1. Health is a public good.
Public goods are things we invest in as a society because they enhance societal functioning and allow human rights and dignity to flourish. Education is (for the sake of argument) an example of a public good: Individuals and society both do better if people have access to quality education. People are more fulfilled and informed, democracy runs more smoothly, and businesses have access to a qualified, productive pool of workers with the fundamental tools to succeed. Therefore, individuals are called on to contribute a small portion of their property (income) to ensure that everyone has access to education.
Most affirmative authors start from the premise that, like education, health is an indisputable public good. Healthy people are happier, have better quality of life, and are more productively engaged in their communities and labor forces. Proponents of universal healthcare argue that universal care is the only way to guarantee health as a public good. Since it’s a universal benefit, they argue, it’s logical for everyone to contribute according to their means.
Some explanation of this position:
Pavlos Eleftheriadis, “A Right to Health Care,” Journal of Law, Medicine, and Ethics, Summer 2012.
I believe that these distinctions have resolved the puzzle of the right to health. There are three different domains where the assertion of a right to health takes three different meanings. There is a basic moral right to health care. This right corresponds, first, to a moral and indeterminate and subjective personal duty of benevolence that ought to guide our personal relations and choices. These are strictly personal rights and duties in a purely moral domain. The second domain corresponds to legally enforceable and morally claimable institutional right in law. This duty requires the setting up and supporting a system of health care so as to protect everyone from becoming a second class citizen through poor luck. The duty requires some public system of care or insurance. We may call this the political domain, because the duty is a manifestation of the special responsibility of political authority towards all persons under its jurisdiction. This duty may also be seen as a “constitutional fundamental,” a principle on which the legitimacy of all political power ought to depend on. The political duty to provide a system of health care is an expression of the political duty to protect the equal liberty and equal citizenship of autonomous but vulnerable persons. The difference between the moral and the political domain is that political duties bind persons only in their capacity as political officials, e.g., as civil servants, legislators, or judges. They derive from morality, but they apply selectively in political contexts.
2. Inequality of opportunity necessitates redistribution for public goods.
A related argument for universal health care states that “individual distribution of maximum health is impossible under a non-universal market system.” The argument is that many inequalities of health, unlike other inequalities, can be largely accounted for by looking at individual choice. Health is a special case because:
a. Some people have less opportunity to acquire health care – markets by definition require there to be winners and losers. In this system, those with the best opportunity to get jobs with adequate benefits (or be able to afford them themselves) are those who can afford a college education and have access to transportation and child care. Cycles of poverty arguably mean that individuals that are structurally disadvantaged will be unable to access adequate care.
b. Some people have less opportunity to be healthy than others. Those born with congenital illnesses or who acquire ill health via circumstances outside their control may not be able to access affordable care because they are costlier to insure (insurers know they’ll likely need lots of expensive care so they charge them more or refuse to cover them).
Stephen S. Hansen explains a version of this equality argument –
Stephen S. Hansen, “Libertarianism and Universal Health Care: It’s Not What You Think It Is,” Journal of Law, Medicine, and Ethics 35, no. 3 September 2007.
Because these taxes are meant to fulfill the Lockean Proviso in an alternate fashion, and because the rationale for that proviso is to allow persons an equal opportunity, it would seem reasonable to seek using that funding to provide for a more equal opportunity.19 These funds should be used to compensate others for their inability to use the particular set of resources that one is using; since this cannot be done by creating more land and raw materials, it must be done in some other way. Here, the second major difficulty with the equality of opportunity offered by the Lockean Proviso becomes important. Persons can be unable to put effort into raw materials due to a lack of raw materials, but they can also be unable due to an inability to employ appropriate effort. Ill health, poor genes, and bad luck can all diminish one’s ability to apply effort into basic materials and create property. Keeping to the homestead analogy, someone who had a broken femur as a child that healed poorly, or has chronic asthma, will be less able to manage a plow, chop down trees to clear land, and the like. The same is true in a modern context, as someone with poorly controlled diabetes and hypertension, or colon cancer, will be less able – not unable, but less able – to work hard and climb the corporate ladder. Little can be done about bad luck, and poor genes are still largely uncontrollable, but at least some of the effects of ill health can be managed or removed by good health care. Moreover, much ill health can be removed, managed, or prevented by relatively basic health care, such as vaccinations, regular prenatal care, tions and diseases, regular care of chronic problems such as diabetes and hypertension, and wellness programs. A system to ensure a basic level of health care would enable many persons to better enter the free market work force, and make them better able to stay in it and support themselves in it. Since the goal of the Lockean Proviso is to enable all persons to have an opportunity to succeed, this would help fulfill that goal even in the absence of further raw materials; therefore, a system of provision of universal basic health care is a justifiable use of the funds from raw materials taxes.
