healthcare care access, but of those those social determinants of
Social Determinants of Health
00:04:06
Speaker
health. um So by the social determinants of health, I mean ah things like um obviously the sort of environment in which you lived, do you have clean air, do you have clean water,
00:04:17
Speaker
ah Do you have a ah safe ah physical environment that's free of violence and and things like that? ah so Those have significant impacts on health outcomes. ah So too do people's occupational status and even maybe people's income ah seem to have significant impact on on their health. Their their access to ah a community and a social network seems to affect ah their health and their
Bioethics vs. Political Philosophy
00:04:38
Speaker
well-being. And then also what what we call health behaviors are really huge, right? Substance use, ah diet, exercise, nutrition,
00:04:46
Speaker
all of those kinds of things. ah So again, kind of the the big question has always been about access to health care. ah But as we've as we've learned more about those so social determinants of health, ah political philosophers have gotten more interested in what would be a a fair distribution of of those things. and And some people have even gotten interested in whether they're you know ah whether there's ah a right to health or a right to some kind of equal ah health in in itself, right quite apart from the ah distribution of those factors that determine health.
00:05:15
Speaker
So just ah we'll we'll get back to the right to health in a second, but just to clarify for our listeners, um you know how's your work distinct from, say, like bioethicists or you know public like public health ethicists? What is very specific to the political philosophy realm?
00:05:31
Speaker
Yeah, so so bioethicists are are typically interested in the ethical principles and the ethical guidelines that should govern the kind of individual interaction between a doctor and a patient. And so, you know, under that heading, obviously the the doctrine of informed consent, ah you know, rules around and and principles around around confidentiality, around ah respect for cultural differences, around ah you know, ah culturally sensitive and culturally competent care, ah those those kinds of things, right, the kinds of of sort of ah ethical norms that are going to govern those ah typically kind of one to one physician-patient interactions.
00:06:08
Speaker
although often there are also ethical issues around how you deal with family members and and other people who might be involved as well, of course. And public health ethics, similarly, you know, often the looking at the ah sort of moral principles that should guide public servants, ah in this case, ah people who work in the public health domain, again, in in their dealings, maybe not with individual citizens, but their dealings with the public and and things like that. Whereas we as political philosophers are more interested in ah questions about the sort of you know the the the fairness or the equity of the the system in general. you know What would a just healthcare care
What is a Just Healthcare System?
00:06:40
Speaker
system look like? Would that be one where everyone has access to care? Does that access need to be equal? Or ah does it ah is it enough that everyone has access to a decent minimum? ah and And again, you know thinking about maybe within a public health context, you know what is ah ah ah not what are the the moral principles that should guide public health officials in their jobs,
00:07:00
Speaker
and in their dealings with the public, but rather, you know, what would be a fair distribution of the the social determinants of health, the the social factors that affect people's health outcomes. So we're interested in those more political and more systemic questions.
Dr. Horn's Journey into Healthcare Philosophy
00:07:13
Speaker
Yeah, that's super interesting. How did you kind of get first interested in those, um you know, questions of fairness and in healthcare? care Yeah, ah so for me, I got interested in this all the way back when I was in grad school, back in 2008, 2009, 2010, when I first started thinking about these issues. And there there were two things going on around that time. ah One that was very unique to me, and one that was kind of common to all Americans, ah that sort of came together to get me interested in this subject.
00:07:46
Speaker
ah So the the big thing that was going on that affected all of us ah was that ah you know ah Barack Obama campaigned for president in 2008 with ah a pretty specific and a pretty detailed plan for healthcare system reform.
00:07:59
Speaker
ah that came to be known as the Affordable Care Act or maybe more popularly known as Obamacare. And so during that time, ah you know, both during the campaign and then during the kind of legislative wrangling of 2009 and 2010 to get the Affordable Care Act passed, you know, the Obama administration, ah the the president himself, but then also a lot of his surrogates and and and people in the news media were making some arguments for the Affordable Care Act.
00:08:24
Speaker
about ah you know how this was going to address some significant market failures in the insurance sector, how this was going to make everybody's health care better. It was going to control health care costs and bend the cost curve and all that kind of thing. ah So I was listening with a lot of interest to those arguments as somebody who's really interested in politics and and really interested in policy.
00:08:45
Speaker
And at the same time, there was something going on that was sort of unique to me, ah which is that I was a grad student and I was teaching for the first time courses in bioethics. And at at the end of those courses, I would do a little unit on the political philosophy of health care. And we started looking at, ah you know, the the the philosophical arguments for a right to health care especially people like Norman Daniels, who's maybe the most influential. He's at he's at Harvard. ah He's written a couple of of really influential books on the political vel philosophy of health care. um And they were making a very different set of arguments, ah not the kind of mutual advantage arguments
00:09:20
Speaker
ah that that the president and his surrogates were making, but we're rather making these sort of egalitarian arguments. You know, we think it's really important that ah and in Daniel's case in particular, you know, we may disagree about whether there should be equal outcomes, but we agree about the importance of equality of opportunity. And ah he argued that access to healthcare was really important to protecting equality of opportunity. ah You know, if you're sick, if you're suffering from a disability, you may not be able to ah you know, successfully pursue the same kinds of opportunities that other similarly situated people could, fluid and that seems unfair. ah so So, you know, there's there's sort of two different arguments going on ah for sort of universal healthcare, for why ah we need to sort of reform that the healthcare system.
