Is there a right to healthcare?

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.)

Gradient of justice

Given that there is significant injustice in our society, and granted that we are a long ways from a society that establishes what Rawls called the circumstances of justice -- can we at least have the confidence that we are moving in the right direction?

Some people would argue that our society is doing just that. They sometimes point to the fact of rising nutritional and health status in the poorest 40 percent of our population during a 50-year period, and they might say that the situation of institutionalized racism -- and with it the circumstances of middle-class African-Americans -- has also improved measurably in 50 years.

Unfortunately, these impressions are misleading. In fact, it is more likely the case that inequalities of income, wealth, and well-being have worsened in the past twenty years. Lower-middle income and poor people have the smallest share of the nation's affluence that they have ever had. And many of the programs designed to provide a social safety net have been gutted or have disappeared altogether.

And on the racial justice side -- if general social racism has diminished, the depth of racial inequality and lack of opportunity in large cities has almost certainly increased in thirty years. The lack of opportunity and hope that exists in Cleveland, Detroit, Chicago, or Oakland is truly staggering -- and it is worsening. This wall of deprivation is drawn largely along racial lines. And all too often this impacted lack of opportunity leads to crime and violence.

So we don't seem to be on a trajectory of general improvement when it comes to social justice. The myth of the "trickle-down society has turned out to be more trick than truth. The benefits of economic growth have not lifted the lower middle class. This growth has not dissolved the knot of urban poverty. The public is turning its back on public schools -- surely one of the surest mechanisms of greater social justice over time. And we don't seem to have a public commitment to the basic value of allowing all members of society to fully develop their talents. Even more disturbingly, we seem to be entering a period of time that will involve even greater economic anxiety. And anxious times seem to bring out the worst in people when it comes to competition for scarce resources and opportunities.

What we seem to need is a greater sense of community, a greater recognition of our inter-connectedness and inter-dependence, and a greater common commitment to making sure that our society and its policies work to improve the lot of all its citizens. But most regrettably -- this sense of the strands of community is exactly what is most imperiled by the facts of current inequalities. It is difficult to maintain the strands of civic commitment to each other when fundamental inequalities separate us further and further.

So perhaps we ought to consider the unhappy possibility that our society may be inching towards the deepening chasm of inequality that characterizes South Africa, Mexico, or Brazil today. And if this is true, then the future is ominous.

A good society ...

What sort of society should we aim to achieve in the twenty-first century?

Here is one clear vision. It is a society based on equality and dignity for all citizens. It embodies the idea of social responsibility — the conviction that society has some meaningful obligations to all its members. It embodies institutions that somehow effectively assure a reasonably high minimum quality of life for all. It provides real equality of opportunity for its citizens. It avoids discrimination among citizens based on gender, race, ethnicity, and other irrelevant factors. It is a democratic society: individuals have genuine opportunities to discuss and influence the decisions that affect them — both public institutions and private. And it is a society that commits itself to environmental sustainability and progress towards global justice.

This vision entails numerous rights — rights of expression, association, and participation. And it implies the guarantee of quite a number of social goods by society to all citizens — education and training, access to healthcare, policies that assure housing and food under all circumstances, …

The existing state-society configuration that best matches this set of values is Scandinavian social democracy — of the 1970s. (See Esping-Anderson, The Three Worlds of Welfare Capitalism, for a good discussion of Scandinavian social democracy.)

"Too much" inequality? Yes!

How much inequality is too much? The range of income and wealth inequalities in the US has increased sharply in the past 20 years. The share of income flowing to the top 10% and 1% has increased significantly. And the level of income for the bottom 40% has slightly declined during these years. But to say whether that's a bad thing, we need first to think clearly about what inequality means for our society -- for the quality of life for people at the bottom end, for the strands of community that knit a society together, and for the idea that every member of society is equally worthy of respect and consideration. And we need to think about the mechanisms through which these inequalities are created in our economy -- and through which these inequalities have increased so sharply.

First, the effects. It appears also to be a fact that the symptoms of poverty are more extensive today than they were twenty years ago. The demands on food banks have increased; homelessness appears to be more extensive in many major cities; and of course the problem of lack of access to health insurance and affordable health care appears to be even more pressing. So it would appear that the increase in income inequality in the past 20 years has had a depressing effect on the lives of the least-well-off in our society. At least the economic processes that have improved the incomes to the rich and the super-rich have not also improved the incomes of the middle-income groups and the poor. So the philosophers' argument -- inequalities are not inherently bad if the bottom end is pretty well off -- doesn't apply to today's circumstances.