3. Absolute freedom of property allows freedom to exploit for one’s own gain. The primary argument against universal care is that people should be free to choose how to spend their resources and should not have to subsidize a health care system if they do not wish to.
An affirmative argument, however, is that this absolute right to property has negative implications if preserved in law. The argument goes that the more property rights advocates erode support for “public goods” in favor of absolute property rights, the more those rights will supersede the genuine needs of others and cause systemic abuses under the guise of preserving freedom of choice.
William S. Meyer explains a perspective on this argument:
William S. Meyer, “The Moral Imperative of Universal Health Care: A Talk Presented at the Annual Forum of the National Academies of Practice.” Clin Soc Work J (2007) 35:135-140.
Since the era of Ronald Reagan and Margaret Thatcher, much of the West’s ethos and economics have been dominated by ‘‘neo-liberalism.’’ Neoliberalism—is a theory of political and economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free market, and free trade (Harvey, 2005). The concept of freedom, which we are so eager to export around the world, includes good freedoms, such as freedoms of conscience, of speech, meeting, and association. However, there are also destructive freedoms: the freedom to exploit others; to manipulate science; to make inordinate gains without commensurable service to the community; to substitute spin for substance; to keep technological inventions from being used for the public benefit; to profit from public calamities secretly engineered for private advantage. Under this system, if you will permit a digression, there has been a wholesale redistribution of wealth from the bottom upwards—toward the large corporations, their wealthy CEO’s, and their financial legal advisors at the expense of the poor, the middle class, and even ordinary shareholders. Neoliberalism confers rights and freedoms on those whose income, leisure and security need no enhancing.
That is, allowing a system of “winners and losers” allows the “winners” an inordinate amount of power to decide who receives health care, resources, etc. This can allow the “winners” to take advantage of others and engage in exploitative policies to maximize profits.
4. Inability to sacrifice for the common good is destructive to society and community. Still others take the previous argument further and argue that requiring sacrifices for the common good is actually a productive social project in and of itself. Institutionalizing the principle of sacrificing for the good of others and the community, according to some scholars, breeds solidarity which enhances the ethical foundations of a society.
William S. Meyer explains the ways in which the mere act of making these sacrifices may be termed “pro-social.”
William S. Meyer, “The Moral Imperative of Universal Health Care: A Talk Presented at the Annual Forum of the National Academies of Practice.” Clin Soc Work J (2007) 35:135-140.
Some claim that it is going too far to define basic health care as a human right. I believe that they look at the problem from the wrong perspective. The issue should not be, whether others should be entitled to health care, but whether we, who speak so incessantly about values and morality, should be obligated to provide basic health care for our fellow citizens, even for those who may appear undeserving. We must continually face the question: How shall we envision our relationships with our fellow humans? Shall it be, as Margaret Thatcher once declared, ‘‘that there is no such thing as society, only individual men and women’’—or do we wish to aspire to be our brother’s keepers, to hold ourselves to the biblical ideal of righteousness and a conscious acceptance of social responsibility that proclaims, ‘We are a covenant people on a common pilgrimage’’’ (Harvey, 2005)? Our country has come dangerously close to being transformed from a country of the people to a country only for wealthy elites, from a democracy to an oligarchy. As Bill Moyers said, ‘‘our nation can no more survive as half democracy and half oligarchy than it could survive half slave and half free, and that keeping it from becoming all oligarchy is steady work—our work’’ (Moyers, 2004). We face a choice: living in a society where people accept modest sacrifices for a common good or living in a more contentious society where groups—particularly those with wealth and power—selfishly protect their own benefits. Solving the current crisis in our health care system requires us to continue replacing the ‘‘ethic of individual rights’’ with the ‘‘ethic for the common good.’’
