We discussed this exact issue in my Health Care (Wagner) class. I asked, if America is so insistent on providing public education and not a public health plan, does that mean we believe education is more of an essential right than health? (Not a charged question, I honestly don’t know)

But I do think that, conceptually, the government “meddling” in my education is a lot scarier than the government “meddling” with my health insurance. Just a thought.

As I said last time, it is a right!

Think of all the children and minors who can’t help what economic situation they are in. Likewise, if you have a job and are an “active” member in society, but your work does not offer health insurance and it is too expensive to seek it out on your own or for your family.

In Wyoming, where I grew up, I was fortunate enough to be part of a government run health care program for minors in the state. However, when I turned 18 that was taken away, completely unknown to me. On top of all this, I was in physical therapy for an off season sports related accident, and I did not know that I was uninsured until I received a several thousand dollar bill months later from the physical therapy clinic. So imagine starting college off that way!

Health care is a right. Otherwise only the middle and upper classes are able to live truly healthy lives. But you know, what if they’re situation changes and they become uninsured? Wouldn’t it be comforting to know that though you can’t afford whatever private health care on your own, that there IS something there for you to fall back on that will enable you to live healthfully.

We can also approach this from a utilitarian point of view, wherein rights may not exist independent of social interaction. When we think of peoples’ having a right to free speech or association, it may be that society simply works best when these abilities are guaranteed to everyone. We call them rights, but they may not be in the sense we’ve always imagined rights. Applied to healthcare, simply ask, “Does society work best when everyone has access to healthcare?” My inclination is that a healthier society would be brought about, and that a healthier society would be more productive. So yes, healthcare is a right, but not because we are fundamentally endowed with it in virtue of being humans, or something along those lines.

I love this article Ned, I’m glad you wrote about this!

You raise some issues with amazing arguments on both sides, which is what I love about legal issues. Briefly, I’d just like to point out that the biggest problem with positive rights in our legal system, and society, is that defining certain goods to be distributed equally is quite nice theoretically, but effectively impossible in practice. Our courts have had to approach this problem of positive rights many times. For instance…

San Antonio Independent School District v. Rodriguez… that education is not explicitly or implicitly provided for in the Constitution. The discrepancy in the quality of public education between rich and poor school districts do not make “poor people” a subject class under the Equal Protection Clause. If the court had held “education” to be a fundamental right, imagine the litany of cases that would have ensued. This reasoning was prominent in the Court’s decision.

Padilla v. Commonwealth of Kentucky… currently being argued before the Supreme Court this past week, involves the positive “right to counsel” that you mentioned. The issue being raised is to what extent the quality of performance of a court-appointed lawyer can be considered when a defendant claims they were found guilty due to a lawyer’s ineffectual advice. Strickland v. Washington first established a test for assessing “ineffective assistance claims”, but new challenges to the Court are contesting the reach of this test, and the level of quality of counsel that needs to be provided by this “positive right.” Prominent in oral arguments before the Court is whether a decision expounding upon this “right to counsel” would result in a burden upon the Court System with never-ending challenges to guilty verdicts/pleas.

http://www.scotusblog.com/wp/padilla-v-commonwealth-of-kentucky-does-misadvice-constitute-ineffective-assistance-argument-preview/

Positive-right advocates might argue that such rights only provide a “basic level.” The inherent problem to positive rights is that the people they are meant to provide for will always be clamoring to receive greater and greater quality of [healthcare/counsel/opportunity/wealth...]. This is why the Courts, and Constitutions, are very cautious in providing for such positive rights.

Very good, these are some of the things we need to discuss. Comments are fabulous, thanks.

Agreed. I love this philosophical, more encompassing discussion of what health care actually means.

Chris makes a great point: “The inherent problem to positive rights is that the people they are meant to provide for will always be clamoring to receive greater and greater quality,” which could be a dangerous slippery slope.

But like Ned said, the situation is comparable to public education in that the government doesn’t need to provide top-notch service — though I’m not excusing the inevitable inefficiency — and that a “basic level” can be satisfactory. This is mainly because however poorly distributed resources and quality may be, the other option for those with a public health care would be (wait for it) no health care at all. Let’s assume some rationality in Americans, as difficult as that may be.

If our goal is to create a health-care system comparable to our public education, then we haven’t set the bar very high.

