Money, Solidarity, and Half a Century of Health Reform

This essay explores central aspects of the relationship between money and national health policy from the passage of Medicare in 1965 to the present, including the two most sweeping attempts at system reinvention during that period: the Patient Protection and Affordable Care Act of 2010 (ACA), and the failed Health Security Act of the early 1990s. Its point is not that ethical professionalism has prevailed, though it survives on the skill and dedication of nurses, physicians, and other health care workers. Rather, its point is that one should not criticize the morality of change without interrogating the morality of the status quo. In the 1990s, Jerome Kassirer wrote that "a system in which there is no equity is, in fact, already unethical." The same can be said for a system that overfunds medical care and underfunds other essential social investments, including education. A system that, moreover, cannot be justified by the limited morality of competition in the marketplace because it does not - and could not absent radical change - perform as a functioning market would. In terms of robust market competition with its winners and losers, U.S. health care has been, at worst, a sheep in wolf's clothing.