Benatar et al go on to explain the possible consequences of a failure to adopt this ethic:
Solomon R. Benatar, Abdallah S. Daar, and Peter A. Singer, “Global Health Ethics: The Rationale for Mutual Caring,” International Affairs 79, no. 1, 107-138.
A set of values that combines genuine respect for the dignity of all people with a desire to promote the idea of human development beyond that conceived within the narrow, individualistic, ‘economic’ model of human flourishing, could serve to promote peaceful and beneficial use of new knowledge and power. A global agenda must extend beyond the rhetoric of universal human rights to include greater attention to duties, social justice and interdependence. Health and ethics provide a framework within which such an agenda could be developed and promoted across national borders and cultures. We contend that failure to make paradigm shifts in ethical discourse and in human cooperation worldwide will increase the likelihood of ‘revolt from below’ and the destruction of so much that has been gained in recent decades.
5. Unhealthy people pragmatically harm everyone because they drain emergency resources and lower productivity. Still others argue that there are a number of practical reasons to allow universal care – many of which have less to do with morality or ethics and more to do with societal functioning. Without access to health care, they argue, people will get sicker, faster. These individuals will then show up at emergency rooms to receive routine care (increasing wait times for everyone) or only once their condition has deteriorated to a point where it can no longer be treated. They will also miss work or drop out of the workforce at higher rates. In this scenario, healthy people who buy insurance lose out on quick emergency care and the economy suffers the impacts of poor productivity.
Champlin and Knoedler outline a rough form of this argument:
Dell P. Champlin and Janet T. Knoedler, “Universal Health Care and the Economics of Responsibility,” Journal of Economic Issues, Vol. XLII, no. 4, December 2008.
The presumption that health care costs are the responsibility of individuals is supported by orthodox economics, which treats health care as a consumer good.' In this framework, there is no shared responsibility for health care. There is only individual demand for health care with employers and governments in a supporting and, ultimately, market-distorting role. It is difficult to see how universal health care can be built upon such a philosophy. On the other hand, institutional economics views health care very differently. As Dennis Chasse (1991) notes, John R. Commons, John Andrews and other early institutionalists understood that the social and economic structure of modern capitalism left workers with little bargaining power. As a result, workers "bore an unreasonable share of the costs of economic growth and financial speculation - instability, unemployment, hazardous working conditions, and low pay" (Chasse 1991, 805). J.M. Clark also recognized that problems like poverty, unemployment and industrial accidents are systemic in nature and beyond the reach of individual choice and personal responsibility (Clark 1936). Clark also stressed that the benefits of good health accrue not only to individuals but to employers and the community as well: "there is a minimum of maintenance of the laborer's health and working capacity which must be borne by someone, whether the laborer works or not," or else "the community suffers a loss through the deterioration of its working power" (Clark 1923, 16, quoted in Stabile 1993, 173). More recently, institutional economists and others have questioned the applicability of the choice theoretic framework to health care, since the choice of health care services is, at best, a joint decision, and is often made by others (Bownds 2003; Keaney 1999; 2002). In short, in the institutionalist view health care is treated as a social good that is fundamentally a matter of collective responsibility.
1. Choice is the ultimate good. On the negative side of the resolution, many advocates believe that a guarantee of universal coverage deprives individuals of the choice of how to use their assets and forces them to participate in a program that they may not need or want.
This loss of liberty is arguably more important than possible inequalities for a few reasons:
a. It gives people the liberty to retain their hard-earned assets. If people work to earn money, they argue, they should be able to choose how to spend it and should not be forced to contribute to insurance for themselves or others. This is a critical freedom which provides a proper incentive for hard work. Without it, advocates argue, people will lose the incentive to become productive, innovative citizens because they won’t have any serious stake in their own health care – they know they’ll have it regardless.
This can impact the economy – the National Center for Policy Analysis explains,
National Center for Policy Analysis, “A ‘Right’ to Health Care?” Daily Policy Digest, June 29, 2007.
