National values, institutions, and health policies: what do they imply for [Canadian] Medicare reform?

• Author: Marmor, Theodore R.
• Position: Part III

1. INTRODUCTION

   The Medicare program, it is quite often asserted, is special for Canadians because the program is taken to embody something distinctive and superior about Canadian social values. For some Canadians, it follows that any effort to alter Medicare substantially amounts to an attack on Canadian values and should be rejected. On the other hand, others have claimed that Canadian national values have undergone substantial changes, and that this shift in values may justify (or excuse) amendments and alterations to the Medicare program.

   These are what we will term anti- and pro-amendment positions. Both assume a fairly tight connection between what are called "Canadian national values" and the particular structural features of Medicare. In light of this ongoing debate, we have been asked by the Romanow Commission to investigate the role of "national values" in the shaping (or re-shaping) of health insurance programs in Canada, and more generally in the world of developed democracies.

   Section II is first a methodological commentary on what is and can sensibly be meant by appeals to "national values." It then addresses the general theoretical concerns about how such values might be embodied in the institutions of different Western democracies. Section III begins by taking note of the large number of reports that have recently called for reform of the Canadian health care system. After commenting briefly on the relevance of the value presumptions of these reports for this inquiry, we approach our central topic in Section IV. That part of the paper provides some comparative evidence that shows how loose the connections really are between anything coherently termed "national values" and the concrete forms of social institutions. Many variables besides "values" are at work in shaping and re-shaping particular institutions of social policy, we argue. And, conversely, we claim, many quite differently shaped social institutions may reasonably be said to embody the same set of values. In Section V, w e return to the Canadian discussion of Medicare, and argue that a range of possible amendments would be perfectly consistent with -- and therefore would be not greatly threaten -- Canadian social values. Choosing among those options requires a degree of prudence -- an attention to the political realities of conflicting interests, and to the practical realities of resource management and information -- at least as important as the values that prudence aims to advance. That a social welfare institution expresses the right values is a necessary, but is not a sufficient, basis for its adoption as a wise course of action. Section VI concludes.

2. WHAT ARE "NATIONAL VALUES"? THE PRESUMPTIONS OF THE INQUIRY

   After all, values are held by persons, not by corporate entities that have neither minds nor desires. It is true that we may speak loosely of the "values of the common law," or the "values of the Catholic church." By such usage we mean to locate fundamental doctrines that emerge from the writings, or from the beliefs of the elite, within a certain tradition. But in general, "values" refers to subjective views of individuals about what is worthy or important. In politics, these are views about the ends that social institutions ought to advance, and the virtues they ought to embody.

   One's values are general; they do not dictate preferences for particular institutional structures at any level of detail (Rawls 1971). That one values privacy in health care need not lead one, for example, to endorse a particular set of detailed privacy rules (those contained in the new United States Health Insurance Portability and Accountability Act of 1996 [HIPAA] regulations, say). It leads one only to prefer institutional arrangements that protect privacy over those that do not, and arrangements that protect privacy more over those that protect it less. One's values also compete with one another (Berlin 1998). Efficiency, for example, may need to be sacrificed to favor participatory governance or vice versa. A strong commitment to equality may lead one to limit liberty to some extent. Multiple institutional arrangements may thus have equal claim to instantiating one's values, by giving prominence to them differentially. Precision in statements about "national values" is thus doubly imperiled: such statem ents are necessarily a summation across a broad population of varied individuals' - already general, and already potentially conflicting -- values.

   These cautionary observations should not, however, blind us to the important role that values may play in creating a political community and in guiding its actions. Statements of values may inspire, unite, even "constitute" a people: think of the Declaration of Independence and the Bill of Rights in the United States, or the Magna Carta in Britain. And public statements of shared values -- even if the values come to be shared only after they are publicly stated -- may serve as important guides to action. The fact that values are general and may compete with one another does not, after all, render them meaningless. Values are no policy straitjacket, but there are certain choices they rule out.

   In the context of the Medicare debate, Canada's core national values have been well expressed by Michael Ignatieff: "We [Canadians] think that public taxation should provide for health care and that it is wrong for decent medical care to depend on the size of our bank balances" (Ignatieff 2000). The five criteria mentioned in the Canada Health Act -- public administration, comprehensiveness, universality, portability and accessibility--are themselves values, though perhaps narrower, more "instrumental" values, which give shape to the broad but fundamental public and egalitarian values expressed by Ignatieff. Since their articulation in the Hall Commission Report of 1964 and the Canada Health Act of 1984, the five criteria have gained widespread public support. (It is no coincidence that every contemporary report that calls for Medicare reform feels compelled to do so by alleging the consistency of their proposed reforms with the five criteria.) Our contention is that those five values, because they are genera l and may have to be traded off against one another, may be advanced by a number of different institutional arrangements. But we also claim that there are certain proposed reforms that they rule out.

   Before attempting to substantiate this contention, however, we pause to distinguish values from a number of other important forces that shape public institutions. On the top of that list must be interests. Interests are states of affairs or courses of action that persons are motivated to pursue based on the powerful drive for self -aggrandizement (including self-aggrandizement's prerequisite, self-preservation) (Mansfield 1995, Hirschman 1992). Persons have multiple interests; these are calculable, predictable, objective, and -- like values -- can be traded off against one another (Mansfield 1995). Institutional arrangements that were created because they advanced shared values may survive because they further powerful interests. And institutions created from self-interested motives may well embody values, or serve to establish them in society over time (Immergut 1992).

   Public opinion, too, can shape institutions. (2) Opinions are views, prudential or ethical, about states of affairs or courses of action. These are notoriously more subject to short-term amendment than either values (which, because they are general, are less subject to amendment in light of short-term factual changes) or interests (which one can, in principle, objectively calculate). General opinions grounded in values ("Access to health care should be universal.") appear to be more "sticky" than opinions about particular states of affairs ("Medicare is working well.") (Maioni and Martin 2001).

   Social institutions are also to some degree the products of the governmental and policymaking systems that create them, and those systems are, to use a difficult expression, value-informed. Thus centralist governments will more likely create centralized social welfare institutions; corporatist governments will more frequently create corporate entities whose bargains will determine the particular means of implementing social values. Here is a path by which societal values, by influencing styles of policymaking, may influence public policy. So, for example, Douglas and Wildavsky (1989) identify three distinguishable policymaking styles: competitive individualism, hierarchical collectivism, and sectarianism.

   The social democratic states of Northern Europe have, according to this line of argument, strong traditions of hierarchical collectivism, with moderate support of individualistic norms and weak embrace of sectarian modes of policy promotion (Okma 2002). The United States, by contrast, displays a weaker appeal to collectivism and an active streak of sectarian political mobilization. Market efficiency and individual liberty are, according to polling studies, leading American values. Yet, as Douglas and Wildavsky acknowledge, it is a mistake to assume a very close fit between value-informed modes of policymaking and actual policy. Even the United States, with its seemingly dominant competitive-individualist values in policymaking, managed to enact Medicare, Medicaid, the Veterans Administration health program, the Indian [ie., Native American] Health system, law mandating emergency medical care regardless of patients' ability to pay, tax incentives to encourage the purchase of private insurance, tax incentives f or the provision of private charity care, and publicly funded hospitals that give free or discounted care. No one could reason her way to this set of health care institutions and programs from a premise of "competitive individualism" in policymaking. And this is so even if one concedes the accuracy of the characterization of U.S...