Second, there is some evidence that the social distance between the very-well-off and the not-well-off has increased, with fewer points of contact between social groups. This is sometimes described as the "disappearance of the middle class." The substantial transformation of the American economy that has occurred in manufacturing and the auto industry is emblematic: the jobs that created the possibility of a blue-collar, middle class life in Michigan, Ohio, and Illinois are disappearing, and the next generation of manufacturing jobs are creating incomes that are perhaps only 60% of the levels of the previous generation. So rising inequality is manifest, in part, in the loss of well-paying jobs in the middle -- producing a greater degree of social separation.

This brings us to respect and equality. It isn't too much of a stretch to infer that in a society increasingly separating into "affluent" and "poor", the idea of basic democratic equality -- that everyone is in the same boat; that everyone has an equally worthy life; that we all depend on each other; and that everyone is equally worthy of respect -- has less and less social reality. These widely separated groups have less and less lived experience that reinforces these ideas of connection and equality among all citizens.

So there are ample reasons for judging that the rising material inequality in America is a very bad thing. It is bad because of the consequences it has for people on the lower end of the spectrum; it is bad for the corrosive effects it has on basic democratic values of fundamental human equality; and ultimately it has to be bad for the civic values that undergird a peaceful and harmonious society. How much inequality can a community absorb before it begins to pull apart into mutually antagonistic groups? How many more gated communities will this society need if we continue to fail to achieve the kind of material fairness that allows every citizen to look the other in the eye and say, I respect you and I know that all our benefits depend upon our mutual contributions to society?

If our economy continues to separate our society into rich and poor -- if our largest cities continue to intensify the inequalities of access, opportunity, and quality of life between the urban poor and the suburban affluent -- then surely we have some seismic social conflicts brewing.

What is the value of democracy?

What is involved in the value of democracy? Why is this an important social value? And why should we think that democracy is a good thing for poor people?

Consider first the fundamentals. Why is there a role for democracy in any circumstances? Democracy is a type of political institution -- a form of group decision-making. Political institutions are needed in circumstances in which decisions are needed that affect all members of a group. Each member of a group has his or her own set of preferences about choices that affect the group; so there needs to be a process for arriving at a set of social preferences -- a social choice function. Democracy requires designing a set of arrangements through which each person's preferences will have equal weight in determining the ultimate decision. Otherwise we would have a system in which one person decides (dictatorship) or a minority decides (oligarchy). So democracy represents a set of decision-making institutions that embody respect for the equal worth of all citizens. And the fact that otherwise powerless people can express their preferences through democratic means is a substantial form of potential influence for non-privileged groups.

In addition to the aggregation of individual preferences, democratic values consider as well the circumstances under which the members of a group form their beliefs and preferences. Narrow democratic theory takes individual preferences as exogenous. But broader versions of democratic theory attempt to bring democratic values into the social processes through which beliefs and preferences are formed. The theory of deliberative democracy emphasizes in particular the features of civility, mutual respect, and open-mindedness through which debate and critical examination of issues leads to a fuller understanding of issues and a more reflective set of preferences. This aspect of democracy is valuable because it corresponds to a society in which open and uncensored debate leads to the formation of individual and collective preferences and embodies the ideas of democratic equality among citizens. And less-privileged groups can exercise their voices in these forums to attempt to influence other citizens to support more just policies and choices.

(See Ian Shapiro, The State of Democratic Theory and Amy Gutmann and Dennis Thompson, Why Deliberative Democracy?.)

There is a final reason for cheering democracy: it is possible that democracy is more likely to protect the rights of the relatively powerless in society; democratic institutions can function as a bulwark against the arbitrary power of elites of all kinds. If the powerless have political voice, they then have an ability to advocate for, and democratically support, the policies that favor their perspectives and interests. (This political power is offset, of course, by the political power and influence wielded by elite minorities in most societies.)

(See Adam Przeworski, Democracy and the Market: Political and Economic Reforms in Eastern Europe and Latin America.)

The most fundamental reasons, then, to value democracy are its correspondence to the value of the moral equality of all persons and the capacity it creates for non-elite groups' struggles for justice. Democratic institutions honor the equality of all persons in the fact that each person has an equal voice in deliberating upon and deciding collective policies. A democracy is morally preferable because it best embodies the more basic moral value of fundamental human equality and dignity and it provides a feasible mechanism for pursuing social justice.

