Human Right or Commodity? The Ethics of Universal Health Care
The political storm raging over the Obama administration’s health care reform legislation sometimes obscures the fact that universal health care has been a bone of contention in Washington for decades. The American Medical Association (AMA) first endorsed the idea of health care for all Americans in 1921. In the early 1990s the AMA put forth a short-lived proposal for providing affordable insurance for all citizens but it fell victim to politics and traditional (some would say irrational) fears over the socializing of America’s health care system. Politics favored the push for health care reform this time around - the administration was able to push through its agenda thanks largely to a favorable political climate, though the fate of the program’s implementation is currently being fought out at the federal appeals court level.
It is to be fervently hoped that the vagaries of partisan politics do not undermine this latest attempt to make health care available to all Americans. The stakes are far too high. There’s more in it than the future of America’s health care system. When the first wave of aging baby boomers hits the Medicare rolls, the economic repercussions are sure to be momentous. Of even greater urgency is the cost of more than 40 million Americans living without health insurance. Universal health care not only makes “good business sense,” it is essential for America’s economic stability (CNN, 2009). We have seen the effects of America’s unwieldy and inefficient system in the cost of covering hospital bills that patients cannot pay; the myriad costs associated with personal bankruptcies forced by skyrocketing costs; and the disruption of care that results when physicians are forced to address administrative matters. It is significant that America is the only affluent “First World” nation that does not guarantee health care for all of its citizens, and should be a warning to politicians who obstruct attempts to enact reform (Derickson, ix). Universal health care must be made a reality if the United States is to emerge from its present economic downturn with its standing and prestige on the world stage intact.
One of the most persistent criticisms of the present universal health care model is based on a very basic price-and-supply economic formula. This states that if there is widespread access to health care, the number of people seeking health insurance will drop significantly. “Over time, some individuals and families will choose not to renew their health insurance because they will know that they can rely on universal health care access. Consequently, the existence of universal health care will actually increase the number of those who do not have health insurance in the United States” (Bardes, et al, 464). This has traditionally been one of the great roadblocks in the effort to push through universal health care. Overcoming this historic political impediment required the Obama administration to inject a key provision into the current legislation: as of 2014, all Americans must purchase health insurance.
The rationale for this controversial mandate goes that if everyone purchases coverage it will make insurance universally affordable. Consequently, the health care overhaul legislation requires the states to provide universally affordable coverage through their own markets, or “exchanges.” The “individual coverage mandate” component of the reform legislation is easily its most unpopular aspect. At present, there are more than 30 challenges to the coverage requirement being heard in the courts (the most potent of which features a suit on behalf of 26 state attorneys general). The outcome of these battles, one or two of which is certain to go before the Supreme Court, will determine how extensively the Affordable Care Act is to be implemented. Admittedly, the coverage mandate is a bold new step aimed at countering opposition. It has become a lightning rod in the next phase of the reform movement. But it is inextricably linked to the statute, the success of which hinges on enactment of the coverage mandate. Without this important lever, the move toward universal coverage will fail again.
Right or responsibility?
One of the key issues during the 2008 presidential election was whether health is a right or a responsibility. Polls reflected voter interest in better health care access, and the matter was a “tipping point” issue in the race between Barack Obama and Republican candidate John McCain. During a debate, the candidates were asked their stance on this question: McCain replied that he considered health care a “responsibility.” Obama’s response was that it is, and should be, a right for all Americans (Sherrow, 31). In years past, the Democrat’s answer would have struck many as anti-free market, even Socialist. In the modern political landscape, it reflects the beliefs of a growing segment of the population, which expressed its anger over the Republicans’ perceived lack of concern at the polls. McCain’s answer indicated that he and his fellow Republicans still considered health care a commodity, which providers should be able to offer without government interference (Ibid, 32).
Obama’s election and subsequent passage of the Affordable Care Act indicates that America has finally fallen into line with other affluent nations that have long since realized that everyone should have equal access to health care. The United Nations, World Health
Organization and other international health care agencies have also issued statements declaring that “quality health care is a right” (Ibid, 31). It is encouraging that Americans have come to that conclusion, though there continues to be disagreement over what form universal access should take and how it will impact the market. In any event, it cannot be argued that health care is a vital need and that grave economic consequences lie in store for a nation that fails to see equal access to health services as an ethical matter. The United States has long been a champion of human rights throughout the world. It is high time that this same laudable spirit of activism be applied domestically.
The more things stay the same…
America’s rapidly changing demographics are placing a dangerous strain on its health care system. The unmistakable symptom of this change is cost, which has threatened to spiral out of control as the gulf between the insured and those without health insurance has continued to widen. The increasingly specialized nature of medicine, costly prescriptions and the increasingly litigious care environment have all played a significant part in driving up the cost of health services and the number of people who can’t afford the care they need, sometimes to catastrophic effect. Additionally, “the sheer magnitude of cost-shifting to settle the bill for those who use large amounts of high-dollar services and do not pay for them severely inflates doctor, hospital, and clinic fees” (Kathol and Gatteau, 40).
