Health Care: Right or Privilege?
In the United States today, there exists an ongoing debate concerning the future of health care. America spends 18 percent of it’s Gross Domestic Product (GDP)($2.4 trillion dollars)--more than any other country in the world-- on health care, and still there are 46 million people who are uninsured and denied access to basic medical care (Sanders, 2009). One would think that, in a country that spends this much money for health care, every citizen would have access to, at least, basic health care services but, in the U.S., this is not the case. As politicians and health care policy experts continue the debate (one need only look to the evening news to confirm this), many have been led to ask, “Is health care a right or a privilege?”. Indeed, it would seem that, before a clear direction could be taken toward reforming the failing American health care system, this fundamental question needs to be answered (Pickett, 1978). In this essay, an overview of both stances (right or privilege?) will be presented in the context of comparing the theories of market justice vs. social justice in the U.S. vs. other countries, with consideration given to potential consequences of either outcome. Ultimately, it will be argued throughout, health care should be a universal right of each individual, regardless of what underlying factors currently play a role in preventing their access to humane and compassionate care.
In the U.S. today, the private sector is the major player in health care delivery, and access to our health care system is, for the most part, a de facto privilege, not a right. This privilege is generally restricted to those who have access to insurance through their workplace, or can afford to pay the costs of insurance or medical care out of their own, private funds (Shi & Singh, 2005, p. 10). Therefore, the American system is an example of the “principle of market justice [which] places the responsibility for the fair distribution of health care on the market forces in a free economy” (Santerre & Neun, 1996, p. 7). One of the reasons that this is so is that Americans have a strong sense “of reliance on individual responsibility and a commitment to limiting the power of the national government” (Shi & Singh, 2005, p. 13). Even so, the U.S. does provide government health care programs for specific populations such as the elderly, disabled, and military veterans, yet unlike “most developed countries in the world, which have National Health Insurance programs (NHI) run by the government and financed by general taxes”, America has “been unable to universally provide a basic package of health care at an affordable cost” (Shi & Singh, 2005). Even those Americans who are insured, are often only one dilemma away from joining the ranks of the millions of uninsured. Unfortunate occurrences such as “corporate restructuring, outsourcing, divorce, family crises, chronic illness, and serious accidents” are but a few examples of the precarious situations that could cause one to lose access to health care in the U.S., often with disastrous results, both physically and financially (Sered & Fernandopulle, 2005, pp.6-7). Studies show that medical problems contributed to 62 percent of all bankruptcies in 2007 (Sanders, 2009), so it could be argued that, on many levels, this health care crisis effects not only the health of our people, but the economic strength of the nation. Despite paying almost twice as much on health care per person than any other country, there is ample evidence to suggest that we are not getting what we pay for. The World Health Organization ranks the U.S. number 37 in health systems performance, and the U.S. lags significantly behind other countries in infant mortality, life expectancy, and preventable deaths (Sanders, 2009).
In contrast, many of the developed countries of the world, such as Canada, Great Britain, Germany, and France, have established one form or another of NHI, in which universal access to health care is granted to every resident. It is considered unjust to deny an individual of needed medical care simply because they lack the monetary resources to pay. These countries are examples of the principle of social justice, in which the well-being of society outweighs the well-being of the individual (Shi & Singh, 2005, p. 13). This shift in philosophy, in which health care becomes the right of each individual by law, effectively shifts the responsibility of paying for health care off of private sector entities like insurance companies and Managed Care Organizations, and makes it a public matter (Pickett, 1978). This is not to imply that the private sector is no longer utilized to provide health services or supplemental insurance in these countries. It merely highlights one of the primary differences between market justice and social justice systems, the fact that private sector systems rely on money and market conditions to self-regulate the industry, whereas public sector systems assume responsibility for and take into account the welfare of the public over and above monetary trends of the free market.
