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Is there a right to healthcare?

December 21, 2007

It is worth unpacking, first, why healthcare is so crucial to everyone’s life. Everyone faces illness and accident in life. Maintaining and restoring health and function are crucial to our quality of life and our ability to live fully, freely, and independently. So access to healthcare is one of those core needs that are so closely connected to a good human life that they can be regarded as an essential human good (for example, nutrition, education, and freedom). A life deprived of access to decent healthcare is likely to be one of unnecessary pain, anxiety, and limitation.

The medical resources that are available today for addressing the challenges of illness and disability are incredibly powerful, compared to the first half of the twentieth century. But they are also very expensive — socially and privately. Insurance is a way of spreading out these costs over a population of people with varying levels of risk; each contributes part of the cost of this risk-sharing system, and each is assured of help when the occasion arises. And people lacking health insurance are faced with cruel choices: do without the effective therapies that exist for their illnesses; or do without other crucial things like food, gas for their cars, or paying their rent.

This gives us reason to judge that healthcare is not simply another consumable resource which people have more or less of; it is a good that a decent society needs to ensure that no one is deprived of. Like hunger or illiteracy, it is a social bad that a decent society must be urgently concerned about.

Could a just society take the position that healthcare is simply another private good that people need to purchase with their own resources? That depends essentially upon the circumstances of social inequality. If in fact everyone in society has sufficient income to purchase healthcare or private insurance, then the “private good” approach may be sustainable. In a society in which there is substantial inequality and poverty, however, this position is untenable. Low- and middle-income people do not have the resources to purchase healthcare as a private good. And if social arrangements required this, then unavoidably there would be a disadvantaged population which was more disabled, more ill, and less long-lived than the more affluent population. This is plainly not a just or defensible outcome — anymore than starvation or malnutrition in the midst of plenty is a just outcome.

The general answer our society has provided rests on two legs: employer-provided health insurance and state-funded insurance programs for the elderly, the disabled, and extremely poor children. What this system leaves out is a very large population of ineligible uninsured adults. And there are tens of millions of people in this situation. What does our society do to handle this situation? Very little. Basically we require hospitals to provide free care to extremely ill uninsured poor people, and we provide no avenue to affordable insurance for this group beyond the emergency room.

So, back to our question here : do people have right to healthcare? My answer is that it is a requirement of basic justice that all members of society should have access to healthcare, because this is essential to living a normal human life; that our society essentially recognizes this fact about justice (witness the emergency room contingency); but that this society does a simply terrible job of satisfying this requirement of justice. The tens of millions of people who are uninsured because they cannot afford to privately purchase health insurance are sufficient evidence for that.

So what is the solution? It seems inescapable that there needs to be a system of publicly provided and means-adjusted universal health coverage. This doesn’t mean a national health system. It doesn’t even necessarily mean a single unified national health insurance program, or abolition of private insurance. But it does mean that we must succeed in designing and implementing an affordable option for those not served by the current patchwork quilt of coverage systems. (Several states such as Massachusetts and Maine have made bold attempts to do this.) To date, however, we have not faced up to this simple requirement of justice. Let us look at the moral issue honestly and let us design a just and sustainable system.

(Philosopher Norm Daniels has thought about these issues deeply for many years. His recent book, Just Health: Meeting Health Needs Fairly, is a great contribution.)

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