Friday, December 21, 2007

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.)

Sunday, December 9, 2007

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.

Wednesday, December 5, 2007

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.)