Why affirmative action?

Since the Supreme Court's Bakke decision in 1978, universities that practice affirmative action in admissions have premised their case on the educational benefits that accrue to all students from a diverse student body. This is the heart of the successful University of Michigan defense of affirmative action in the Supreme Court in 2003. What has been largely lost in this debate is any explicit effort to assert that there are fundamental reasons of social justice that should require American social institutions to practice some form of affirmative action. And yet those reasons are if anything more immediate, more fact-driven, and more compelling than the "indirect educational benefits" justification.

Three arguments based on social justice are particularly important. First is the history of slavery and racial discrimination in this country, a history that has persistent consequences up to the present day. Consider the premise that current educational and economic disadvantages for African Americans as a population derive chiefly from these historical facts about slavery and past discrimination -- facts that are manifestly unjust. Is it not then apparent that justice requires concrete social actions and policies today that have the effect of reducing and eliminating current-day disadvantages that derive fairly obviously from past injustice? And given that those historical disadvantages create exactly the current educational deficits that make further educational progress more difficult, is it not clear that there need to be processes in universities to assist in increasing the percentage of African American students who have benefited from high-quality university education? This line of thought creates a positive obligation for current institutions to "affirmatively" work to overcome current inequalities created by past injustice. The tool of affirmative action is one such tool, and justice requires that it be used.

Second, the broad conception of equality of opportunity discussed in a prior posting has special relevance to the case for affirmative action. If various sub-populations in a society have less than full access to current opportunities because of substantial structural inequalities of access to critical resources in the past, then it is very convincing that society needs to find tools for leveling out these opportunities. Access to excellent higher education is fundamental to achieving decent life prospects. Again, affirmative action is such a tool and should be available.

Finally, these two arguments converge when we consider that the current educational disadvantages suffered by young African American students themselves derive from current social arrangements that are deeply discriminatory. The fact that current racial structures impose very different life prospects on different groups gives rise to a pressing non-historical reason for "affirmatively" addressing these inequalities. Unjust racial inequality of outcome is not simply a fact about the past; it is a fact about the present. The racism associated with the fact that inner-city (largely minority) schools are underfunded and substantially inferior to suburban (majority white) schools in providing educational opportunities to the children they serve, indicates a powerful basis for concluding that affirmative action programs need to be available as a tool. Affirmative action can help redress current injustice along racial lines.

So there are powerful reasons based in facts about historical injustice, equality of opportunity, and the injustice of the current distribution of educational resources, that all lead to the conclusion that affirmative action policies should be lawful and available to large social institutions, especially in education and employment. The fact that the terms of debate have been limited in such a way as to simply exclude these considerations of past and present racial injustice is itself an obstacle to our society's successfully addressing these injustices.

Real equality of opportunity

Let's say that our basic moral commitment is the idea that every human being ought to have real equality of opportunity as he/she pursues a life plan. What does this mean, in detail, and what implications does it have for social justice?

Equality of opportunity can be construed in broader or more narrow ways. Narrowly, we might say that persons have equality of opportunity if they are considered for positions, benefits, and burdens without respect to "personal" characteristics -- their family origin, race, age, ethnicity, health status, etc. Only the objective and person-independent features that are relevant to performance ought to be considered in selecting people for opportunities. (This is how equality of opportunity is construed in employment.) Does this narrow construction really capture the moral value of equality of opportunity, however? Evidently it does not, because it ignores the history of how various individuals came to have the objective characteristics and talents they possess today. If two candidates for firefighter are compared on the basis of their current physical fitness, but one had a childhood of normal nutrition and the second was chronically malnourished, then we would be reluctant to say that they are currently enjoying equality of opportunity. The choice between them today depends on objective differences of fitness for the job; but the differences that currently exist were not themselves created through a fair process.

So we should broaden the definition of equality of opportunity and require that each individual should have had access to the resources normally necessary for the full development of his/her capacities as a human being. These would include decent nutrition, access to health care, and access to education of comparable quality. And we might even add in an empirical assumption, that there is a range of levels of provisioning of these social goods within which any individual has the possibility of achieving high levels of performance. That is, it might be maintained that there is a (reasonably high) level of provisioning of health care, nutrition, and education that is "good enough" to permit the individual to have a fair chance to compete for opportunities in a " narrow equality of opportunity" environment.