Opponents of social justice theories often resort to emotional arguments such as labeling NHI programs as “socialized medicine”. They, however, seem to have no problem with the fact that we deal with other basic needs such as education, police, and fire protection in a similar manner (Sanders, 2009). It is interesting to note that the most strenuous opposition to this type of health care reform in America comes from the individuals and organizations who are reaping enormous financial benefit from the currently existing health care systems and insurance company payment structures. These companies have a fiduciary responsibility that lies not in the well-being of human beings, but in maximizing profits for their share holders. These entities maximize profits in any way possible, including denying needed health care services to millions. To make matters worse, private insurance companies reportedly “spend an incredible 30 percent of each health care dollar on administration and billing, exorbitant CEO compensation packages, advertising, lobbying, and campaign contributions” (Sanders, 2009). Kereiakes and Willerson (2004) further elaborate: Through double-digit inflation in consumer premiums, these" corporate insurers have posted record … profit gains… while the number of Americans who are uninsured continues to climb…The dollars paid for administrative costs and corporate salaries" are directed from the actual point of patient care. (pa ra. 2) Given this “misalignment of incentives in the current system”, it is no wonder that America spends 18 percent of its GDP on health care expenditures, while “other high income nations cover everyone [with similar outcomes] while spending only 7 to 10 percent of their GDP”(The Rekindling Reform Steering Committee, 2003, p. 115). From a larger perspective, it is clear that the U.S. is perpetuating a system that devotes massive resources to a health care system “that is unfair, inefficient, and ineffective in ensuring the nation’s health” (The Rekindling Reform Steering Committee, 2003, p. 115). Many in the U.S. might respond to the preceding statement by asking, “How is it fair that I work my whole life, paying into the system, and then some freeloader who never worked a day in his life, or worse yet, is here illegally from a foreign country, gets to take advantage of free health care having never contributed a dime?”. This viewpoint reveals a somewhat adolescent world view in relation to taking responsibility for society as a whole. Often, this viewpoint is accompanied by an erroneous belief that, by denying these “freeloaders” medical care it is, somehow, not costing the average working citizen any money. Nothing could be further from the truth. According to the health advocacy group Families USA, “privately insured Americans pay at least hundreds of dollars more in premiums each year to help cover the cost of caring for the nearly 46 million uninsured” (Trapp, 2009). This is due to a phenomenon called cost-shifting, in which “some hospitals, physician group practices, and other health professionals are able to recoup the cost of caring for the uninsured by negotiating higher payment rates from private insurers” (Trapp, 2009). In 2008, almost $43 billion “in costs were cost-shifted to private insurers, adding an average yearly cost of $4,803 to families annual premiums” (Trapp, 2009). This basically amounts to “a large, hidden health tax” on the American working class. “Senate Finance Committee Chair Max Baucus (D, Mont.) and other lawmakers have sited cost-shifting as one key reason to adopt health system reform that would cover as many of the 45.7 million uninsured as possible” (Trapp, 2009). This would, in theory, eventually reduce the practice of cost-shifting to the point that private insurance premiums could be lowered while, simultaneously providing health care access to the 46 million people who are currently uninsured. It seems obvious that reforming America’s health care system into a European-style, NHI system would be the right and moral decision, however, even this more humane and effective system would not come without its own set of problems, which would need to be addressed.
For instance, “a public system is no better able to employ competent people at lower wages, purchase supplies and equipment at lower prices, or construct, renovate, and maintain buildings less expensively than is the private system” (Pickett, 1978, p. 239). Realistically, there is no way to provide more and better health care for less cost. Emphasizing preventive, ambulatory, and home health care would be an obvious start in containing costs in a NHI system, however, this alone would be insufficient. Because this type of system “would tend to inflate at the same rate as the private system”(p. 239), for the new system to survive, it would most likely be necessary to raise taxes enough to cover the inflationary costs of the goods and services necessary to maintain its viability. To combat this tendency, much could be learned by paying close attention to some of the methods used in France’s NHI system (ranked No. 1 by the World Health Organization in 2000). Studies show that, compared to Americans, the French consistently visit their physicians more often, “are admitted to the hospital more often, and purchase more prescription drugs” (Rodwin, 2003, p. 35). In order to contain the costs of providing this level of care to its citizens, “France has imposed strong price controls on the entire health sector” (p. 35). Even so, the French enjoy a “higher aggregate level of services and higher consumer satisfaction with a significantly lower level of health expenditures, as a share of the GDP, than in the United States” (Rodwin, 2003, p. 35). This dynamic is good for the general public, but not without serious issues that would need to be addressed.