Universal Healthcare Challenges
00:10:05
Speaker
Again, the the sort of mutual advantage and efficiency arguments that the administration was making, and these egalitarian arguments that the the philosophers were making that I was teaching in my in my bioethics class,
00:10:16
Speaker
And at the time, it just seemed to me that the arguments that Obama was making were just much better arguments. I found them so much more persuasive. um In particular, you know, but the the trouble with equality is that whenever you're making an equality argument, yes, you're you're you're saying that we should like, you know, move the people who are badly off off, we should make them better off. um But you're also creating so you're creating winners.
00:10:40
Speaker
ah but But you're also creating ah losers because you're also arguing at the same time that in order to bring up the badly off, we need to bring the the better off down. right They need to pay higher taxes. They need to ah you know they need a sacrifice to to to promote equality. um Whereas I found the the Obama administration's arguments based in, again, the the idea actually that um these healthcare system reforms are going to make everybody better off, that ah that the the current healthcare care system is is not really serving anybody's interests effectively and that we can actually, you know, sort of improve everybody's situation, ah not only by expanding access, but also by getting costs under control and and things like that. That just sounded to me like a much much more persuasive argument. And I looked around and there was not really anybody making those kinds of arguments in the philosophical literature. And so I saw, ah you know, I saw an avenue for me to to to say something that that and people hadn't really been been saying before.
00:11:34
Speaker
Yeah, it's it's definitely refreshing listening to you talk. I feel like in like when you're actually in a healthcare care setting, it just sort of gets divided into this black and
Right to Health vs. Right to Healthcare
00:11:42
Speaker
or white issue. Like, do you think people should have health care? Yes or no. And like, they're all like sort of the nuances of like, how you should do it. And and and you know, what like people's actually rights to health care are kind of just, you know, goes by the wayside. So um yeah, you mentioned right to health care is is is right to health and right to health care. Are those two separate concepts? Are those generally used interchangeably?
00:12:04
Speaker
ah No, i I think those are actually very, very different concepts. And as we get to know more, ah not ah not more ah philosophically, but more sort of empirically about, again, what are called the social determinants of health, the kinds of things that that make people ah that make populations healthy. um As we learn more about that, we see that actually a right to health care and a right to health are are very, very different things, um as especially if you're interested in, ah you know, what are behind ah health disparities, right? Why why is it that well off individuals enjoy significantly longer lives and significantly lower levels of different kinds of morbidity than than badly off people? um It turns out that the answer to that question is not really because those better off people have better access to health care.
00:12:55
Speaker
ah you know ah that that that really what is driving those health disparities between better off and and worse off people is is much more about those those social determinants of health that I talked about
Healthcare Access vs. Social Determinants
00:13:06
Speaker
earlier. um Health behaviors are are huge, ah but so too are sort of environmental factors, so too are economic factors, right? These things have big impact on on people's people's health outcomes. ah Norman Daniels, that political philosopher of health that I mentioned earlier,
00:13:21
Speaker
He likes to talk about health care as like the the ambulance waiting at the bottom of the cliff, right which is that, of course, you know if you fall down the cliff, you really want that ambulance to be there, of course. But when you're trying to understand those so sort of population-level health disparities, again, why are why are some people healthy? Why are some people sick? It's much more about who's falling down the cliff in the first place. um and and And again, that has to do more with those those those social determinants of health.
00:13:47
Speaker
um and and and and and that that I was talking about earlier.
Debating Universal Healthcare in the US
00:13:51
Speaker
And so as a result, right the um the the classic debate in the political philosophy of health care, especially in the United States, or I should say the classic debate in the political philosophy of health in the United States has been around a right to health care. The US is really unusual compared to other developed countries in not having a universal health care system. I think still almost 10% of Americans don't have some kind of basic health insurance plan um And there's just there's no other developed country that is that that can say that, right? um all All of our peers have have established some kind of universal healthcare care system. And so, you know, there's there's obviously been a big debate, especially in among philosophers in the United States, around, you know, is there a right to healthcare? What is the best argument for that?
00:14:35
Speaker
ah Should we think about that in terms of equality or sufficiency? Or should we say with the libertarians maybe that that you know we don't need to have any kind of state interference in the healthcare care sector? That's been the the the classic debate that's been going on ah you know for for decades and decades. ah But then again, in in in more recent years, as we've learned all those things that I just told you about the social determinants of health,
00:14:57
Speaker
um People have have have started to realize that as as important as access to health care is, and and I think it's really, really
Equal Health Opportunity
00:15:04
Speaker
important for various reasons, that alone is not going to get you, it might get you equal access to health care, but it's not actually going to get you to equal health outcomes unless you also attend to those social determinants of health.
00:15:17
Speaker
And so in in more recent years, again, philosophers have started to ask not just is there a right to health care, but is there a right to health or is there a right anyway to a sort of ah equal opportunity to be healthy? ah the the The right to health is a little tricky ah in particular because, ah you know, first of all, to some extent, health is just dependent on on on nature, on on random chance of of who gets sick or who who gets you know a particular
Measuring Healthcare System Performance
00:15:45
Speaker
ah genetic condition or something like that, right? Those those things we can't really socially control. um But even among the things that we can socially control, a lot of those things are, as as I said, ah downstream of individuals' health behaviors, individuals' ah choices around health.