Of course, these unfortunate outcomes are the result of a badly flawed managed care system, which took decision-making authority away from physicians and placed it firmly within
the purview of health plans. This grand plan to control costs must be seen as a failure, part of a typically American inclination toward specialization. The high cost of compartmentalizing services has favored the wealthy. In some cases, physicians have dropped long-time patients, insured or no, in favor of more well-heeled clientele. By 2008, this phenomenon had become sufficiently prevalent that the electorate decided the time for radical change had come. The managed care system had to be overhauled if the “human right” to health care was to be protected for Americans and for succeeding generations. There’s a whiff of economic elitism in this undemocratic behavior, which fortunately raised the hackles of enough Americans to force change at the executive and legislative level.
Another problem with specialization is its counter-intuitiveness. The treatment of patients frequently requires a multi-disciplinary approach, which the specialization inherent in managed care too often complicates. The dominant feature in this system has been a deliberate separation between physical and mental health care, which a review of treatment outcomes has shown to be unworkable and often unproductive. “Accumulating studies now conclusively support the appropriateness of integration…” (Kathol and Gatteau, 40). The notion of universal care does not necessarily presume the integration of services, yet the reform act does provide for a more seamless system. As such, the Affordable Care Act represents a considerably more integrated and efficient system than managed care could provide. Diffusion, inefficiency, cost-overruns and an excessive reliance on bureaucracy are the hallmarks of managed care, a system that runs counter to the egalitarian principles of universal health care.
Employer-provided insurance no longer a given
The gradual erosion of employer-provided health insurance is another argument in favor of universal health care. Once a commonplace benefit, subsidized insurance has become a casualty of inflated costs. Since 2000, premiums have risen by 73 percent, which has forced an unprecedented rollback among employers and motivated companies to favor temporary workers and contractors, who do not typically receive benefits (Swartz, 2007). The impact of rising premiums among small employers has been significant over the past 20 years. People of “working age” represent the largest group of uninsured. Of the nearly 50 million uninsured, nearly 60 percent fall within the 19-to-45 year old age group. A quarter of all 25-to-34 year olds are uninsured (Ibid, 2007). These figures, which have increased exponentially during the managed-care era, make an eloquent statement in favor of universal health care. The severe downturn in America’s economy in recent years has only aggravated a very serious situation. Universal health care would fill the void left by once ubiquitous employer health insurance coverage. This is an important part of the rationale behind health care reform, without which a disastrous vacuum would almost certainly be left.
If lower- and middle-class Americans are no longer able to secure health insurance through their employers, health care stands in danger of going the same route as higher education, a once universally attainable goal steadily becoming the exclusive province of the wealthy. Health care must be held apart as an inalienable right that cannot be permitted to float beyond the reach of hard-working Americans. The best way to avoid that lamentable scenario is a universal health care system. In a Bloomberg Businessweek article from 2007, Katherine
Swartz wrote that “universal coverage involves a social compact – and individuals should be required to enroll” (Swartz, 2007). The health care overhaul’s individual coverage mandate draws on the “social compact” theory in calling on everyone to get involved. This is the only practical way to finance universal health care.
Preserving the right to choose
The ability to choose coverage tailored to individual needs is central to the Affordable Care Act. Citizens are required to purchase coverage as of January 2014 or face income tax penalties, but this does not mean there will be a restrictive, tightly controlled list of choices. Individuals will purchase insurance through state-offered exchanges, each with a minimum of two multi-state plans and probably additional plans for individuals and small businesses. In the spirit of free-market choice, individuals will be able to purchase plans through HMOs, PPOs or fee-based coverage. The one overriding requirement of all this is that easily affordable health care be made available to all citizens (Fritscher, 2010). Tax credits will be available for those whose incomes are less than 400 percent of the federal poverty level. While this does not amount to a “single-payer” system (though Vermont has moved in that direction), it comes far closer to a universal health care model than any national program yet put forth. It is an elaborate compromise between political pragmatism and economic necessity, one that recognizes the importance of preserving the right to choose while forcing the United States down a road that leads to universal health care. Those who do not yet consider health care to be a right want to maintain a system that keeps it squarely in the category of a commodity.
