Reforming America’s exclusionary health care system was one of Bill Clinton’s first priorities as President. Clinton’s plan collapsed, and nearly eight years later, more than 40 million Americans are still uninsured. But if this New Democracy Forum’s lead article by Norman Daniels, Bruce Kennedy, and Ichiro Kawachi is right, something worse than the defeat of health care reform happened to public health in the 1990s.

Drawing on a wide range of epidemiological studies, Daniels, Kennedy, and Kawachi argue that socioeconomic inequality itself is bad for our health: it is healthier to have higher income, and live in a wealthier country, but also to live in a more equal society. So inequality--which has grown substantially since the 1970s--is arguably the dominant public health problem. From this striking assertion it follows that we need to broaden the terms of the health care debate, to shift away from an exclusive focus on expanding access to care (as important as that is), and toward redressing underlying socioeconomic inequality--through early childhood intervention, improved nutrition, better working conditions, and income redistribution.

The respondents to Daniels, Kennedy, and Kawachi dispute their analytical claims and political conclusions. Analytically, respondents ask how exactly inequality--as distinct from concentrations of poverty--produces bad health. And they also question the importance of inequality as against access to care in explaining public health. On the practical side, several argue that changing the distribution of income may be far less feasible than improving access (especially to primary care). So even if economic justice might deliver greater gains, we are more likely to get improvements by concentrating on better access. These critics suggest that Daniels, Kennedy, and Kawachi are making the best the enemy of the good.

This disagreement is important. More important, though, is a point of agreement: that great social inequalities are unhealthy. And yet, for all the present talk of "health care reform," and the importance of the issue for Americans, this basic point is virtually absent from public debate.

Joshua Cohen

Joel Rogers