Is healthcare a right?
This question has become highly politicized in recent years. Before thinking about the answer, we should note that this is an entirely different question than whether or not the government should provide healthcare to all citizens. Separating these two questions is very important. There are many government services that are beneficial to the people that the government provides which are not fundamental human rights. Conflating the two issues can lead to irrevocable damage to our civil liberties. What’s more, confusing fundamental human rights with those things which are simply nice for society as a whole or which might be better characterized as aspirational ambitions of a developed country, undermines and devalues our essential liberties.
Human rights are things which are not possessed and therefore they are things which cannot be taken away except through constraint of violence. For example, the freedoms of speech, thought, publication, religion, and of assembly do not require the government to give anything to anyone to enable or empower the freedoms; they do require the government to protect citizens from anyone who might threaten to remove them or constrain those freedoms through violence. Even the right to bear arms does not compel the government to give arms to citizens; it merely compels the government to protect the citizens from those (including the government itself) who would attempt to limit this right.
Classically, civil rights are things which meet these criteria:
- cost-free, meaning the government spends no money to give the right to citizens
- immediate, meaning they can go into effect immediately without any work
- justiciable, meaning that a court can determine precisely if the right has been provided
- negative, meaning the state can protect them simply by taking no action, as opposed to need for the state to take a positive action to give the right to citizens
- non-ideological/non-political, meaning that there is near-universal agreement that the right is valid
- precise, meaning that the right is easily defined.
In this sense, all citizens have the right to healthcare just as they have the right to not have healthcare. This subtlety is vastly important. Healthcare is a right of citizens in the same way that car ownership or home ownership or comic book ownership is a right of citizens; all people are allowed to partake in these activities if they like but none are compelled to do so and the government isn’t compelled to provide free comic books to its citizens simply because comic books contribute to the overall pursuit of happiness.
Again, note that this does not prohibit the citizens from choosing healthcare or comic book ownership as a desired goal for the common good. Governments are entitled to give its citizens economic or social rights. These types of rights are aspirational, resource-intensive, vague, and require positive action from the government to grant them to its citizens. These are often called ‘rights’ by progressives, but in actuality they are privileges in a truer sense. Safety-net and welfare programs, for example, are a privilege of being a citizen in many developed countries, but they fail to be a true fundamental human right.
If the citizens of United States, and the several states together, decided that it was in the public interest to provide free comic books to all US citizens with taxpayer dollars, then so be it. A privilege of citizenship might be to read the latest issue of X-Force. Yet, this decision should not be in the hands of the comic book industry, who naturally favor it for its own self-interest. Once comic books are considered a fundamental human right (or constitutional right), then the government becomes compelled to produce and distribute comic books in perpetuity, no matter the cost and no matter the encumbrances to doing so.
The government would also have to deal with practical matters, such as which comic books should be distributed and which should not. Naturally, various torts would be established and various segments of society would sue the government for abridgment of their rights to read a comic book that the government did not see fit to distribute (Devil Dinosaur anyone?). Some comic book writers might be compelled to author and draw comic books that they do not want to, and, in many cases, their services would become compulsory by the government in order to provide this constitutionally-guaranteed right. One can see where the comic book industry would support the idea that comic books were a constitutionally-guaranteed right; the industry would have a vastly larger audience and few limitations on what they are allowed to charge to provide their services. So, the American people should be circumspect and judicious before deciding to make comic books a constitutional right.
Healthcare as a right faces many of the same challenges that comic books do as a right. Whenever a service is compulsory because it a human right, then the rights of others will be necessarily abridged. Let’s think of some practical problems. Think of the military draft: a person can be drafted into the military and forced to kill people against his will; but we decided to give the government the right to do this in order to protect our common freedoms. Still, the fundamental human rights of the draftee are being violated. Giving such awesome powers to the government should be done only in such extraordinary circumstances.
Just as we must decide which comics to distribute, so too we must determine which healthcare services are fundamental rights and which are not? Should cosmetic surgery be a constitutional right? Should patients with less than two years of life expectancy be allowed to get coronary artery bypass surgery? Or renal transplants? How do we decide the value of a given intervention and whether that intervention should be granted to a citizen? Is it worth spending $1 million to improve life expectancy by one month? Is it worth spending $1 million to improve quality of life by 5%? Should we pay for erectile dysfunction drugs? Should we pay for abortion? These types of questions must be answered in an unambiguous way if healthcare is a right.
It would likely come as a surprise to most lay people and most physicians that we have simply no idea which healthcare services or preventative medicine services are essential and which are not. There is considerable scientific uncertainty regarding things like cholesterol medications, blood pressure medications, cancer screenings, mammography, and virtually every other healthcare service that many people wrongfully believe to be essential. I, as a physician and a taxpayer and a scientist, don’t want to pay for other people to have routine vitamin D levels checked or other unnecessary health screenings, like yearly cholesterol screenings, nor do I want to pay for other equally ineffective and unscientific services that various industries and patients will sue for in such an environment, like acupuncture, reflexology, aromatherapy, etc.
When the government provides an essential service, like military protection of the country, it does so though through micromanagement of services and personnel. In order to guarantee that citizens would have equal access to certain medial services, it would be necessary for the government to regulate the types and quantities and locations of medical services and personnel throughout the country. For example, a cardiologist might be required to move his family to live in a certain area so that there was a legally equitable distribution of cardiologists. This type of conscription already occurs in other countries, such as the United Kingdom. The more that a service like healthcare is viewed as a fundamental right, the more likely it is that these types of infringements on the rights of others will occur.