It seems likely that if the administration was truly in the business of enacting tight government controls, as some fear, those who already have health insurance would be required to purchase a government-approved plan, or choose from a menu of such plans. But the reform act allows those who already have coverage to maintain their current plan with no change. In fact, the law specifically prohibits states from forcing individuals to join an exchange or purchase a different plan. The act does stipulate that penalties await those who refuse to carry insurance, otherwise “you can purchase any plan you want, from the company you choose” (Ibid, 2010). As it stands, the plan enacted in 2010 is notable for being a voter-empowered initiative aimed at fixing a costly and badly broken health care system. But it is also a realistic, results-oriented product of Washington’s political “grist mill.” Most importantly, it is an important step in overcoming powerful business interests that have for too long hampered efforts to streamline health care and move the United States toward a universal care system.
Constitutional stumbling block
Politics is, by definition, a gradual process of give and take. In this tumultuous environment, moving the U.S. toward universal health care will take time and unfold in phases, the Affordable Care Act presumably being one such phase. The genius of American democracy is that the crucible of electoral politics and constitutional jurisprudence has a purifying effect, in which policy endures a process of streamlining and refinement on the way to becoming law. This process is unfolding at present in the dozens of challenges to the reform act’s individual coverage mandate. In what will likely prove the landmark challenge, Judge Roger Vinson ruled in December 2010 that the law’s coverage requirement represents an abuse of congressional power. That wasn’t all. Vinson also determined that this key component of the overhaul act is so inextricably linked to the very basis upon which the statute was founded that it rendered the entire law unconstitutional. The U.S. Department of Justice challenged the judge’s ruling, oral arguments were heard in June 2011 and it is expected that the challenge will likely wind up before the U.S. Supreme Court.
Vinson attacked the central issue, the lynchpin in the great historic debate over universal health care. Without the individual coverage mandate, reform becomes an empty term and the universal care loses momentum. The (gradual) move toward universal health care comes down to the perspective of federal appeals court judges and, in all likelihood, Supreme Court justices. Thus far, the judges hearing such cases have broken along ideological lines, with those appointed by Democratic presidents aligning in support of health care reform and Republican-appointed judges in opposition. This returns us to the question of perspective and whether the judges who will determine the future of reform regard health care a right or a commodity. We probably won’t know the answer to that question until next year, with hearings at the appeals level set to play out through December 2011.
Recent legal precedents have tended to be inconclusive. Several states have tried to force employers that don’t offer plans to pay fees to help provide funding for health care, with mixed results. San Francisco became the first city to provide universal health care for its citizens, however, a group of area restaurants filed a joint lawsuit claiming that the city’s requirement violated the federal ERISA law. In January 2008, a federal appeals court judge permitted the city to proceed with the fee plan. A suit filed against a similar law in Maryland was upheld, with the presiding judge ruling that charging employers a fee violates federal law (Appleby, 2008). The outcomes of these cases underscore the necessity of ensuring that everyone has access to universal care and the importance it carries for businesses as well as individuals.
The affinity of the United States government for business and fostering a healthy free-market environment has had a deleterious effect on the nation’s health care system. Worse, it has had a negative long-term impact on the nation’s economic well-being. The millions who cannot afford insurance under previous approaches, the individuals who cannot pay large hospital bills and cancer patients who can’t afford the treatments and medicines they need offer testimony to America’s callous disregard for the human toll of inaction. America may lead the way in terms of innovation, technology and treatment, but it still lags behind the rest of the world in health care accessibility. The Affordable Care Act represents the best chance to realize the long-sought-after ideal of universal health care and must be supported by the courts and at the state level.
References
Appleby, J. (17 Jan. 2008). “Universal health care plans up against U.S. law.” USA Today
Bardes, B.A., Shelley, M.C. and Schmidt, S.W. (2009). American Government and Politics
Today 2008: The Essentials. New York, NY: Wadsworth Publishing.
CNN Politics. (15 June 2009). “Obama makes case for universal coverage, end of medical red
tape.” Web. http://articles.cnn.com/2009-06-15/politics/obama.ama_1_health-care-malpractice-doctors/4?_s=PM:POLITICS
Curry, T. (11 August 2009). “Everyone into the risk pool – or else.” Msnbc.com. Web.
http://www.msnbc.msn.com/id/31782553/ns/health-health_care/t/everyone-risk-pool-or-else/
Derickson, A. (2005). Health Security for All: Dreams of Universal Health Care in America.
Baltimore, MD: Johns Hopkins University Press.
Fritscher, L. (26 March 2010). “Understanding the Obama Health Care Plan.” About.com. Web.
http://phobias.about.com/od/treatment/a/obamaplan.htm.
Kathol, R. and Gatteau, S. (2007). Healing Body and Mind: A Critical Issue for Health Care
Reform. Westport, CT: Praeger Publishing.
Sherrow, V. (2009). Universal Healthcare. New York: Infobase Publishing.
Swartz, K. (2007). “Universal Health Care: No Sick Joke.” Bloomberg Business Weekly.