Using the available statistical information that, the French use their NHI provided health care services more often than people in the U.S., it could rightly be assumed that physicians and medical employees would end up with a significantly increased workload if a NHI program were adopted in the U.S.. Add to this the fact that “prices per service unit are exceedingly low by U.S. standards” (Rodwin, 2003, p. 35), and you end up with medical workers and physicians doing more work for less pay. This would be an obvious source of discontent and opposition from physicians, nurses, allied health, and their representative professional organizations. A possible solution to this problem may lie within the inherent change that would come about by implementing a governmentally managed NHI system. One of the benefits of simplifying the way hospitals and physicians are paid for services in a NHI system include cutting out the private insurance companies to a great degree (although they would still be used for supplemental insurance to cover whatever the NHI didn’t pay) which would result in a significant reduction of the previously mentioned problems of mismanagement of health dollars, unreasonably high CEO compensation packages, and unfair manipulation of access to needed health services. This simplification would be beneficial by “reducing paperwork and limiting structures that divert health dollars to management rather than patient care” (Rekindling Reform Steering Committee, 2003, p. 116). By simplifying existing payment structures and reducing the non-clinical staff that are currently utilized to deal with these issues, money could be diverted and used to keep the salaries of those involved with direct patient care at a competitive level. Also, a simplified governmental accreditation process (perhaps directed by currently existing non-Federal entities such as state’s Department of Health) could replace the current private processes, such as Joint Commission, that cost hospitals and other health related services an exorbitant amount of money to pay for, and even more to implement. This could represent a significant decrease in administrative spending that could be diverted to actual patient care. Moving forward with an emphasis on quality patient care with less administrative bureaucracy could be the answer to keeping health care salaries competitive. Another suggestion would be for our legislature to pass laws forbidding the corporate owners of hospital systems in the U.S. to reduce salaries of direct patient care employees below current averages, and mandating that any necessary salary adjustments be made by reducing and capping the salaries of the over-compensated administrative personnel to a maximum of $225,000.00. That alone would make a hugely significant improvement.
Other issues that seem to arise whenever the topic of health care reform come up are supposed decreased geographical access to services, long waits for necessary procedures, and the incorporation of and distribution of new technology. In the U.S., distribution of medical care and technology is not based upon need, and this can cause “striking disparities in the geographic distribution of health resources and inequalities of health outcomes by social class” (Rodwin, 2003, p. 35). Substantial available evidence from Britain’s Health Service has shown “a beneficial redistribution of available medical care” has caused “a general improvement in the health of English citizens” (Pickett, 1978, p. 239). As for the question of queues or long lines for service that supposedly come with a NHI system, the U.S. “seems to be producing equally long lines-- except for surgery, and lavish diagnostic and treatment schemes-- without demonstrably equivalent benefit to the patient” (Pickett, 1978, p. 239). Besides, these long lines “may be more rational utilization control mechanisms than deductibles or out-of-pocket payment devices” (Pickett, 1978, p. 239). As to the problem of incorporating and distributing new technology, the enormous costs associated with research and development and utilization of these new technologies, accompanied by the need to spend even more to train and staff the labor force to use it, seems to suggest that the problem lies more in the U.S. system than in the more conservative NHI systems of Europe and Canada. “To control medical costs, almost all other nations have tried to limit, mainly through central planning (supply-side rationing) the distribution and utilization of high-tech procedures” (Shi & Singh, 2005, p.103). These nations tend to wait for the U.S. to develop new technologies so that they can incorporate them into their NHI systems in a more controlled, cost-effective way. Perhaps, slowing the pace of developing technologies in the U.S. would encourage other nations to begin their own research and development in these areas, and in so doing help to globally redistribute the cost of this type of research. This could become yet another way in which the U.S. could greatly reduce it’s health care expenditures. Any negative impact on geographic access to services caused by these types of changes could be offset “by providing mobile equipment or by using new communications technologies that allow remote access to centralized equipment and specialized personnel” (Shi & Singh, 2005, p.113).
