Health care in the United States—basic human right or entitlement?

Most European nations have had some form of national insurance for more than a century. The primary reasons for the emergence of these programs was not payment of medical expenses, but instead income stabilization and protection of wage loss due to sickness . These original entities are in some ways analogous to the American Social Security program. Since their inception, European social insurance programs have evolved into flourishing universal health care systems. Both the European Union and the United Nations recognize health care as a basic human right; 38% of the constitutions of the United Nations' members guarantee medical care .

The United States, Mexico, South Korea, and Turkey are the only member nations of the Organization for Economic Cooperation and Development that do not recognize universal health care as a basic human right. Our Constitution and the Bill of Rights do not guarantee access to health care. This is expected in nations with older founding documents. South Africa established universal health care in 1996, 2 years after ending apartheid, but 47 years passed after the Civil Rights Act of 1964 before America instituted the Patient Protection and Affordable Care Act (ACA), our first successful attempt to require by law universal health insurance coverage in more than 200 years .

The reluctance of the United States to embrace universal health care may be traced to some earlier ideological movements. The writings of William Graham Sumner had a profound effect on America in the last three decades of the 19th century . One of the founders of western sociology, Sumner brought Darwinian evolution and Malthusian economic theory into the center of the American sociopolitical arena. His ideology mirrored capitalism in many aspects and was thus readily accepted by most Americans at the time. It was based on the notion that the population was increasing geometrically but resources were increasing arithmetically. ‘Civilization has a simple choice,’ Sumner said, ‘liberty, inequality, survival of the fittest,’ or ‘not-liberty, equality, survival of the unfittest. The former carries society forward and favors all its best members; the latter carries society downward and favors all its worst members.’ Sumner believed the pressure of a competitive system would strengthen a society over generations. A correlate of this principle was inferred: government assistance was interference with the natural selection of the free market.

Societal Darwinism perhaps influenced medical Darwinism, a survival of the fittest, and therefore fueled the acceptance of unequal health care, or health care as a privilege or entitlement rather than a basic human right. Many generations were guided by this maxim, although the 20th century brought a shift toward the idea of equal opportunities to reach the American dream; hence, the development of social safety nets that protect Americans at times of vulnerable conditions. This shift is not linear and has waxed and waned as the ideologies of the governments in power have varied. A Texas legislator asked in 2003: ‘Where did this idea come from that everybody deserves free education? Free medical care? Free whatever? It comes from Moscow. From Russia. It comes straight out of the pit of hell’ . Today politicians do not say such things in public because most Americans believe that citizens should be guaranteed health care. Eighty-three percent of Americans say having health insurance is absolutely essential or very important, and 70% say it is important that the nation has universal health care coverage (as in Medicare for Americans 65 years or older) . Still, some people follow Sumner's philosophy. At a 2011 Republican debate, Ron Paul was asked about a young man who decided not to buy health insurance and subsequently fell into a coma. His response, met with applause, was: ‘That's what freedom is all about: taking your own risks.’ The young man was free to choose not to have health insurance and may die; so be it—freedom of choice and survival of the fittest.

America is the land of opportunity: reward for hard work, but also equal opportunity. To offer equal opportunity, all Americans need comparable or fair access to health care and education. Children without viable opportunities for both are disadvantaged from birth. Inequality inherently leads to opportunities lost, poverty, and often compromises on moral principles to access basic necessities.

The United States is the richest nation in the world, and we spend more on health care than any other nation (18% of our gross domestic product; two to three times more than other advanced nations). Yet, we rank poorly in objective measures of health care outcomes . Among 16 high-income nations, the United States ranks low in avoidable mortality, suggesting unbalanced access or improper utilization of proven treatments. Americans also rank 27th (of 34) in life expectancy. This is magnified in the mortality differential between low-earning and high-earning individuals. Gains in lifespan are becoming increasingly concentrated in higher income populations. Men born in 1940 in the top 10% of income live a decade longer than men in the bottom 10% of earnings. As income inequality increases in America, so does health care inequality.