So many brilliant scholars have written about new and innovative ways to provide education for every American in some other fashion than public control while avoiding many of the problems that plague our education system today… like how bad teaching is incentivized.

While a lot of brilliant alternative plans have been proposed, arguments against implementation of these new plans always falls back to, “It would just be too difficult”, or “That’d be nice, but a complete overhaul just isn’t realistic.”

We should take our time with health-care and do this right, and not make the same mistake as Americans did with public education.

I would not say that bad teaching is incetivized, but rather that teaching is not viewed as an appealing job because everyone knows that

1. It does not pay much money at all, and in our society, wealth is the be and end all.
2. It is also one of the hardest jobs that there is. Try teaching a group of 30 13 year olds. It’s terrifying.
and
3. No Child Left Behind and standardized tests have ruined education because the preparation for the tests and meeting the minimum standards is more important than actual education and intellectual growth.

Thus, there are a good number of poeple who aren’t necessarily cut out to be teachers, though they have noble intentions. We’ve all had these people, and they’re horrible.

But again, think if we did not have public schooling at all and how uneducated everyone would be. Likewise, just as Rob said, if we had health care, though a basic one, it would make for a more productive and healthier society.

To those against having your tax money be used for health care, your taxes go towards funding public school to help educate other people, are you against public schools and helping others get an education too?

No, I think the government should ensure education and healthcare for everyone. That doesn’t mean the means of doing so has to, or should be, a be a “public” system.

@Rob: I hesitate to involve a utilitarian conception of rights in the argument just because I don’t like the implication that rights are somehow conditional on benefiting society at large. After all, there’s a perfectly reasonable argument to be made that society doesn’t gain much utility from, say, the KKK having First Amendment rights–but the idea that we’d restrict someone’s liberty because of his worldview, no matter how repugnant, disturbs me.

Sure you could argue for utilitarianism with side constraints, but where do the side constraints come from? That’s just a compromise with non-utilitarians, not a cohesive worldview in of itself.

This is why I’m a Rawls fan, instead (although I don’t take most of his basic concepts as far as he does). It’s difficult for me to imagine a rational actor in the original position turning down universal health care.

@Chris: The problem with taking our time to “do health care right” is it’s not really a political reality. The way you get good programs through a Congress that’s inherently resistant to change is by starting out with the basic framework of a sort of crappy compromise measure, and then building on that once it’s ratified. Right now, we just need something.

And I reject the notion that there’s no rush to get that something out on the table. As we speak, people are dying because they don’t have access to health care. A lot of people. Right now I feel like the goal should be to get them covered as quickly as possible, and then revisit the situation a couple years down the road and make changes where necessary.

Nicely done, Ned. This article has some real balls. I loved reading it.

The older I get, the harder it is to see things in black and white. I think most political viewpoints only scratch the surface when it comes to eliminating a problem – and that only makes it more frustrating to see everyone fighting all the time.

The best solution I have heard for the health care situation has been giving low-income families tax credits for health care costs, but even that solution is not without its shortcomings.

Blah, problems without solutions are always hard.

@Ned: “As we speak, people are dying because they don’t have access to health care. A lot of people.”
This is true, but I’m hesitant to state that “public” health care is the best solution. As other commenters here have noted, only a basic health care plan would be created (similar to the basic public education, etc). There would be limitations to what level of care doctors could provide: emergency health & ambulatory care and medications would probably be the upper limit. It would be terrifying for a low-income family using a public health plan to discover that the medications their doctor prescribed them for free were only masking the symptoms of a much more life-threatening condition whose treatment they still may not be able to afford. I would love to see a comprehensive public health option but I think that discussion would lead to the education of surgeons and their skill levels, and whether the government could afford to train specialized surgeons….

@Nick: “The best solution I have heard for the health care situation has been giving low-income families tax credits for health care costs”, I agree, but yeah there are shortcomings with that as well. It’s so difficult thinking of what the best solution might be, because it doesn’t look like anyone can win in any proposed situation.

@Rebecca: I think you may have missed my point. I acknowledge that there will be huge gaps in whatever health care we’ll be able to provide based on legislation that we can get passed in the immediate future. That’s not an argument for not running with it, though. Pretty much anything would be an improvement on the status quo. And part of the idea of getting a public option through now is that at least then we’ll have a legislative foundation to tinker with in the near future when we want to improve our health care system further.