00:16:02
Speaker
And so those things, too, are are very not so easy for the state to control. ah So so maybe instead of talking about a right to health, we should talk about the right to something like an an equal opportunity to be healthy or or something like that. ah but But anyway, yes, those things, a right to health, right to health care are very different, I think, as we learn more about what what's behind each of So if you're, if you're trying to like, um, you know, in research, you just have to essentially measure things to kind of come up with, with conclusions. If you're trying to measure how well our healthcare care system is doing, do you feel that, you know, measuring people's access to healthcare is more important or people's health outcomes are more important or how how do you as a philosopher kind of say like, you know, what, what is a good measurement of how our healthcare care system is doing?
00:16:47
Speaker
ah thats That's interesting. um I mean, I think that, um ah you know, ah the the first thing I'll say is that this is not something I thought a lot about, and it's it's not something that I have ah any great expertise on. ah But just to to answer your question kind of off off the ah top of my head, um I think that, you know, again, that it's it's difficult to draw conclusions about the healthcare system from ah sort of population level information about health disparities and and things like that because
00:17:18
Speaker
ah those health disparities are often not downstream ah so much of access to care, ah but are rather downstream of all those other non-healthcare factors that we were talking about, ah environmental factors, community factors, ah socioeconomic factors, behavioral factors, ah things like that. And so, um you know, you can look, you know, if you want to know how well the healthcare system is is doing, I suspect that you can, you know, you can look at statistics like, you know, deaths amenable to healthcare, care um you can You can look at at metrics that measure access and and things like that. um Whereas ah the sort of population level health data I think is maybe more effective as information about how well the public health system is doing um and and maybe how well the political system is doing in general at ah you know providing people with the things that they need to live long healthy lives.
00:18:15
Speaker
To think about the the right to health care again, um you know what are the main arguments that are used to kind of defend that right to health care? I know you mentioned ah Professor Daniels um and the egalitarian approach, but what are what are kind of the main arguments ah related to that? And then how does your approach perhaps differ um from some of those you know traditional arguments?
Philosophical Support for Universal Access
00:18:37
Speaker
Sure, just to start with that kind of traditional arguments. Traditionally, I think when philosophers have tried to defend universal access to health care, a right to health care, they've looked to arguments that are based in equality, or if not equality, then sort of nearby values like sufficiency, right, making sure that everyone has enough, or or something like that.
00:19:01
Speaker
ah So, you know, you look at the healthcare system and the healthcare system definitely does do a lot of redistribution of wealth that looks like it has an egalitarian character to it.
00:19:12
Speaker
ah Most obviously, in countries that have universal health care systems, ah they tend to be funded through taxation, ah which is often typically somewhat progressive. And so, ah you know, rich people are in general subsidizing the health care of ah less well-off people. And that has the sort of egalitarian character to it. You're transferring resources from rich to poor.
00:19:31
Speaker
ah But then also, of course, another thing that the healthcare care system does is that it transfers resources from healthy people to sick people. And you can also see that as a kind of egalitarian redistribution, right? Sick people are badly off. They're suffering. um And importantly, they're suffering in a way that seems kind of and undeserved, right? it's not downstream from any of their choices. ah Usually when we get sick, it's through no fault of our own. And so you can also see like the the transfer of of resources from healthy people to sick people that the healthcare care system affects. You can also see that as a kind of egalitarian project.
00:20:04
Speaker
um so ah Those have been the kind of main arguments that philosophers have offered. As I mentioned, Norman Daniels is maybe the most famous person in this regard. ah His view is that we should think about health care ah in terms of equality of opportunity and protecting ah equality of opportunity. As I already said, you know ah Daniels sort of acknowledges that the US is not a society that's necessarily committed to equal outcomes. ah But we do at least pay some lip service to the idea of equality of opportunity.
00:20:34
Speaker
ah That's why Daniel suggests we provide a universal system of education, for example, right? We don't think that your access to education and skills and job training should depend on how well off your parents are. That seems to be ah an egalitarian commitment.
00:20:49
Speaker
And he wants to argue that we should think about the public provision of health care or the public guarantee of some ah you know adequate level of health care ah in the same vein. and Again, if you know if if I have a serious disability or a serious illness that prevents me from from working or that prevents me from you know competing effectively for jobs, we should we should see that as the same kind of unfairness as you know someone who who can't get a of K through 12 education for example, because their their family is not is not well off enough to to afford it. And our sort of intuitions around equality should be ah should should be offended by that. um Daniels is not you know the only person to have offered you know ah these kind of egalitarian arguments. there's There's a bunch of others, but I won't.
00:21:33
Speaker
and I don't know that we want to kind of go into the the weeds of all of them. But again, what they all have in common, I think, is that they tend to see the health care system as justified by some kind of commitment to equalizing access to care, um maybe in the you know in in the name of a more equal distribution of of of wealth or in the name of ah compensating for and undeserved health inequalities.
