the important and the not-so-important, horribly conflated.

Health Care Reform

In healthcare on March 16, 2010 at 5:11 pm

With the possibility of a final vote on the Reform bill later this week or early next, and the paroxysms of overly-detailed reporting from CNN and the like popping up now, I’m posting a (long) essay below that I wrote last year for Temple Med’s PULSE publication that simplifies (perhaps fatally so) the debate:

“I think health care is a privilege, I wouldn’t call it a right. [I]n our country and in any civil society there should be a safety net for basic health and food and shelter, but that doesn’t mean that the whole system should be designed around the belief that people can’t make their own decisions, can’t be responsible for themselves.” – Senator Jeff DeMint (R – SC), Charlotte Post, 21 August 2009

[note: “Conservatives,” becomes, unfortunately, a sort of blanket term in this essay for individuals supportive of Senator DeMint’s quote. My apologies to those who identify as Conservative but disagree with the Senator.]

Many Conservatives assert that there is no such thing as a “positive human right”—rights exist only if they represent something that can be impinged upon. Stated another way, no one is owed anything from birth—yet, what Americans earn through hard work and creativity must be protected. And while this belief is usually well reasoned, it is undergirded by a fear that is both baseless and shallow: that an unnamed, faceless “other” is leeching away the hard-earned (money, health care, jobs) of “real” Americans.

A more pragmatic and ethically responsible view recognizes disparate levels of access and agency (which together form what could be called “Opportunity Rights”) available to modern Americans. It identifies developmental, psychological, and socioeconomic barriers to success in this country—and gives weight to unjust impediments imposed on individuals by the accident of their birth, rather than the consequence of decisions made as an adult. Understanding health care as a scarce resource, proponents of this view look beyond cost or market-driven rationing (our current system) and question how we can integrate moral and ethical considerations into tough decisions made about the allocation of care. Furthermore, it demonstrates and defends the systemic benefits of altruism, rather than dismissing it as a profitless deficiency.


I call the fear of Conservatives “baseless,” as it is undermined both by 1) the reality represented in numerous longitudinal studies of inequality and social immobility in America, and 2) the hypocrisy of Conservatives’ condemnation of Government Intrusion/Assistance. It is “shallow,” as it aligns (or attempts to align) personal and national values along financial/monetary metrics—ignoring important ethical and moral considerations even as proponents of the “health-care-as-a-privilege” argument present themselves as models of moral rectitude.

The Conservative ideal of the market as the perfect allocator/arbiter of wealth—evenly and fairly distributing financial benefits to the most deserving and hard-working Americans—is compromised by unequal distribution of opportunity. The Economic Mobility Project surveyed 2100 adults and ran ten focus groups earlier this year and found that respondents overwhelmingly believe that personal attributes “like hard work and drive” are the key determinants of an individual’s economic success. A majority also disagreed with the statement that “In the United States, a child’s chances of achieving financial success is tied to the income of his or her parent.” Yet, these studies demonstrate that the above statement is true—disadvantage is primarily a product of one’s birth. And that statement represents the reality faced by a higher proportion of American children than in most comparable countries.

But how does the opportunity gap connect to health care? The work of Evans and Schamberg (2009) has firmly established a link. As reported in the Proceedings of the National Academy of Science, these researchers:

“[a]nalyzed the results of their earlier, long-term study of stress in 195 poor and middle-class Caucasian students, half male and half female. In that study, which found a direct link between poverty and stress, students’ blood pressure and stress hormones were measured at 9 and 13 years old. At 17, their memory was tested. Given a sequence of items to remember‚ teenagers who grew up in poverty remembered an average of 8.5 items. Those who were well-off during childhood remembered an average of 9.44 items. So-called working memory is considered a reliable indicator of reading, language and problem-solving ability — capacities critical for adult success. When Evans and Schamberg controlled for birth weight, maternal education, parental marital status and parenting styles, the effect remained.”

The traditional “rights” fiercely defended by Conservatives—property, guns, liberty—seem almost trite when discussing the consequences of poverty on a child’s cognitive development and brain elasticity. These are irrevocable changes—property and liberty can be restored through legal action; the stress of poverty limits the opportunities available to an individual for their entire life. The question becomes: Is there a hierarchy of rights—should a corporation, which is legally defined as a “person” in this country, receive the same protections as an actual human being; should “negative” and “positive” rights be viewed with equal merit? I would argue that our society has, unfortunately, already established a hierarchy of rights—and both Conservatives and Liberals have become entrenched in a certain “right exceptionalism,” each believing the rights they defend to be more important than those championed by their opponents.

What differentiates these two groups is their view of the Government’s role as upholder (or obstructor) of their favorite right of the moment. The Conservative argument—that Government intrusion in certain aspects of the market is harmful to the quality and quantity of goods provided by that market—willfully ignores history: Conservative administrations have unapologetically tinkered with the market to the benefit of their supporters for decades. “The reality of the contemporary United States is that, even as income inequality has exploded, the average tax rate paid by the top 1 percent has fallen by about one-third over the last twenty-five years.” Jonathan Chait writes in “Wealthcare,” a clear-headed examination of the Conservative arguments against health care reform, adding “Again: it has fallen.” In many ways, the health care reforms proposed represent, rather than a drastic shift leftward from the laissez-faire ideal, a correction to the intrusion of Government (or the equally important lack of intervention, i.e. the inept or absent regulation of the insurance industry) in an already biased and inequitable market.

Still, it is worth considering whether the question of “Is Health Care a Right?” can or should be resolved by arguing, as I have, that economic inequality—independent of one’s hard work or ingenuity—decreases poor individuals’ access to care and disproportionately limits the agency of those under the poverty line to change their situation for the better. This view, backed by an overwhelming pile of evidence, nonetheless neglects somewhat the ethical and moral implications of the Right vs. Privilege debate.

In an editorial published in the Lancet earlier this year, Persad et al look at the various systems in place for the allocation of scarce medical resources—transplants, highly-specialized surgery, etc. But the ethical principles for allocation they present in this paper can be translated, I believe, to the larger Right-vs.-Privilege  debate. The authors evaluate four categories critical to making ethical allocation decisions—“treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness”—while also asserting that no single principle is “sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems.”

The larger point this editorial presents is both humbling and challenging in its simplicity: The decisions we make about health care are unique. No system relying solely on ethical or economic or moral metrics yields equitable results. Rather, our debate should focus on the intersection of these seemingly disparate viewpoints. There is great value in a sort of “altruism of the disciplines” in a field (health care) already hindered from meaningful progress by imperfect information. An honest dialogue must be built, though, on top of the thesis that health care is a right: a unique and ambiguous right—but a right nonetheless.


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