@Ned: Thanks for your response, that does clarify your point. Unfortunately having that bare foundation off of which the system would build is only the start, hopefully it’ll be able to expand until it is on par with European health care.

I see your point Ned but I just think anything involving a public conception of health-care is going to be detrimental to achieving a more-ideal plan in the future. The near-impossibility of trying to solve our education problems in America is a perfect example of why a public solution can become the problem itself.

Though, I’m sure you would disagree with me.

If it’s a truly minimalistic approach you want to advocate, and you’re willing to concede that a public conception of health-care *might* not be the best solution, and are willing to leave it up to more extended deliberation… why not just provide the uninsured with money straight from government taxes for the time being?

Insure the uninsured, then have a more reasoned, and less emotional / urgent debate afterwards?

This is great stuff.

I recommend taking a look at libertarian economist Tyler Cowen’s attempt to define progressivism: http://www.marginalrevolution.com/marginalrevolution/2009/08/what-is-progressivism-1.html

I think this point is important: “Limiting inequality will do more to check bad governance than will the quixotic libertarian attempt to limit the size of government.”

This is what Ned is getting at (though he gets there through a much more eloquent and philosophically-grounded way). I agree. As I mentioned briefly on the previous health care thread, we only have some limited amount of health care to divvy up among the populace. What’s the best way to ration it?

It’s not an easy question, but I think any system that relies heavily on price rationing (as the current system does) leads to terrible inequality in care. Even many libertarians who propose purely free-market reforms recognize this and want there to be subsidies for the poor.

But listen to libertarian hero Ayn Rand, in a speech from 1993 about the Clinton plan: “Under the American system you have a right to health care if you can pay for it, i.e., if you can earn it by your own action and effort. But nobody has the right to the services of any professional individual or group simply because he wants them and desperately needs them. The very fact that he needs these services so desperately is the proof that he had better respect the freedom, the integrity, and the rights of the people who provide them.” (http://97.74.65.51/readArticle.aspx?ARTID=590 – via http://www.thehealthcareblog.com/the_health_care_blog/2008/10/is-health-care.html)

Yikes. Think about how many people are left devastated by illness or medical bills – do they deserve that just because they can’t pay?

Health care is absolutely a moral obligation any developed country has to its citizens. Whether or not it is a “right,” in the sense that you should receive it as part of being human, doesn’t really matter.

@Charlie: I’d love to talk with you about Ayn Rand sometime. Your comment, however, makes everything so much more simplified than it actually is. Whether or not health-care is a “moral obligation” or “right” has the same result: it provides no understanding of what quality should be obligated.

As I pointed out, our Constitution provides a “right to counsel”, but unfortunately we are left to decide what level of quality counsel that “right” is meant to provide. Rich people can buy the best and brightest lawyers in the world, yet I would be shocked if you thought the inequality of lawyers between rich and poor should be equalized. To strip an intelligent lawyer of his prerogative to sell his services to whomever he chooses goes against autonomy and almost every civil liberty out there. Alternatively, if I follow your logic on health-care, we should be providing poor people with the resources needed to procure (approximately) equally intelligent lawyers as rich people can get. Unfortunately, there is not enough bright lawyers to go around. As we find in the current case before the Supreme Court, there is not even enough competent lawyers to go around.

In the same way, there is not enough health-care to go around. Approximate equality of health-care, a necessary implication of your argument that health-care is a “moral obligation” is not only indefensible, it’s unrealistic.

Of course your predicted response to this, leads us back once again to defining what a “basic level” of care would look like. Unfortunately, no one really wants to be specific because telling someone the statistics say they don’t meet the requirements for that kidney, or that expensive procedure, or that really smart doctor, isn’t pleasant. It isn’t pleasant because it takes the control away from the individual over their own life. Your Ayn Rand critique seems like you would call her health-care views heartless or maybe cruel. However, your envisioned government system of rationing is nothing more than a bureaucrat or Health-Care Czar playing God with people’s lives. A system that takes away individual control of your own life, whether rich or poor, is not an acceptable way of rationing health-care and is far more inhumane than a capitalistic system, however heartless you may believe it to be.

“In China, Rx for Ailing Health System” from last Thursday’s Wall Street Journal:

“… In the first decades of Communist rule, China made significant public-health strides. Initiatives reduced malaria deaths and infant mortality rates. Workers on collective farms and in state-run factories received almost universal, if very basic, medical care.