In conclusion, it would seem that the major obstacles to reforming America’s health care system do not lie in any technical, procedural, or financial impossibilities, but simply in the deeply ingrained thought processes that Americans have inherited from their forebears and society. When not simply reacted to on an automatic and un-inspected emotional level, the question of providing health care to every human being as a basic right is, unquestionably, the right thing to do. Basic human tendencies such as fear of the unknown, resistance to change, apathy, and greed are the real obstacles. The most valuable thing that each and every American can do to bring about reform is to closely examine their indoctrinated beliefs and so-called “values”, and assess them to see if those old habituated thought-forms truly represent the way they wish their present reality to be. Do Americans really want to allow their fellow humans to suffer or die because they, for whatever reason, have fallen into unfortunate monetary circumstances? Do they really want to allow the super-rich executives of a corrupted health care and insurance system grow fat off the corpses of the underprivileged and unfortunate? Has America, somehow, lost it’s way? When they truly examine their health care system, haven’t they allowed it to become about big business and big profit, and in the process forgotten about basic human decency and compassion toward their fellow man? In stark opposition to how America has allowed greed, antiquated attitudes, and personal prejudices to create an unfair and inhumane health care process, in France’s NHI system, “coverage increases as individual costs rise, there are no deductibles, and pharmaceutical benefits are extensive. In contrast to Medicaid, French NHI carries no stigma and provides better access” (Rodwin, 2003). The French system (and others), although not perfect, represents a common-sense approach which honors the inherent value of human life and the greater good of society as a whole. While Americans “are so accustomed to the current system of public and private funding that [they] have difficulty envisioning a radically different method of funding” (Haft, 2003), the Europeans and Canadians have taken a mature and compassionate, common-sense approach to health care which actually serves society, rather than bleeds it to death in the name of corporate profit. Before any real progress can be made on a societal level, each individual needs to deeply examine their own conscience and, with compassion and maturity, make a stand against the status quo by declaring the inherent rightness of making health care available to any person who needs it. Haft (2003) expounds:
Health care is a right, [and] we should declare that belief
in a clear, unequivocal and enduring manner. Once health
care is declared a right, we will be able to address the issues
with much more purpose and clarity and find ways in which
to allow the American health care system to find its place
among the systems that support our unalienable rights”. (Para. concluding)
Do the right thing, America!
Haft, H. (2003, Jan-Feb). Is Health Care a Right or a Privilege? Physician Executive,
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Kereiakes, D. J., & Willerson, J. T. (2004, January 1). US Health Care: Entitlement or
Privilege? Retrieved July 27, 2009, from
Pickett, MD, MPH, G. E. (1978). The Basics of Health Policy: Rights and Privileges,
The 1977 Presidential Address. American Journal of Public Health, 68(3), 236-240.
Rekindling Reform Steering Committee (2003). Rekindling Reform: Principles and Goals. American Journal of Public Health, 93(1), 115-117.
Rodwin, PhD, MPH, V. G. (2003). The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States. American Journal of Public Health, 93(1), 31-37.
Sanders, Sen. B. (2009, June 8). Health Care Is a Right, Not a Privilege. Retrieved July 27, 2009, from www.huffingtonpost.com/berniesanders Web site: http://www.huffingtonpost.com/rep-bernie-sanders/health-care-is-a-right-no_b_212770.htm
Santerre, R. E., & Neun, S. P. (1996). Health Economics: Theories, Insights, and Industry Studies. Chicago: Irwin.
Sered, S. S., & Fernandopulle, R. (2005). Uninsured in America: Life and Death in the Land of Opportunity. Berkley and Los Angeles: University of California Press.
Shi, L., & Singh, D. A. (2005). Essentials of the US Health Care System. Sudbury, MA: Jones & Bartlett.
Trapp, D. (2009, June 8). Unpaid care hikes private insurance premiums by billions But estimates differ on the total effect, in dollars, of uncompensated care for the uninsured.. American Medical News, Retrieved 07/31/2009, from
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