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THE ETHICS OF UNIVERSAL HEALTH INSURANCE THE ETHICS OF UNIVERSAL HEALTH INSURANCE ALEX RAJCZI 1 1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2019 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging- in- Publication Data Names: Rajczi, Alex, author. Title: The ethics of universal health insurance / Alex Rajczi. Description: New York : Oxford University Press, 2019. | Includes bibliographical references and index. Identifiers: LCCN 2018052565 (print) | LCCN 2019005831 (ebook) | ISBN 9780190946845 (updf) | ISBN 9780190946852 (epub) | ISBN 9780190946869 (Online Content) | ISBN 9780190946838 (cloth : alk. paper) Subjects: LCSH: National health insurance. | Health insurance—Moral and ethical aspects. Classification: LCC RA412 (ebook) | LCC RA412 .R35 2019 (print) | DDC 368.4/2—dc23 LC record available at https://lccn.loc.gov/2018052565 9 8 7 6 5 4 3 2 1 Printed by Sheridan Books, Inc., United States of America For my mother, my father, and my wife It is only common sense to recognize that the great bulk of Americans, whether Republican or Democrat, face many common problems and agree on a number of basic objectives. —D wight D. Eisenhower CONTENTS Acknowledgments ix Note on Sources xiii Introduction 1 ONE Information about Health Care Systems 6 TWO The Ethical Issues Raised in Health Care Debates 54 THREE Personal Cost 81 FOUR Efficacy 166 FIVE Fiscal Issues 210 SIX The Case for Universal Health Insurance 233 SEVEN Beyond Health Care 248 References 297 Index 323 ACKNOWLEDGMENTS This book is not the work of one person, but of many. I am indebted to many colleagues and students at UCLA, Cal State Long Beach, Bowdoin College, the National Institutes of Health, and Claremont McKenna College, where I’ve taught for 15 years. I am grateful for the opportunity to serve on the ethics commit- tees of three hospitals: Kaiser Fontana, Kaiser Ontario, and the University of California, Irvine. Many friends outside academia offered support without knowing it; they provided me with the life away from work that is so important to working well. And of course I am indebted to my family, both Rajczis and Sabeans, for providing that safe harbor without which a flourishing human life would simply be impossible. I owe special thanks to certain people. Some helped spark the ideas in this book or offered their insights on some or all of the manuscript: David Adams, Alex Aznar, Amy Berg, Michael Botta, Mike Diaz, Michael Green, Paul Hurley, Paul Menzel, Allison Scott, Bob Shapiro, Jon Shields, Paul Snell, Sara Stern, Laura Sucheski, Peter Thielke, and Jonathan Wolff. A few spent a truly heroic amount of time on the book, including Cory Davia, John Farrell, Frank Menetrez, and several anonymous