00:21:55
Speaker
Just to just to kind of clarify, there though, with the egalitarian approach, it's more about equality of opportunity versus equality of outcome? Well, look that's how Daniels positions his view. Again, you know he he just acknowledges that the United States in particular does not appear to be particularly committed to equality of outcome.
00:22:13
Speaker
ah But but we we do seem to, ah you know, have some ah ah not only ah sort of theoretical commitments, but some kind of embodied commitments to equality of opportunity in the form of, you know, we've already implemented a a system of of universal education. ah We have also already taken some steps to ensure equal access to healthcare.
00:22:36
Speaker
ah There is, of course, the Medicaid system, which provides ah health care to low-income people ah in in in most states. um There is the Medicare system, which provides a universal ah system for people ah over the age of 65. There's also the MTALA regulations, right which require that if a If a person with a medical emergency shows up at an emergency room, you have to provide treatment, even if they have no insurance, even if they have no way of paying for it, right? These these are all, ah he thinks, sort of expressions of our commitment as a society to to promoting something like equality of opportunity. um so So again, I mean, yeah there are other philosophers who would say, no, I actually
00:23:15
Speaker
I believe that the best argument for universal health care is not about equality of opportunity, but about equality of outcome, right making sure that people are are equally healthy or or have the equal opportunity to be healthy anyway, um have equal access to care. But but again, Daniel's view is, the most I think, the most well-known and the most influential in the and in philosophy.
00:23:38
Speaker
Okay, and then just to yeah, so so now it sounds like your arguments that you make in your, ah you know, one of your your big publications was a a market failures approach to justice and health.
Market Failure Approach to Healthcare Justice
00:23:49
Speaker
How does that kind of differ from the the classic like um Daniel's view of of sort of egalitarian, ah you know, the egalitarian approach to justice and health?
00:24:00
Speaker
Yeah, so the the paper you're referring to is ah is a paper that I co-wrote with a philosopher by the name of Joseph Heath. He's at the University of Toronto. ah He is also ah my PhD supervisor as it happens. And in this paper, we ah we say some things to kind of question the egalitarian approach, and maybe we can talk about those in a minute. um But we we put forward our alternative view that we ought to think about the the best argument for a universal health care system as an argument that is grounded in mutual advantage or ah the the more sort of technical language that we use is the language of economic efficiency. ah that That in particular, you know, the the most striking feature I think of the healthcare care system is that um ah private markets for healthcare insurance just don't work very well. um the obama This was the part of the Obama administration's argument all the way back in 2008 that I found very, very
00:24:54
Speaker
ah enlightening and very persuasive. um You know, if you put out a sign that says health insurance for sale, you're not going to get a random sample of the population that are going to show up to buy health insurance from you. actually what's going to happen is that disproportionately the people who are gonna wanna come buy your voluntary free market health insurance are precisely the people who are most likely to need it, right? People who already have some kind of serious health issue or anyway already know or already expect that they're gonna have some kind of serious health issue in the future. um That's not gonna be everybody, ah but it's gonna be disproportionately attracting those sorts of people. um Economists call that an adverse selection problem.
00:25:32
Speaker
ah the insurance market is going to work well if you have a kind of random sample of the population ah where ah you know the people who do get sick, ah their health care can be paid for by the people who don't. um that's That's kind of how insurance works. um it's it's I would say actually not um as it might appear at first glance, ah insurance is not an egalitarian institution. ah We're not helping the sick ah because they are badly off or out of some kind of you know a humanitarian or egalitarian concern for them, we're we're helping them as part of a scheme that helps us to manage risk more effectively, right? um ah that that that That makes everybody better off, right? Even though I don't consume significant healthcare, care I really value the protection that my insurance provides knowing that if I do get sick, ah you know the insurance that I have will will pay for it. ah But again, going back to the the kind of market failure story, if you if you try to sell insurance on the private market,
00:26:26
Speaker
um ah in a sort of unre unregulated fashion, you disproportionately attract the the sickest people, you disproportionately select, attract that kind of adverse selection of risks.
00:26:37
Speaker
And um this is a little bit counterintuitive, but um people imagine maybe that the problem with unregulated insurance markets is that sick people can't get insurance. um But the adverse selection problem ah suggests that the problem is actually the opposite, that it's too easy for sick people to get insurance in ways that drive up the average cost of insurance for everybody and then healthy people, people who don't necessarily expect to ah to need significant health care. They end up deciding, you know what, $10,000 a year for health insurance that I may not even need? i don't That's not a good deal for me. And so they decide to drop out. um and you know and and And that causes sort of average prices to rise. ah and And as prices go up, you know even really expensive health insurance may still be very attractive for people with very expensive health needs.
00:27:27
Speaker
um And so they continue to be, you know, ready to buy insurance, ready to buy into the system. um But as those prices creep up, more and more healthy people drop it out. And you can get what's called an adverse selection death spiral going in just this way, right? Where prices keep rising and and premiums keep rising ah to the point where ah the the the insurance system just kind of prices itself out of existence. um This is a real phenomenon that economists have have documented.
00:27:55
Speaker
ah And that's a situation that just makes everybody badly off. I wouldn't like that even, again, as a person who doesn't have, is fortunate enough not to have significant health costs. I would not like that situation. That wouldn't be good for me. ah and And most countries around the world have solved this problem in in in one way or another.
