THE NATURE OF
HEALTHCARE
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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