Further: As a result of universal care, patients would demand far more medical care because additional consumption would cost them little; higher tax rates would discourage work and productivity, yielding less economic growth and wealth. Another difficulty is how to deliver all this medical care -- declaring health care to be a right does nothing to solve the problem of getting the right resources to the right place at the right time.
b. This undercuts inequality arguments. Negative authors argue that choice facilitates equality better than corrective redistribution because everyone has an equal opportunity to make good choices that will result in benefits to themselves and their families. This is not, they argue, inequality but rather a kind of radical equality which, in exchange for fewer guaranteed services for an individual (health care, education, etc.), opens more possibilities for individuals to make unconstrained decisions. Thus, if an individual doesn’t want health care but would much prefer to spend that money on something else, they can. Advocates argue that these possibilities are necessary for a fulfilling life.
2. Right to property should supersede other rights. As a similar argument, universal care detractors argue that the right to property should be one of the most fundamental of all rights. This is because the integrity of property rights is not only necessary for choice but also to ensure that an individual will be protected from government policies which are not in their interest and from the government taking what belongs to them.
Without the integrity of property rights, they argue, the government can take anything away from its citizens – the old adage that “a government that’s big enough to give you everything you want is big enough to take everything that you have” is instructive on this question.
That is, this can become a debate about weighing the benefits of giving governments the ability to redistribute resources for the greater good versus the possibility that the government will abuse that power to deprive individuals of what they need and deserve based on their hard work in service of those with political power. In the health care context, a “guarantee” of care must be funded through taxes which arguably further erode the amount of take-home pay anyone can keep and spend on the things they find important.
3. Inequality is inevitable and health is too complex to fully equalize. There a number of subjective dimensions to health care. This makes it difficult to establish truly “universal” coverage, let alone guarantee it. For example:
a. Health is determined by a complex interaction of genes and the environment. It’s hard to determine how much of someone’s behavior is influenced by poor choices versus things completely out of their control. Should individuals have to pay a subsidy to bail out a lifelong smoker and compulsive overeater who uses drugs? This person has arguably made knowingly short-sighted and poor choices. Many would argue that inequality for these individuals isn’t necessarily morally damaging.
b. There’s no clear standard for what constitutes the standard of care. Which procedures are necessary and which procedures are merely “best-case” scenarios? For example, is a person with a leg injury entitled to the provision of only the care which is necessary to support their immediate recovery (cast, splint, possible corrective surgery) or to longer-term care that will not necessarily make a life-or-death difference (physical therapy, palliative surgeries, etc.)
Although not advocating against universal care explicitly, Don Peck lays out some of the conundrums that undercut the “health as a public good” and “equality” arguments.
Don Peck, “Putting a Value on Health,” Atlantic Monthly, January/February 2004, Vol. 293, Issue 1.
Yet the fact is that the system already rations; we just don't acknowledge it openly. Every day on the front lines and in the back offices of the health-care profession ICU nurses, hospital executives, and Medicare and insurance-company administrators make difficult cost-versus-value decisions, How long should a man in a coma he allowed to linger in an expensive ICU bed while others who could benefit from the specialized care wait? Is it worth $7,000 to give Xigris — a drug to treat virulent infections that can develop in hospital settings — to an uninsured patient with less than three months to live? In a recent survey of 620 critical-care physicians, 68 percent said they had rationed medications or procedures in the preceding year. Such decisions are often morally complex, even agonizing — and often benefit patients with money: overall, people who have health insurance receive about twice as much medical care as those who lack it. Without intervention this gap will most likely widen: a majority of Americans will continue to receive state-of-the-art care, whereas a growing minority will be shut out of the insurance system, finding themselves without access either to the cutting-edge treatments of 2004 or to proven forms of medical care that have been available for decades. So the key question is not whether health care should be rationed in the United States; it already is. Rather, the question is how health care should be rationed. How should the potential benefits of reduced pain, improved quality of life, or extended life be weighed against the high costs of the medications or procedures involved? And who should weigh them? These are hard questions with high moral stakes. We do ourselves a disservice by dismissing them with a platitude like "You can't put a value on health." That may be true in the abstract, but one can put a value on different treatments and practices. When we decline to do so, we are automatically putting a lower value on other areas, such as education and security, in which increased spending might in fact