Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Article 25, The Universal Declaration of Human Rights

The Constitution of the World Health Organization (WHO) articulated in 1946 that “…the highest attainable standard of health is one of the fundamental rights of every human being.” Since that declaration, the world has undergone transformative changes, riding on the back of technological discoveries and innovations. Yet nearly every nation has been grappling with the question – is healthcare a basic human right, a privilege granted by the marketplace or simply a product?

Health care is a product when it is commoditized and sold by profit-seeking corporations. It is the product of a financial industry that makes billions of dollars year after year selling people the promise of access to doctors’ services and hospitals.

Health care is a privilege when it is granted by insurance companies to people who are in good health and earning a good salary. It’s a privilege that insurance companies can revoke when people need it most.

Health care is a human right when people say it is, and have the courage and determination required to make it so. 

Irrespective of the philosophical discourse, access to healthcare is of paramount importance, and there can be no argument about it. Keep in mind that what societies actually do may not coincide with what they should do as a matter of justice. If, however, there is widespread belief that people owe each other access to certain kinds of care, and this belief is embodied in institutions that attempt to do that, it may give us some evidence about what people think they owe each other. Of course, we find different institutional provisions of access in different settings, and the differences may not reflect differences in belief as much as differences in resources or social history.

Nearly all developed countries provide all their residents with access to a broad set of public health and individual medical interventions. In these countries access to care is assured despite income and wealth inequalities through universal coverage health systems. The method of financing these universal access systems, as well as their organizational structure, varies considerably. Some systems are funded through general tax revenues as in Canada; others through payroll taxes, as in several European countries; and others through a mix of public and private insurance schemes, as in Germany.

The commitment to universal access is hardly limited to developed countries, for various middle income countries have recently provided universal access or attempted to do so incrementally, and there is a recent effort to include low-income countries in the effort to secure universal coverage. The WHO advocates universal coverage in low- and middle-income countries (WHO 2010). A key issue in these efforts is the comprehensiveness of the benefit package, which in some reforms is a “thin” benefit package that may not cover many needed services and that requires significant out-of-pocket payments even for covered services. 

However, there are ambivalences even when we espouse egalitarian views.

The question is whether one can get healthcare if one doesn’t have money to pay for it, yet gets billed and has to deal with it one way or another eventually. Or does it mean that healthcare is basically free, in the sense of covered by taxes with no debt or out of pocket charge to the recipient, the way it is in some Western European countries?

How equal must our rights to health or health care be? Specifically, must everyone receive exactly the same kinds of health-care services and coverage, or is fairness in health care compatible with a ‘tiered’ system?

Around the world, even countries that offer universal health insurance differ in their answers to this question. In Canada, for example, no supplementary insurance is permitted. Everyone is served solely by the national health-insurance schemes, though people who seek additional services or more rapid service may go elsewhere, as some Canadians do by crossing the border. In Britain, supplementary private insurance allows about 10 per cent of the population to gain quicker access to services for which there is extensive queuing in the public system. Basing a right to health care on an obligation to protect equality of opportunity is compatible with the sort of tiering the British have, but it does not require it, and it imposes some constraints on the kind of tiering allowed.

In a society that permits significant income and wealth inequalities, some people will want to buy coverage for these additional services. Why not let them? After all, we allow people to use their after-tax income and wealth as they see fit to pursue the quality of life and opportunities they prefer. The rich can buy special security systems for their homes. They can buy safer cars. They can buy private schooling for their children. Why not allow them to buy supplementary health care for their families?

One objection to allowing a supplementary tier is that its existence might undermine the basic tier either economically or politically. It might attract better-quality providers away from the basic tier, or raise costs in the basic tier, reducing the ability of society to meet its social obligations. In principle, however, it seems possible to design a system in which the supplementary tier does not undermine the basic one. If that can be done, then a system that permits tiering avoids restricting liberty in ways that some find seriously objectionable.

A second objection is not to tiering itself but to the structure of inequality that results. Compare two scenarios. In one, most people are adequately served by the basic tier and only the best-off groups in society have the means and see the need to purchase supplementary insurance. That is the case in Great Britain. In the other, the basic tier serves only the poorest groups in society and most other people buy supplementary insurance. 

If the basic tier is not undermined by higher tiers, and if the structure of the inequality that results is not objectionable, then it is difficult to see why some tiering should not be allowed. There is a basic conflict here between concerns about equality and concerns about liberty, between wanting to make sure everyone is treated properly with regard to health care and wanting to give people the liberty to use their resources (after tax) to improve their lives as they see fit. In practice, the crucial constraint on the liberty we allow people seems to depend on the magnitude of the benefit available in the supplementary tier and unavailable in the basic tier. In spite of the objections, there appear to be some merits in tiering.

Conceptualizing and measuring access to care is more complex a task than it might seem at first. In part, this is because health care is non-homogeneous in its function, for it does quite different things for us. In addition, there is disagreement about the nature of health care as a social good: some think it is just a commodity, to be purchased in a market like other commodities; others claim it has a special moral importance that distinguishes it from some other market goods. If we are to make sense out of claims that we owe each other equal or at least equitable access to care, and this means we must overcome various barriers to access to care that create inequitable access, then we need to be clear how to determine when access is unequal or unjustifiably unequal.



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