Archive for the ‘Distributive Justice’ Category

On Formulating the Bases for a Recognized Right to Health Care

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If one were to argue that health care is a right rather than a privilege, it first appears that one has little grounds on which to support such an argument. However, upon closer examination, one can find several reasons, grounded in historical and philosophical reflection, which actually provide ample support for revising our understanding of health care services in contemporary society.

First, a right to health care is implicit within the Constitution. Article I, Section 8 states, “The Congress shall have Power to lay and collect Taxes, Duties, Imposts and excises, to pay the Debts and provide for the Common Defense and General Welfare of the United States.” The definition of welfare states it is “the health, happiness and fortune of a person or group.” The “Necessary and Proper Clause,” contained in the same Section, states that Congress can act in a manner “necessary and proper for carrying into Execution the forgoing Powers….” Taken together, these two clauses imply that Congress has the responsibility to make provisions for securing the health, happiness, and fortunes of the public. The people thus hold a corresponding right to health provided by their representative institutions.

Second, historical change has seen an advance in technology and an expansion of previously defined rights. Also, other advanced industrial democracies implicitly and explicity recognize a right of their citizens to health care.

These claims encompass a variety of issues.

As history has progressed, our understanding of personal liberty, and thus rights, has expanded. We now recognize rights that are much wider in scope than what the framers of the Constitution and its Amendments conceived. For example, African-Americans hold full rights of citizenship, and women now have the right to vote. The framers of the Constitution did not imagine so vast an expansion of the rights of citizenship. Yet nothing is amiss in this expansion.

Technological change has greatly altered the effects access to health care has on people’s lives. Prior to World War II, lack of access to health care had little impact on life expectancy, as Tuft University professor of philosophy Norman Davies notes in his book Just Health Care (1985). However, as health care technology has advanced over time, lack of access to health care now significantly reduces one’s life expectancy and the quality of life one can expect while still alive.

Historical change itself requires the recognition of a right to health care. With disparities in life expectancy tied to differences in access to health care, maintaining health care as a privilege distributed on the ability to pay grants those with more economic resources the right to longer lives, and thus more of a right to life, than those with fewer resources. This resembles a cast-like system of social differentiation, one incompatible with standard American norms of liberty, and corrosive of the ideal of political and moral equality.

Additionally, the United States is an advanced industrialized nation and one of the three wealthiest nations in the world in terms of per capita income. Health care should therefore be among the highest priority services that the government delivers to its persons. A comparison with other advanced industrial democracies illustrates that the United States falls short of its peer states. [Spending data is from; life expectancy data is from] Data is presented in the following format: Country Name (health care spending per capita in US dollars / life expectancy in years).

Japan (2,729 / 83.0)

Italy (2,870 / 81.8)

Spain (2,902 / 81.8)

United Kingdom  (3,129 / 80.4)

Australia (3,353 / 81.6)

Sweden  (3,470 / 81.4)

Belgium (3,677 / 80.0)

France (3,696 / 81.0)

Germany (3,737 / 80.3)

Austria (3,970 / 80.4)

Netherlands (4,063 / 80.6)

Canada (4,079 / 80.7)

Switzerland (4,627 / 82.3)

Norway (5,003 / 81.0)

United  States (7,538 / 78.2)

Note that the public sectors of the non-US countries plays significantly greater roles in providing health care to their citizens than does the United States. These public sector activities range from subsidized private health insurance (Switzerland and Austria) through wholly public provision of health care in a truly socialist system (the National Health Service of the United Kingdom). However, what these countries all have in common is their treatment of health as a basic right of citizenship. Note also the incongruity between these advanced industrial democratic states. US spending is 192% of the OECD average while life expectancy in the US is  96.6% of the OECD average. A better way to look at that would be to measure the variance between these states. Using standard deviations, we find that US per capita health care spending is 3 standard deviations above the mean, which is astonishing; US life expectancy is 2.45 standard deviations below the mean. This is also astonishing and statistically provides support for the contention that treating health care for a right improves the effective delivery of health care.