add more to life expectancy and quality of life. By refusing even to countenance sensible limits on the health care citizens have a right 10 demand, we make universal health-care coverage — a worthy goal that we are long overdue in attaining-nearly impossible. It would be un-American to suggest that those who can afford truly comprehensive insurance — call it "Cadillac insurance" — should be prevented from buying it. And no one is suggesting that. But if we will not consider that perhaps not everyone who pays premiums should be guaranteed Cadillac insurance, more Americans each year will be left unable to afford any coverage at all. At the very least we need to begin a national conversation about the meaning of "medical necessity" — for instance, does it include knee surgery for someone who is not in acute pain but wants to continue playing recreational tennis or touch football? what about bariatric surgery (stomach stapling) for those who are not morbidly obese? — and to launch an honest discussion about what kind of rationing would be fairest and most efficient. To start the conversation, here's one scenario: Imagine a system in which everyone has insurance (including prescription-drug coverage) offering a basic standard of care almost equal to what the insured enjoy today, but people who want the very latest and most expensive treatments must either buy supplemental insurance or pay out of pocket. (For one vision of how coverage might be extended with little disruption, see the sidebar at left.) As innovations prove to offer dramatically better care, or somewhat better care at roughly equal cost, basic coverage would be extended to include them; but the standard for what could be included would be set high (perhaps with the help of an institute like the one proposed by Shannon Brownlee on the facing page). With fewer patients opting for expensive new treatments that are only marginally more effective than older ones, research doctors, drug companies, and medical-hardware makers could devote more of their R&D resources to making existing treatments cheaper and more effective. Though health-care spending will never stop growing completely, it would grow more slowly under this scenario. Similarly, although the rate of improvement in health-care quality might slow marginally, improvement would continue. America would still have care equal to the best in the world — and the system would cover more people. Would that sort of rationing really be so bad?
The impact of the “must allow everyone all care, all the time” norm is substandard care. According to Dr. John Goodman:
John Goodman, “Empty Promises,” National Center for Policy Analysis, John Goodman’s Health Policy Blog, October 13, 2010.
So what would it take to provide these services, if all the beneficiaries opted to take full advantage of them? In a 2003 study researchers at Duke University Medical Center estimated that it would require 1,773 hours a year of the average doctor’s time — or 7.4 hours every working day — for the average doctor to counsel and facilitate patients for every procedure recommended by the Task Force. And remember, every so often a screening test turns up something that requires more testing and more doctor time. Overall, it’s probably fair to say that if everyone took full advantage of all of the services the Task Force recommends, we would need every family doctor in America working full-time on the task — leaving no time left over for any other medical services! Not only can the current supply of medical personnel not come anywhere close to providing what has been promised, there will be collateral damage when patients try to get these services. For one thing, health care costs will rise. Numerous studies have shown that screening tests and similar services add to health care costs, rather than reduce them. For the individual whose cancer is caught in its early stages, say, treatment costs are lowered because of early detection. But this savings is more than offset by the cost of screening thousands of healthy people who do not have cancer. Another consequence: As millions of healthy people try to get free preventive services they will crowd out care for sick patients whose need for care is greater. This will especially be true if patients are in insurance pools that pay doctors different rates. Patients in higher-paying plans seeking preventive services will tend to displace the more urgent needs of patients in lower-paying plans.
4. Universal access reduces actual access to quality care. Some argue that universalizing coverage will actually make it harder for people to receive quality care by forcing lowest-common-denominator solutions and overwhelming the health care system.
Some common arguments include:
a. Waiting periods.
Michael Tanner and Michael Cannon, “Universal health care’s dirty little secrets,” Orlando Sentinel,April 10, 2007.
What these politicians and many other Americans fail to understand is that there's a big difference between universal coverage and actual access to medical care. Simply saying that people have health insurance is meaningless. Many countries provide universal insurance but deny critical procedures to patients who need them. Britain's Department of Health reported in 2006 that at any given time, nearly 900,000 Britons are waiting for admission to National Health Service hospitals, and shortages force the cancellation of more than 50,000 operations each year. In Sweden, the wait for heart surgery can be as long as 25 weeks, and the average wait for hip replacement surgery is more than a year. Many of these individuals suffer chronic pain, and judging by the numbers, some will probably die awaiting treatment. In a 2005 ruling of the Canadian Supreme Court, Chief Justice Beverly McLachlin wrote that "access to a waiting list is not access to healthcare."
b. Perverse incentives.
