DISTRIBUTIVE JUSTICE AND SOCIAL POLICY: A CASE STUDY BY SUSAN MARIE SWIDER B.S.N., DePaul University, 1979 M.S., University of Illinois at Chicago, 1983 THESIS Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing Sciences in the Graduate College of the University of Illinois at Chicago, 1988 Chi cago, Illinoi s F ~ .......... Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. THE UNIVERSITY OF ILLINOIS AT CHICAGO The Graduate College /baAiJ /J>; / / / / ____________ I hereby recommend that the thesis prepared under my supervision by Susan M. Swider entitled Distributive Justice and Social Policy: A Case Study be accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Committee Final Examination UNIVERSITY or ILLINOIS AT CHICAGO D517 Rev. 1/87 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGMENT I would like to thank the members of my dissertation committee for their assistance and encouragement: Dr. Wendy Young, Dr. Dorothy Camilleri, Dr. Olga Church, and Dr. J. Warren Salmon. I also appre­ ciated the chance to work with the faculty and graduate students of the Women's Health Group at the College of Nursing, University of Illinois at Chicago, who provided a supportive environment for testing out new ideas and asking new questions. I am grateful for the love and support I received from my many friends during the process of my graduate studies, especially Tonda Hughes, Deborah Perils, and Bill Kabat, who had faith in me and expressed it frequently, as needed. I also thank Rod Yarling, who introduced me to the idea of examining the. moral implications of health care decision-making. And I express my appreciation and love to my parents, who taught me to examine the moral implications of my personal decision-making. I also want to express my appreciation and love to my dissertation chair, Dr. Beverly McElmurry, and my husband, John Rogers. They have both given tirelessly of their time, attention, and support. They are each a unique and irreplaceable part of my graduate work and of my life. SMS iii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS Chapter Page I INTRODUCTION.......................................... 1 A. Introduction................................... * 1 B. Significance . ............................. 2 C. Significance for nursing ......................... 6 D. Research question ................................. 7 E. Assumptions ...................................... 8 F. Definition of terms.. ............................. 9 G. Overview ........................................ 10 II LITERATURE REVIEW .......... 12 A. Conceptual framework ............................. 12 B. Distributive justice ............................. 15 1. General definition .......................... 15 2. Criteria of distributive justice ............. 25 a. N e e d .................................... 25 b. Justice as fairness....................... 27 c. Utilitarianism.......................... 30 d. Merit/desert............................ 31 e. Ascription .............................. 34 f. Equality ................................ 34 C. Conclusions...................................... 35 III METHODOLOGY.......................................... 39 A. Research design .................................. 39 B. S a m p l e .......................................... 43 C. Data collection.................................. 44 D. Data analysis.................................... 45 E. Discussion of approach ........................... 49 1. Reliability and v a l i d i t y .................... 49 2. Strengths and w e a k n e s s e s .................... 51 IV DATA ANALYSIS I: LEGISLATIVE HISTORY .................. 55 A. Introduction..................................... 55 B. Analysis of problems and strategies ................. 55 C. Legislative history of policy ..................... 61 1. 1965 62 2. 1971/72 ...................................... 67 3. 1973 70 4. 1575 70 5. 1976 71 6. 1977 71 7. 1978 74 8. 1979 75 iv r Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1. TABLE OF CONTENTS (continued) Chapter Page 9. 1980 76 10. 1982 78 11. 1983 78 D. Conclusions...................................... 79 V DATA ANALYSIS II: DISTRIBUTIVE JUSTICE CRITERIA ........ 82 A. Criteria of distributive justice ................... 82 1. Justice as fairness........................... 83 2. Utilitarianism.............................. 87 3. Equality ................. 90 4. M e r i t ........................................ 93 5. C h o i c e ...................................... 99 6. Financial n e e d .............................. 103 7. Ascription .............................. 107 8. N e e d ........................................ 110 B. Conclusions....................................... 116 VI CONCLUSIONS AND RECOMMENDATIONS ....................... 125 A. Methodology...................................... 125 B. R e sults.......................................... 133 C. Relationship to nursing........................... 143 VII A P P E N D I C E S ........... 147 Appendix A .......................................... 148 Appendix B ......................................... 151 CITED L I T E R A T U R E .................................... 156 V I T A ................................................ 162 v W Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. E LIST OF TABLES Table Page I DATA SOURCES BY TYPE AND YEAR ......................... 46 II CATEGORIZATION OF PROBLEMS ADDRESSED IN PUBLIC DEBATE ABOUT FEDERAL FUNDING FOR HOME HEALTH CARE UNDER MEDICARE, 1965-1984 .................................. 56 III CATEGORIZATION OF STRATEGIES SUGGESTED TO ADDRESS PROBLEMS RAISED IN PUBLIC DEBATE ABOUT FEDERAL FUNDING FOR HOME HEALTH CARE UNDER MEDICARE, 1965-1984 60 IV DISTRIBUTIVE JUSTICE CRITERIA EXPRESSED IN PUBLIC DEBATE OVER HOME HEALTH CARE UNDER MEDICARE BY YEAR (%) 119 V PRIORITY LISTING OF CRITERIA OF DISTRIBUTIVE JUSTICE BY TYF2 OF DEBATE AND A C T O R ........................... 122 vi E_--------------------- Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i . LIST OF FIGURES Figure Page 1 Hochschild’s (1981) continuum of distributive justice. 22 2 Conditions for situations of distributive justice. 24 vii F----------------- Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF ABBREVIATIONS ANA American Nurses' Association DHEW Department of Health, Education and Welfare viii r . ------------------------------ ■ .. — ■p * Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. SUMMARY This research focused on explicating the conceptions of just distri­ bution of resources underlying one example of health policy. The policy used as a case study was federal funding of home health care under Medi­ care, during the period 1965-1984. The data consisted of the public records of debate on federal policy for home health care during this twenty year period. Based on the analysis of the concept of distribu­ tive justice, eight different criteria used to define the concept were operationalized: Ascription, Equality, "Justice as Fairness," Choice, Financial Need, Merit, Need, and Utilitarianism. Content analysis was performed on the data using these criteria, as well as several other policy-relevant variables. These variables included problem statement addressed in the debate, strategies suggested to address the problem, outcomes of the debate, type of debate, actors involved, and time period. Results indicated that the most frequently mentioned criteria for distributive justice used in the debate ware Ascription, Need, and Merit. Ascription was used in large part because the policy under dis­ cussion here focused on one specific group, the elderly. The criteria of Need and Merit were often used in opposing arguments. Much of the debate focused on allocating resources to meet a wide variety of the needs of the elderly; however, opposing arguments were made stressing that individuals have a responsibility to meet their own needs at what­ ever level they can afford. Discussions of the criterion of Need ix Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. SUMMARY ( cont. inued ) decreased towards the end of the twenty year period studied and were replaced by concerns with cost containment via cost shifting for ser­ vices to the elderly themselves. Criteria of distributive justice used in the public debate varied only slightly by actor. Representatives of special interest groups, such as health care providers and consumers, were more likely to make statements about distributing resources to meet a wide variety of health and social needs of the elderly. No clear patterns were discerned between problems addressed, strate­ gies suggested, and criteria of distributive justice. This was largely because the distributive justice arguments made were often expressed in global terms, thus the same criterion of justice could be used to sup­ port opposing problem and strategy statements. These global arguments were common because of the difficulty of making specific justice state­ ments in