00:28:14
Speaker
just by making it mandatory for people to buy insurance. ah and and And that solves your adverse selection problem because, again, it it just guarantees that you're going to get a random sample of the population that your insurance pool is going to include both the sick people and the healthy people that are kind of necessary to to sort of balance things out.
00:28:34
Speaker
um And so, you know, when philosophers talk about healthcare and the right to healthcare, they often talk as if the the sort of NHS in the UK is like the model that they have in mind, right? um So the UK really has like fully socialized medicine where doctors work directly for the state and healthcare is provided to everybody as a public service, just like police protection, just like fire protection, just like public school.
00:28:59
Speaker
um And philosophers often talk as if, you know, that's the ideal. But that arrangement is really quite rare, even among other developed countries that have achieved universal coverage. um You know, many countries have systems not of socialized medicine, but socialized insurance. um That's how they do things in Canada. ah Each province runs a universal health insurance scheme, but doctors are are private practitioners.
00:29:24
Speaker
um If you look at the systems of of most of European countries, um there's often a kind of mix of public and private insurance. um Some countries like Switzerland have a fully private system. ah But what all these systems have in common is that it's not optional to buy insurance. You don't have the but choice to go uninsured. And that is the the reason for that, I would argue, um and often this is very explicit um ah in in countries that that that that ah have these mandatory private systems, for example. um The reason why it's mandatory is precisely to prevent that adverse selection dynamic from getting started and therefore you know preserving access to insurance for everybody, for for healthy people as as well as sick people. And again, that's that's an arrangement that makes everybody better off. And and and so i find I find that to be a um more plausible argument, I guess, for ah for universal coverage compared to um the the egalitarian argument.
00:30:21
Speaker
so What I'm getting is kind of like that the the big market failure kind of related to healthcare is that we're not sort of distributing risk correctly. and As a result, you sort of get these ah you know this adverse selection phenomenon where people who are sick are kind of going for health insurance,
Market Failures Beyond Insurance
00:30:39
Speaker
which is driving prices up. does that kind of Is that is that kind of a good way to summarize what the big like market failure is within our our healthcare system?
00:30:46
Speaker
Well, so I would say that that is the big market failure in the health insurance system. And so in a sort of unregulated free market for insurance, ah that would be the the big barrier for most people in getting care. um It's not the only market failure in the health care system. ah ah that there There are also just significant market failures in the relationship between patient and provider.
00:31:12
Speaker
um you know it's It's a hallmark of all professional relationships, actually, that you know the professional has a very specialized body of knowledge that makes it difficult for their client or their patient to judge whether they are ah you know ah recommending the appropriate treatments, whether they are themselves even qualified to provide those treatments,
00:31:34
Speaker
um There's also a, ah you know, what, what, ah so so there's that as so asymmetry of information. um There's also what economists would kind of dryly call like a sort of market power and provision, ah which is that, you know, if I'm my appendix is is about to burst or if I'm suffering from a heart attack and I show up at the emergency room, I am not in a position to haggle with you about price. right Whatever it is that you say in that situation, right like whatever you want to charge me to get that appendix out or or to to treat that heart attack, like I'm going to be prepared to pay it. um So you can call that like market power if you want to use the kind of dry language of of economists. But you could also just call it like there's an intense vulnerability, right? And and a possibility for for exploitation. um And this is actually common across the professions, right? Lawyers, accountants. um they They're also um in in kind of similar situations, right? Both having that that body of knowledge that makes it hard for their patients or their clients to assess how well they're doing their job. And also having that sort of tremendous ah power ah to affect
00:32:35
Speaker
the well-being and and the the the the lives of their of their clients. um and And so you know that's another source of market failure in the sense that um um it's often um actually like harmful to to both sides. right um That is, it's it's it it often leads patients maybe not to seek care,
00:32:55
Speaker
um if they're ah unsure of ah you know whether they can trust their doctor, whether their doctor has their best interests at heart. And of course, it's also bad for physicians if they're losing patients, right? And and so ah what one way to understand the traditional field of medical ethics or or bioethics is as a solution to those trust problems that arise in any kind of professional setting.
00:33:17
Speaker
right um By um committing yourself to a professional code, committing yourself as a physician to the idea that you are going to be looking out for the good of your patients and not just using your power and your knowledge to your own advantage.
00:33:33
Speaker
um by making that commitment in a conspicuous way and and maybe even empowering a professional organization to enforce those commitments in cases of very egregious violations. You can help to sort of address that trust problem, right? And you can make patients feel more safe.
00:33:49
Speaker
going to their physician, ah you can make, ah therefore make physicians better off because patients are going to be willing to come come see them and and and so on. And the state may have a role here to play as well in in licensing physicians, in promulgating regulations about you know how physicians should treat their patients and things like that. um You can understand all of this actually, you know if you wanted to have a kind of unified market failures theory of medicine. You can understand all all of that as as a response to the sort of special features of the market for healthcare care and and other kinds of professional services that that create that trust problem and that call for a kind of conspicuous commitment to the well-being of your patients as ah as a way of managing that trust problem and and and making patients feel safe ah trusting their physicians.