John Goodman, “Four Trojan Horses,” National Center for Policy Analysis, John Goodman’s Health Policy Blog, April 15, 2010.
Perverse Incentives for Health Plans. We have heard much from the White House and Congressional leaders about how insurance companies are abusing people. You haven’t seen anything yet. Inside the health insurance exchange, no insurer will be able to charge a sick person more or a healthy person less. So insurers will try to attract the healthy and avoid the sick — even more than they do today! Furthermore, after enrollment the perverse incentives will not end. Health plans will tend to overprovide to the healthy (to keep the ones they have and attract more) and underprovide to the sick (to discourage the arrival of new ones and the departure of the ones they already have). Of course, there are countervailing forces: professional ethics, malpractice law, regulatory agencies. But ask yourself this question: Would you want to eat at a restaurant that you know does not want your business? You should think the same way about health plans.
Finally, some even argue that it makes no difference:
Michael Tanner and Michael Cannon, “Universal health care’s dirty little secrets,” Orlando Sentinel,April 10, 2007.
Supporters of universal coverage fear that people without health insurance will be denied the health care they need. Of course, all Americans already have access to at least emergency care. Hospitals are legally obligated to provide care regardless of ability to pay, and although physicians do not face the same legal requirements, we do not hear of many who are willing to deny treatment because a patient lacks insurance. You may think it is self-evident that the uninsured may forgo preventive care or receive a lower quality of care. And yet, in reviewing all the academic literature on the subject, Helen Levy of the University of Michigan's Economic Research Initiative on the Uninsured, and David Meltzer of the University of Chicago, were unable to establish a "causal relationship" between health insurance and better health. Believe it or not, there is "no evidence," Levy and Meltzer wrote, that expanding insurance coverage is a cost-effective way to promote health. Similarly, a study published in the New England Journal of Medicine last year found that, although far too many Americans were not receiving the appropriate standard of care, "health insurance status was largely unrelated to the quality of care."
5. Alternatives exist that are more ethical. There are a variety of counterplans, such as health savings accounts and charity which illustrate ways of increasing the volume of available care but preserving choice and other important values.
Charity may seem like an obvious “counterplan.” Allowing people to donate to free clinics that address what they feel to be unmet needs preserves choice while increasing the volume of available care. There’s plenty of evidence on this question.
A more sophisticated solution, however, is the health savings account developed by Dr. John Goodman. Here, he explains the basic premise:
John Goodman, “The Universal Health Savings Account,” National Center for Policy Analysis, John Goodman’s Health Policy Blog, August 1, 2008.
Suppose you could make only one improvement in our health care system. What would it be? For me, the most valuable improvement we could make would be to create a universal health savings account (HSA). Every individual (and his employer) would be able to deposit up to $200 in an HSA every month. This account would wrap around any third-party insurance, serving as a source of funds for whatever the insurer did not pay for. But there would be no requirement of third-party insurance. Employers would be encouraged to automatically enroll their employees in health savings (say $50 or $100 a month from the employee, matched by the employer) and, if a choice has to be made, these HSAs should be seen as preferable to third-party health insurance. Not long ago, 60 Minutes highlighted a program that parachutes doctors into an area and provides free primary care. When the group set up shop over several days in Knoxville, Tennessee, people lined up early (some traveling 200 miles) to get mammograms, treatment for toothaches and other primary care. Sadly, the demand exceeded the capacity and many had to be turned away. No one should ever fail to see a doctor because he lacks $100 to pay the fee. Ditto for other primary care. A RAND study found that after people enter the health care system, they tend to get the same care regardless of whether they have health insurance and regardless of the type of insurance they have. But they first have to enter. No one should ever fail to enter the system because of a lack of money.
That’s all for today. Good luck in November/December! We’re happy to answer questions in the forums or, if you’d like a free case critique, please e-mail your attached case to lauren dot sabino at ncpa dot org.