If America spends so much on health care, why do Americans fare poorly compared with European and other advanced nations? The paradox of the uncoupling of high spending and medical care outcomes may be related to the for-profit nature of the United States health care system, a circumstance absent in most other nations. In the European health care systems, most of the money is spent on patient care. In the United States, less than one-third of the dollars are vested in patient care. The rest is diverted toward profits for the health care industry: high costs of hospital care; expensive procedures, drugs and devices; physicians' fees; ancillary services; excessive administrative bureaucracy and regulations; and high salaries and bonuses to health care associates. Also, large sums of money are spent by insurance companies to deny (rather than provide) health care (what some refer to as ‘denial management’), and by health care providers to access a better share of profits. Thus, while universal health care is opposed by some who claims that it will be prohibitively expensive, it can be in fact, in the long run, both more efficient and more affordable if implemented properly.

As physicians, we are guided by two universal principles of the Hippocratic Oath: protection of patients from harm and injustice at both the individual and societal levels . Not providing patients with needed health care is both harmful and unjust. The United States is unique among advanced nations in not guaranteeing basic health care to citizens. How can this be a sound moral and ethical proposition in a country that promulgates fairness, equal opportunity and the potential of the American Dream? American exceptionalism, the for-profit health care industry, and physician concerns over income are the root causes that have hindered progress toward universal health care . The excuses, stated and implied, have varied over time, from opposition to ‘socialized medicine’ morphing with anticommunism, to fears of hospital desegregation, to antiwelfare sentiment, and more recently, to the unaffordable costs of universal health care.

Medicare and Medicaid, signed into law in 1965 by President Johnson, were the first American steps toward universal health care. Since then, improvements have been attempted to provide better and more expanded health care at affordable costs. The ACA is a step in the right direction . Presidential candidate Ben Carson labeled the ACA as ‘the worst thing…since slavery’. The reality is that the previous system enslaved 50 million uninsured and another 15–30 million underinsured Americans to the fear of illness and its devastating consequences.

One year into its implementation, the ACA has delivered on some promises. The rate of uninsured Americans fell from 18% to10% (uninsured rates are even less in states that accepted the ACA Medicaid expansion—7% versus 14%) . Health care spending is lower than previous estimates. Insurance rate premiums are lower on average. More people approve of the ACA (43% versus 42%). Eighty-one percent of people enrolled in ACA plans are satisfied with their coverage . And most importantly, it is saving lives.  None of the negative predictions concerning the ACA came true (mass cancellation of existing insurance policies; increased cost of care; soaring insurance premiums; job destruction; ‘death panels’; ACA death spiral).

What should the health care industry position be in relation to endeavors toward universal health care? Until recently, medical professionals and those with adequate insurance shared the burden of covering the uninsured through higher premiums, overuse of emergency rooms, and complex billing strategies. These short-term solutions are no longer the best option for the health care industry. Over time, the benefit derived from universal coverage and affordability will provide funded access to health care to an additional 50+ million Americans who can afford reasonable health care and access to much needed care, medications, procedures, and hospitalizations as needed. Deeper penetration of covered stable health care will ultimately benefit all components of the health care industry including insurance companies, drug and medical devices companies, hospitals, physicians, and other associated health care providers. By endorsing the universality of health care in the United States, the health care industry will do good and do well.

Freedom should not translate into a denial of other human rights, including affordable health care to all. The American Dream is born from the premise of equal opportunity, not absolute freedom. Sumner's ideology of social Darwinism is not consistent with fairness in a country that spends more on health care that any other, but fails to distribute it justly or effectively. In this case, ‘natural selection’ implies historical privilege and inheritance, what some refer to as the luck of the ‘reproductive lottery,’ rather than merit and hard work. To live up to the ideals put forth in our constitution, equality of access to health care is a critical building step, and health care should be considered a fundamental basic human right. Explore health insurance plans harrisburg and get the best plans for your family, if you want to know more details then please send your queries in the comment section.