00:34:40
Speaker
So based on all these kind of like problems we talked about, um you know how do you how do you feel in the context of your your market failures approach that like the state should get involved to kind of ah you know build a better health care system?
State's Role in Healthcare Market Failures
00:34:54
Speaker
Yeah. I mean, I guess the the main thing that I often want to say about these kinds of questions, you know what what should the state be doing and and how can the state get involved?
00:35:02
Speaker
um I do think it's good to be a little bit modest about the power of philosophy to settle what are, in fact, often very practical and very like detailed questions of you know policy design and regulation and and things like that. um you know so so So I don't know that I'm going to have like very detailed ideas for what the the state should be should be doing. um My main agenda in my work has been, you know as i as I explained a few minutes ago, kind of pushing this idea that
00:35:33
Speaker
the The mandatory purchase of insurance is ah necessary as a solution to that that market failure, that adverse selection problem that we just talked about. And that's why I would say that's why every developed country in the world has some kind of universal health care system, not because they're all ah better than we are and more committed to the value of equality.
00:35:55
Speaker
um the The reason why they all have this system is because they they they see that it's actually beneficial for all of their citizens, that it protects ah health and the health insurance system for for everybody. um Now, what that actually looks like in practice, as I've already said, I'm a little agnostic about.
00:36:11
Speaker
Um, you know, I think there are some complex, uh, you know, often political problems to be solved there. There's often also what economists call or what, what ah policy types call like path dependence. You know, once you've, once your healthcare system is set off down a certain path, it may be kind of hard to just, it it might be hard for ah a market-based system like the U S to just jump to a single payer system. Right. We've kind of, we've already gone too far down, down this path.
00:36:36
Speaker
um And so that may constrain the kinds of choices that that that are are possible within our system. ah you know If you ask me, I would say that a system of regulated private insurance, like they have in Switzerland, ah like they have in in the Netherlands, is probably more appropriate for a country like the United States, both because of the way that our system has has functioned historically, and because of our sort of political culture being much more ah you know ah sort of anti-state and more congenial to to private solutions.
00:37:05
Speaker
ah And so, you know, for for those kinds of reasons, I tend to think that like, ah again, a system of regulated private markets is probably more suitable for the U.S. But that's not a philosophical judgment. That's just a kind of, ah you know, a sense of of what's possible here ah in on the road to universal coverage. um I think from a philosophical point of view, whether you want to have universal private insurance, whether you want to have a system of of universal social insurance like they do in Canada, whether you want to have full on socialized medicine of the kind that they have in the U.K., um you know, from a philosophical point of view, all this seemed to me to be just equally effective ways of solving the adverse election problem.
00:37:43
Speaker
And the choice among them is going to depend on more, you know, again, more sort of particular kind of empirical considerations and the considerations of a of a country's history and a country's political culture that that I'm not going to be able to to to solve.
00:37:58
Speaker
um I mean, having said that, right just maybe just one last thing, um you know, there there are also obviously a role for the state to play in addressing the the issues of ah professional conduct and professional regulation that I just talked about. You know the state obviously has a role to play in licensing doctors on the state may also have a role to play in, ah you know, enforcing certain other kinds of standards of of conduct that maybe, you know,
00:38:22
Speaker
the The state has maybe greater powers of enforcement compared to what like the American Medical Association can do. ah So there might be a role to play there. So so there's ah there's a lot of things to say, but but I think that ah you know these these kinds of questions are going to get beyond what philosophy can tell you and get into complex issues of policy design.
00:38:43
Speaker
So, yeah, I should probably know my health care policy a little better, but wasn't the individual mandate in the ACA kind of geared towards what you were saying to acquire, you know, everybody have health insurance?
Affordable Care Act Analysis
00:38:55
Speaker
And I guess that didn't really, it wasn't enforced properly to go far enough. Yeah. So um this is interesting. So and as i was I was telling you, you know, I got interested in this stuff because I was really interested in the ah arguments that the Obama administration was making around the ACA and at Back in that time, 2008, 2009, 2010, the individual market insurance reforms were really where the administration was focusing most of its attention. but that there There was also in the ACA a big expansion of Medicaid and some big changes actually to the ways that employer-based insurance um is regulated. um But those things were not talked about nearly as much as the reforms to the individual health insurance market.
00:39:37
Speaker
And yeah, you're exactly right. um they They like to talk about theur the individual market reforms as a three-legged stool um because they they they wanted to do three things that they thought were all necessary for the stool to stand, right? You can't have a two-legged stool. It just falls over. Right. So the first thing was what they called a guaranteed issue. ah They didn't want insurance companies to be able to refuse people coverage on the basis of preexisting conditions. They didn't want insurance companies to be able to exclude coverage for preexisting conditions.
00:40:09
Speaker
ah because that obviously offends people's intuitions about about fairness. ah Just because you're sick doesn't mean you should be locked out of the health insurance market forever. um But ah guaranteed issue ah would create or exacerbate those adverse selection problems I was talking about. So ah guaranteed issue made ah the individual mandate necessary. um In particular, right if if insurance companies are required to sell you health insurance no matter what,
00:40:37
Speaker
then you've actually like if you do that alone, you've destroyed the insurance market altogether because I can now just wait until I get sick to buy insurance. If they can't say no to me, like why do I need to buy insurance at all until the day when I have suddenly very expensive ah health needs?