“That system started to unravel in the late 1970s as China began to embrace capitalist-market economics. Rural communes were disbanded and inefficient state enterprises went bust. Funding for public hospitals and clinics slowed. Out-of-pocket payments for medical services rose from 20% of health-care expenditures in 1978 to roughly 50% in 2006, according to government figures….”
http://online.wsj.com/article/SB125556557369186287.html

There is a world of difference between a healthcare “industry” (in any form) and a system based on and serving social need, where people can get healthcare without qualifications. In a rational and just society this positive right does exist, and has existed in the past. It does not and cannot exist in an economy where the imperatives of profit rules.

You have to watch “Raymond Lotta: Health Care Under Capitalism, Health Care Under Socialism” an 8 min video at http://www.youtube.com/watch?v=K7eHGtA7CSs, to get a sense of this.

Raymond Lotta is speaking October 26th, 7pm, in Cantor on “Everything You’ve Been Told About Communism Is Wrong: Capitalism Is A Failure, Revolution Is The Solution.” This is not the best of all possible worlds we should stay tinkering on the sidelines of, and Lotta will show how humanity’s made unprecedented leaps in moving beyond exploitative and class-divided society, and how we can do even better next time. I encourage everyone interested in positive rights to come to this program and continue this discussion with this communist.

@ Chris:

First of all, we’re not talking about a system in which would be unable to purchase insurance or treatment above and beyond a basic level of guaranteed care. If you want to pay for a super-expensive drug or surgery, you will still be able to do that. It’s not like extending medical coverage to everyone suddenly means everyone has to get the same care.

Of course I agree that what it comes down to is defining a basic level of care. And, you’re right, determining who can receive a transplant is a difficult ethical problem. But how these lead you to say that my calling health care a “moral obligation” is indefensible and unrealistic seems odd to me.

It sure is scary when you describe a “health care czar playing God.” But eventually we do have to decide who can get the transplant. I think that your ability to receive that transplant should not depend on whether or not you can outbid the sick guy in the room next to you. How could it possibly make sense to let a near-death, rich old man get the transplant that will keep him alive two months longer instead of a poor young woman who could live for 40 years?

What’s the better moral choice in that situation? Either way, someone will still be unable to “individual[ly] control [their] own life.” Why is money a better decision maker than a team of scientists, doctors, and ethicists? (BTW, we’re obviously not talking about some omnipotent health czar determining your life and death. Comparative effectiveness review and other programs designed to ration care should be run by scientists, not politicians).

You accuse me of oversimplifying, but then you wash away my argument simply by calling it indefensible.

Let’s have health care blogger Ezra Klein finish this:

“A 2001 survey by the policy journal Health Affairs found that 38 percent of Britons and 27 percent of Canadians reported waiting four months or more for elective surgery. Among Americans, that number was only 5 percent. This, Americans will tell you, is the true measure of our system’s performance. We have our problems. But at least we don’t sit in some European purgatory languishing without our treatments. That’s rationing.

“There is, however, a flip side to that. The very same survey also looked at cost problems among residents of different countries: 24 percent of Americans reported that they did not get medical care because of cost. Twenty-six percent said they didn’t fill a prescription. And 22 percent said they didn’t get a test or treatment. In Britain and Canada, only about 6 percent of respondents reported that costs had limited their access to care.” (http://voices.washingtonpost.com/ezra-klein/2009/08/we_ration_we_ration_we_ration.html)

I would rather we wait for non-essential care so that we can all afford the basics. Seems pretty defensible to me.

“And, you’re right, determining who can receive a transplant is a difficult ethical problem. But how these lead you to say that my calling health care a “moral obligation” is indefensible and unrealistic seems odd to me.”

I was connecting how “moral obligation” leads to an idea of at least approximate equality of care. A moral obligation to provide health-care that allows for vast inequalities between rich and poor doesn’t quite make sense together. Thus when government attempts to equalize care, problems of scarcity of the best (a.k.a. expensive) treatment (which is what we’re talking about with inequality between rich and poor) make this “moral obligation” impossible to fulfill (indefensible). Just like the how the government can provide basic legal advice, it is impossible to assure that everyone receives even competent legal advice. Anyways, that is sorta beside the point. I was trying to convey how using terms like “moral obligation” and “right” is distracting and incoherent.