Third, considerations of national security and survival should motivate us to consider health care a basic right of citizenship. There is an increasing risk that terrorists may acquire biological weapons as Harvard University professor Jessica Stern warns in the journal International Security. There is also an increasing risk that “natural” epidemics can spread quickly in an increasingly globalized world due to transportation technology as Columbia professor Laurie Garrett warned in The Coming Plague. The spread of SARS illustrated, in the last decade, just how quickly infectious diseases can move half way around the globe. Ninety-six years ago, the Spanish Flu killed 50 million persons worldwide and 650,000 in the United States. The contemporary world is much more interconnected and densely populated, suggesting that any similar pandemic outbreak could potentially spread much more quickly. The interests of the nation-state and society as a whole are, in such a world, best served by ensuring that the population has the widest possible access to health care. Preventing the spread of deadly pandemics certainly requires more thorough preventative measures than those that emergency room access can provide. Jeff Koplan, Vice President for Global Health at Emory University, argues that universal health care “would encourage previously uninsured or under-insured people to visit doctors when they’re sick, and would thus be a preventative strike against future pandemics” ( Just as fire protection for an entire neighborhood depends on the fire department addressing any particular burning building, so too the public health status of the entire nation-state can only secured by treating a dangerous infection in any particular person.

Fourth, Practical and Patriotic. Noted non-radical founder of the modern German state, Otto von Bismarck, enacted national health insurance in the LATE NINETEENTH CENTURY. He did so, as historian Stephen Richter points out, to undercut the appeal of the German Social Democratic Party, then the largest socialist party in the world. Health care provision gave the working class a greater stake in the success of the (fairly new) German state and helped turn them away from more radical solutions. In the United States, where social divisions appear rampant and growing ever larger, recognition of a right to health car—and its provision to the almost fifty million Americans who lack any sort of health insurance—may be able to ameliorate these social divisions. Doing so would give persons currently excluded from access to health care to economic or employment status a stake in society rather than shunting them aside as unworthy of social concern.

Fifth, equal protection and the norms of distributive justice demand that a right to health care be recognized in the United States.

Both poor children and the elderly have what, in effect, is a right to health care under the Medicaid and Medicare programs. If one is young and poor or retired the government provides one with health care. However, those between the ages of 18 and 67 are denied this right to health care, and this deprivation amounts to a violation of equal protection under the law, particularly since those who are 18 to 67 do most of the work in the United States and thus pay the most payroll taxes, which support these public health insurance programs. Why should taxpayers fund health care programs for the poor and the elderly while be ineligible for those same benefits? The working poor are particularly hard struck by this cruel irony, for they make too much money to be eligible for benefits, are often too young to collect those benefits, and yet do not make enough money to purchase private health insurance.

Additionally, expanding Medicaid would be much cheaper that current plans in the Affordable Care Act to subsidize the purchase of private health insurance by lower income individuals as Sara Rosenbaum argues in the New England Journal of Medicine.

Tufts University philosopher Norman Daniels writes that “none of us deserves the advantages conferred by accidents of birth—either the genetic or social advantages. These advantages from the ‘natural lottery’ are morally arbitrary, because they are not deserved, and to let them determine individual opportunity—and reward and success in life—is to confer arbitrariness on the outcomes.” He continues: “[I]f it is important to use resources to counter the advantages in opportunity some get in the natural lottery, it is equally important to use resources to counter the natural disadvantages induced by disease….” This does mean that we should try to level all outcomes and all natural differences between persons. But it does mean that we should make sure that all persons can get annual checkups and a chance a preventative care.       Preventative care, after all, can be one of the key means to control health care costs over time, as David Gorn pointed out at California Healthline where he wrote that preventative care of chronic conditions is central to controlling rising healthcare costs in California, and probably also the United States as well.


Written by jjvedamuthu

June 5, 2012 at 17:02