00:40:54
Speaker
ah So the individual mandate was thought to be necessary as a response to ah the the guaranteed issue regulations. We're going to have to require everyone to buy insurance. And then ah the third leg of the stool was the subsidies, right? That if you're going to now require people to buy insurance, you're going to have to help the people who can't afford market rate health insurance with ah you know some kind of subsidies to to to make that more affordable for them.
00:41:18
Speaker
ah and And so, ah yeah, that that was the original three-legged stool. And you're right that um under the previous Trump administration, I believe, they they basically um got rid of the individual mandate. It still exists in law, but they just, like, they zeroed out the penalty. um So previously, if you didn't have insurance, you'd have to pay some kind of tax penalty. um And the Republicans in in under the previous Trump administration ah just just eliminated the the penalty.
00:41:43
Speaker
um What was interesting was that actually after getting rid of the individual mandate, like the the stool didn't fall over. um And the reason I think, my understanding, again, I'm a philosopher, but but my understanding of of what happened there was just that um um right now Most people in the Obamacare individual market are so heavily subsidized by the government that they don't need a mandate to get them to buy insurance, right? Like if if the government is heavily subsidizing your insurance, um you're going to buy it anyway, even if there's no penalty for for not buying it.
00:42:19
Speaker
And so ah the the individual market ah as part of the ACA, as as far as I know, is still functioning pretty well. Again, because you you didn't get that huge adverse selection problem. People ended up staying in the market, not because of the individual mandate, but but just because of the subsidies ah themselves.
00:42:38
Speaker
So yeah, um, to wrap up here, you've, you've alluded to the fact, right, that you kind of reside in the realm of, of philosophy.
Influence of Political Philosophy on Policy
00:42:44
Speaker
Um, and, uh, you know, I'm, I'm, I'm, I'm in a medical school. I'm kind of like, um, you know, more in the the boots on the ground. So how, how do, uh, you know, political philosophers of health like yourself kind of collaborate with, with physicians, with healthcare care professionals. And I guess even to a larger extent, lawmakers to build a better healthcare system where, you know, all the,
00:43:08
Speaker
the great thoughts that you're having about you know universal coverage and so forth, how they can actually be you know put into action. Yeah, that's a good question. I was trying to think about you know what physicians can do in in this realm and and how people can sort of collaborate. And it's it's really hard to say, in part because we are talking about political change. And the way that political change usually happens is you know through the voting booth, through electing politicians that that make this a priority, ah things like that.
00:43:37
Speaker
um the The one thing I will say, you know there was a there was a story ah last week or the or the week before um that I think was kind of like illustrative and in in this regard. um You may remember one of the major insurance companies had sort of announced a plan that they were going to cap the fees that they were willing to pay to anesthesiologists during surgery.
00:43:59
Speaker
um And I think that the way that they explained what they were doing was not very well put. um they They made it sound like they were going to just like cut off your anesthesia in the middle of surgery, which ah which would be like obviously quite quite bad. But what they were trying to do was like get some kind of handle on exploding costs. And they were goingnna they were they were worried that anesthesiologists were kind of overcharging and they wanted to put some some pressure on them to so kind of keep keep costs under control. And um you know I don't know how physicians ah responded to this, but it was really instructive to me actually to see the response online, ah even from people who sort of identified as left-wing. um they were They were really outraged by this because insurance companies um are are are evil, right? They're they're trying to like you know cut our access to healthcare control. But actually like on on this issue, the insurance companies are on,
00:44:51
Speaker
our side, meaning like the patient's side, right? like They're actually trying to keep our premiums down. They're trying to control the the growth of healthcare care costs. um but But it was a kind of interesting object lesson in just how difficult healthcare reform is, um in part because um you know um Americans are, I think, rightly just very sympathetic to providers. They like their doctor. They like their healthcare care provider. um The people they don't like are are the insurance companies because they're the ones that are charging them these premiums and then they're also denying their their their claims and and the the insurance companies are are evil and and and bad and and and so on. and And so this was just kind of illustrative to me of some of the real challenges of like moving towards a universal healthcare system or a more universal system in the United States.
00:45:34
Speaker
Because um you know the the biggest obstacle there is just kind of the sticker price, right? Just how much it costs. I mean, healthcare care in America is really expensive, even compared to other wealthy countries. And you know if if we could magically snap our fingers and we could get healthcare care costs that were in line with what they have in Canada or what they have in the UK,
00:45:53
Speaker
um you know funding a universal health care system would would be no problem.
US Healthcare Costs and Universal Adoption
00:45:56
Speaker
Or I shouldn't say it would be no problem, but it would be much easier, especially for a a very rich country like the US. But precisely because we spend so much on health care, it is really hard to to to make the the sort of i guess the taxation required to fund a universal health care system. It's it's difficult to to make that happen. um And again, in in part because of the ways that, you know again, ah People tend to be very sympathetic to physicians, very sympathetic to providers. um It is really hard to kind of get those costs under control. I don't know if there's a moral there ah for for how ah physicians can help. I guess just like, you know, maybe don't don't don't be so outraged when when ah people try to get costs under control. But you know as somebody who also doesn't like it when my salary goes down, I'm not in a position to to sort of sit here and lecture you about that.