And “money” is not a third party in this situation that is comparable to Government serving as the “Ration-er.” Money serves as a means of allowing people to ration their health-care themselves. The rationer is the individual. Yes, I realize some people have more money than others. Being productive, or saving your money for health-care, should, and does, have its advantages.

The “mandatory-savings system” that Greg Lefkin linked to in the other article is a great example of how the government can serve to ensure that even poorer people will have ample amounts of money that will allow them to ration themselves a sufficient amount of health-care. Choice, and rationing, remains with the individual, where control of care should be regardless of whether you have enough money to buy the top-notch insurance.

“Being productive, or saving your money for health-care, should, and does, have its advantages.”

When one hospital visit can cost a family a couple grand, I’d say it’s pretty hard for a family of modest means to save their money for health-care. I know from experience that it’s a lot easier said than done.

@ Chris:

I am on record as being a fan of Health Savings Accounts and the Wyden-Bennett plan. You before approved of Ayn Rand’s sentiment, but now you are significantly softening your position by arguing that the government should step in and help poorer people receive care. I totally agree!

But I think that whether we have a public option or we just force private insurers to accept everyone and achieve the same goals through the exchange, we should ensure that everyone be able to afford health care. You seem to agree with that. But you don’t think it’s a moral obligation? If it’s not, why should the government help out the poor and lower middle class? (Currently, subsidies are likely to be available to up to 4X the poverty line, ~$90,000 for a family of four).

You also didn’t respond to my hypothetical situation about the transplant. How is it an “individual” choice if the young woman doesn’t have the money to buy the transplant?

@Charlie: While I love Ayn Rand, I don’t approach everything from a purely objectivist perspective. I did like her comment that you quoted because it was descriptive of the importance of individual choice in the process of rationing health-care. The “moral obligation” stuff was sort of a side issue, more to do with Ned’s article. What I really wanted to refute was that your idea of government rationing is any way OK. It’s not.

But you’re right, we both have the same ideal ends in mind: universal health-care through “helping poor people receive care.” Our means are quite different and the difference gets at why you think a lower middle class person who can’t afford care is stripped of their individual choice.

Your idea of “help” is really better described by the word “give.” One of the many problems with your “moral obligation” claim is that it implies the problem is that American society is not providing this health-care for some of its members. This is inaccurate. The problem is that some Americans aren’t providing health-care for themselves. Before you jump all over this, let me qualify the statement by saying the reasons for my version of “the problem” are manifold. Society sure drags some people down, and disadvantages and advantages abound. Some people are also less productive, less skilled, or have less willingness to succeed. That is *somewhat* of another discussion, though. Yet, fixing opportunity problems does not lead to “help” turning into “give”.

For your hypothetical, let’s imagine a situation with mandatory savings accounts and disaster insurance required by the government to see if money can’t serve as means for individual choice in a near ideal situation. Also I’m going to make the “young woman” into just a “woman” because that adjective changes everything to beyond a basic understanding (stay with me, I’ll address that after). The woman didn’t lose her individual control of health-care for various reasons. She apparently didn’t buy a disaster health-care that would cover transplants and instead violated the law by using that money to buy anything in excess of what would be required to live (i.e. anything besides basic shelter, food, transportation to work etc…). Or, she decided to allocate the resources of her savings account to other purposes, whereas someone else may have led a healthier life, saved more money, or scrimped on other health-care so that their savings could be used towards something of more value to them.

This description obviously neglects the possibility that the poorest people in our society don’t spend any money except that which goes towards the most basic necessities of life (I don’t think this is a realistic description of anyone, but I’m willing to imagine there could be someone). Or that there just isn’t enough excess money after the basics of life to put towards a savings account or disaster insurance (a more realistic version). Whether this is because of unemployment, young age, laziness, or lack of achievement, I can concede government subsidies of a savings plan would be in order. The idea that these subsidies should be anywhere near in line with “approximate equality of care” as your “moral obligation” implies, is dangerous in that it creates a welfare-culture that masks the real problems of opportunity in our society.

In the end, our disagreement boils down to different conceptions of justice. I think justice requires that we enable everyone to have the greatest *opportunity* to improve their own situations, and ultimately provide health-care for themselves. I disagree with the idea that justice requires health-care for everyone. Obviously, I think mine is more virtuous, but I like hearing you defend yours too!

TLDR:: If you’re still reading the comments section of this article, you’re probably interested enough to enjoy what I wrote!