If we take this somewhat broader view of equality of opportunity, then we are immediately forced to consider the workings of basic social institutions and the distributive consequences they have for rich and poor. Do the resources available to the poor exceed the minimum level of provisioning specified above? Or are significant numbers of the poor sufficiently disadvantaged in their current performance by the history of unequal access to resources, that today's competition fails the broader "equality of opportunity" criterion?

In many of the instances we can observe today the answer to the final question is "yes". Children who have attended under-resourced elementary schools and high schools have substantial deficits in terms of high-end cognitive achievement -- so a "neutral" competition between them and better-educated children fails the test. Children whose nutritional status and health status is sufficiently compromised that their cognitive development has been impaired, are equally unfairly treated when subjected to "narrow equality of opportunity" processes. And this has immediate implications for the social inequalities that exist in American society between rich and poor, urban and suburban, white and black, and rural and urban.

When we shift the focus to international inequalities across levels of human development, we come to a similar conclusion: because of gross inequalities in the availability of resources during the process of human development for children and young people, we cannot conclude that contemporary distributions of positions, opportunities, and burdens are the fair result of institutions embodying equality of opportunity. Nutrition, health, and education are factors that are very unequally distributed in the country and the world today; and the bottom end of the distribution falls well below any reasonable standard of "good enough" for full human functioning.

The implication, then, is a strong one: if we think that fair equality of opportunity is a compelling moral principle, then we also must conclude that a very significant reform of some basic social institutions must occur if we are to be able to assert that contemporary society is just.

A progressive majority?

Progressive politics center on a few core commitments -- the value of some kinds of equality (equality of opportunity, equality of access to some central social goods like education and healthcare), a concern for the pattern of rising inequality in income and wealth in the United States since 1980, a commitment to the idea of a social welfare net for all citizens, a concern for international justice, a concern for the global environment, and a concern that our nation should not use military force aggressively or wantonly. These values highlight inequality and injustice as particularly important wrongs, and they support political agendas that would strive to create greater equality and justice in our country and the world.

The question here is, why has it been supremely difficult to create a progressive majority in the United States?

Consider first a material calculation of interests. Let's assume that people choose what party or candidate to support based on the effects that party would have on their own interests, if successful in gaining office. There are tens of millions of Americans who lack access to health insurance. Even larger numbers fall below the level of a family income of $50,000. And increasing millions of young Americans are finding that the rising privatization of the costs of public education are making university attendance impossible. The progressive values mentioned above suggest policy goals that would address all these interests. So why does this constituency not create an electoral majority, based simply on a calculation of material interest? Why has a party not emerged that successfully crafts an agenda capable of mobilizing this majority?

Consider next the workings of a factor that has played such a decisive role in American politics, fundamentalist moral and social values. These are the "social issues" that get the blogosphere going and that motivate some voters so strongly. These values are working against the material interests of the majority just enumerated (because they lead to the success of parties and politicians dedicated to an anti-progressive agenda). So why do these values find a foothold among non-privileged voters in sufficient numbers to swing elections?

One part of the answer to these questions derives from a more realistic understanding of the mechanisms of political choice formation in this country. Parties and candidates are able to influence voters on the basis of their ability to raise campaign moneys and to use these funds to put together marketing campaigns that shape the minds of potential voters. This appears not to be a rational process, but rather one that turns on emotion, misrepresentation, and framing. It is an exercise in applied social psychology rather than rational debate. So if campaign strategists can turn funding into persuasion, then the "material interest" theory above is to some extent neutralized. And therefore we shouldn't expect a majority defined simply in terms of its shared material interests, to turn into an effective electoral majority.

Combined with this point about political funding and marketing is the creation of a substantially greater sophistication when it comes to disaggregating and combining the micro-demography of a particular election. Targeted campaign marketing has turned into a big business and an effective political strategy. The tactics of mobilizing the faithful while depressing the opponents have reached the level of a fairly successful form of social engineering.

What these points amount to is a fairly gloomy assessment of today's democracy. Parties succeed in distracting voters from their real interests and commitments by shaping meaningless ideological debates, framing issues in false or misleading terms, obscuring the real underlying issues, and manipulating election outcomes with micro-electoral information. And so the real interests of a majority of voters may continue to be ignored.