00:46:48
Speaker
I'm sensing sort of a tad of sympathy for insurance companies they're because they're they're in this this very difficult position where they're expected to lower costs and deliver more more goods in the healthcare care space. And like while you know perhaps there might be some things they could be doing better, ah it's a really tough position in the American private markets to like to to to play that role.
00:47:11
Speaker
Absolutely. I mean, they're they're definitely in ah in a difficult situation referring exactly the reasons that you say. you know On the one hand, people don't like it when their premiums go up. On the other hand, they don't like it when their claims are denied and and when they can't get the most ah you know the the the most effective and the most appropriate care. ah And you know those those are just kind of incompatible objectives, right? Or they push in opposite directions. And yeah, that just makes it a very difficult situation.
00:47:39
Speaker
With that, it's time for a lightning round, a series of rapid fire questions that tell us more about you.
Lightning Round with Dr. Horn
00:47:45
Speaker
Okay. um So we're in the winter here, so I'm curious to hear what's your favorite winter activity? Favorite winter activity. It's got to be watching football, especially playoff football. Oh, yeah? Who's your, who's your team? Well, I live in Chicago. so I gotta say the Bears, although it is, it's hard, it's hard. I grew up in Ohio, in Central Ohio. So in college football, I love Ohio State.
00:48:10
Speaker
Well, yeah, now's my time to rub it in that I went to to Michigan and we've beaten you guys four times in a row. So I am aware. But we don't have to look at like the early 2000s. That's that's a whole different story. ah Curious to hear whether you have any nicknames. ah I do not. I don't think I do. um So Chad is actually ah my middle name. My first name is Lindell. I've always gone by Chad. ah My parents, I think, named me Lindell Chadhorn with the intention that I would be called Chad.
00:48:38
Speaker
ah So chat is it's kind of a nickname. But but no, i it's when you have a one syllable name, it's hard to get a nickname. That is true. Yeah, I guess. Yeah, um' I'm John. So I haven't really ventured into the nicknames too much. um Favorite place to hang out in Chicago?
00:48:55
Speaker
Favorite place to hang out in Chicago, ah my apartment.
00:49:02
Speaker
um I know you said you you studied in in in Toronto, so i'm I'm curious to hear if there's anything you miss about living in Canada.
00:49:13
Speaker
One thing I missed about Canada was that I feel like the political system in Canada feels much less ah high stakes and much less anxiety provoking ah in in certain ways, right? I feel like in in the US, s like everything is kind of ramped up to 11. And it was night like, Canadians are just very chill. They're very polite. And and I enjoyed that that part of living in Canada. ah Yeah, so I think that would be the the thing that I miss most was the kind of just the Canadian calmness.
00:49:43
Speaker
and Interesting, because I feel like sometimes i I get these like, you know, small video clips of like bickering in the Canadian Parliament, but it sounds like you don't feel like that's representative of the the kind of political system at large. It may also it may also be the things have changed since I lived there. I haven't i've but lived there in a decade now, but ah But I think that the, you know, again, like the the the stakes in Canadian politics and and and and the, um you know, are are are just a ah little bit less, they feel a little less extreme compared to the US. What's your regular sleep schedule?
00:50:18
Speaker
Uh, interesting. Uh, during the, during the school year, I normally go to bed pretty early and get up pretty early. Typically go to bed around 10 or 11 and get up around six. Um, but, uh, if class is not in session, then I get up, you know, you know go go to bed a little later, maybe midnight, sleep till seven or eight. Nice. And lastly, uh, what's one change you'd like to see in healthcare? care one change that I'd like to see in health care. Well, well yeah one thing I was thinking about as I was kind of preparing for this podcast, um one way in which the US is actually really unusual compared to other countries is not just that we don't have a universal health care system, ah but that we also don't have um ah like a sort of centralized body that like negotiates payments for providers. um So they call this in the health policy literature, they call this like all payer rate setting.
00:51:06
Speaker
Um, so it's actually kind of unusual, right? Like if you become a physician, like you have to negotiate prices with all these different insurance companies, not only, I mean, Medicare and Medicaid, I think set their, their payment rates, but you also have to deal with, you know, a whole host of private insurers. Um, whereas most of our peer countries, um, they, they just have like a centralized body that that deals with this. and And my understanding anyway, from again, I'm an awful loss over, not an economist. I, uh, uh, uh, um, kind of an amateur economist, I guess, but, but my understanding is that, that, um, that.
00:51:36
Speaker
people attribute a lot of the ah sort of explosion in health care costs in the U.S. to the fact that we don't have sort of more effective ah cost controls in those ways. I think having a a single body that would set health rates throughout the health care system, ah reimbursement rates, is probably unrealistic in the United States. But, um you know, we have sort of taken some steps in that direction, allowing Medicare, for example, to negotiate ah prescription drug prices, things like that.
00:52:02
Speaker
um And I think anything you could do to kind of move further along that way would be would be good, because again, I think the biggest obstacle to expanding coverage in the US is just the the cost of it. All right, Dr. Chad Horn, thank you so much for joining the show. Yeah, thanks for having me. This was fun.
00:52:28
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.