If healthcare is a constitutional right, then what else might be? For many citizens, house or car ownership is fundamentally more important; the right to have a job or food or free education might be more important; the right to use the Internet or have a gym membership are strongly related to quality of life and equal access; the right to take vacations or go to the movies lead to happiness and fulfillment. What is the standard by which we should determine what is a fundamental right and what is not? Are all things that contribute to quality or quantity of life fundamental rights? If so, and since I believe that laughter is the best medicine, then the government should provide free access to comedy shows and comedic movies to all US citizens. Oh, and hot tubs.
Such is the slippery slope of redefining what a fundamental human right is; remember, a right is not a thing possessed that can be removed. The government does not give rights to anyone; as such, a right is not a thing that can be given such as a comic book or a Pap smear or a new car.
Imagine if car ownership were considered a fundamental human right. It is hard to be a participant in our democracy in most parts of the country without a vehicle. Safe transport is often the key to a good job and access to many other things in life, like healthcare, education, companionship, and even access to the hospital and the doctor’s office or pharmacy – things that directly contribute to our health, happiness, and well-being. Which car should the government give us? Should we all get Kia Rios or Porsche 911s? Can I apply my Kia money towards the cost of a Porsche if I want to do so? Will the government also pay for gasoline, maintenance, and insurance? How often will I get a new car? Will there continue to be competition in the car industry which has had the natural effect of driving down price and increasing quality and innovation? Or will we go the way of the former Soviet Union and have just a handful of rust-buckets in the name of equal car ownership?
The healthcare segment of American society has incredible problems. Thinking of healthcare as a fundamental right solves none of those problems. A single-payer system might indeed be the right answer, but not because healthcare is a fundamental human right but rather because it might have economic advantages and it might save some responsible citizens from being victimized by irresponsible citizens. What do these inflammatory words mean? Well, when one person chooses not to buy health insurance and then smoke cigarettes or rides a motorcycle without a helmet and harms himself, the tax payers are often left to pick up the tab. So the citizens of the country might come together and decide that it’s best to provide healthcare for everyone to create a large risk pool and help control costs. But such a system comes at a cost and a loss of rights that citizens should agree to. Various European social democracies have taught us over the last 20 years or so that such efforts face significant challenges and they must necessarily be limited in order to remain affordable (recall the economic collapse of Greece or the French riots over €1 prescription copays).
In the United States, many have fancied the idea of “Medicare-for-all” as a way of creating a single-payer system. Medicare is a very imperfect system; it does not pay for birth control, cancer screenings, and prescription drugs that most other insurance plans do cover. It is by no means a free healthcare system to its enrollees. Most patients still pay premiums, deductibles, and significant out-of-pocket expenses. In 2015, Medicare provided this imperfect coverage to 55 million citizens; this is roughly 1/6 of the US population. It provided this coverage at a tax payer cost a $540 billion dollars or about 15% of the $3.7 trillion federal budget. In other words, to expand Medicare to the entire population, as imperfect and minimalistic as it is, would cost about $3.2 trillion as of 2015 costs, which is more than all of the revenue collected by the Treasury Department in that year. Of course we would save the 9% of the federal budget spent on Medicaid using the 2015 budget, but it would still require a federal budget of approximately $6 trillion to pull off such a system.
Where does that $6 trillion budget come from? There are approximately 120,000,000 taxpayers in United States, though many of these taxpayers actually receive a net refund due to tax credits. Still, that represents $50,000 of tax collections from every single person who pays taxes in the United States, each year. Want to make the rich pay for it? The threshold for being among the top 10% of income earners in the United States is $77,500; so even the top 10% can’t afford $50,000 per year in taxes. That’s before we even consider making higher education free or forgiving the $1.2 trillion of student loan debt. Here’s another way of thinking about it: every working citizen in the United States, added together, only makes about $9 trillion per year; the federal government would have to take two-thirds of all of this money in order to provide Medicare for all and pay the other government expenses.
So what we really need is a dramatic cut in the cost of healthcare. We need a system that incentivizes patients to do things that are good for their health, like exercise, lose weight, or stop smoking. From a budgetary perspective, we need more taxpayers in the US economy. Some 94 million able-bodied Americans are not in the workforce and at least 15 million of these are looking for a job or would look for a job in a better economy. Every taxpayer added helps to lower the expenses of healthcare and solve the universal coverage problem. During the time of the implementation of the Affordable Care Act (ACA), the US debt grew from about $11 trillion to about $20 trillion today. This occurred without providing coverage to 31 million Americans with another 20 million having such high deductibles that the insurance went mostly unused. Costs exploded, particularly the costs of prescription drugs. The real problem with the ACA was that it did nothing to drive down costs but essentially put the comic book creators in charge of which comic books everyone should be given.
It doesn’t really matter who pays for healthcare unless the costs are controlled. We easily spend twice as much money as we should because the system allows for its exploitation. To use the car analogy again, the ACA essentially mandated that everyone buy a Kia, including people who lived in the city and never drove a car; then, it allows the cost of gas to go up so much that even people who needed the car and had one could never afford to drive it; finally, not only did the cost of gas become prohibitive, but the Kia itself saw its price rise from $12,000 to $50,000, while the top third of taxpayers and employers were compelled to buy a car for themselves and buy the cars for the bottom two-thirds of the population. So strapped with new car-buying expenses, that part of the population had little money to invest elsewhere.
If we really believe in the value of universal car ownership, we would’ve been better served to give everyone a $10,000 tax credit that they could take advantage of if they wanted to purchase a car. Many would buy a used car while others would apply the credit towards a Cadillac. But under the ACA, insurance companies were actually incentivized to increase costs because their profit margins were limited to a percent of total expenditures; so in order to make more money, they had to grow the size of the healthcare economy (and thereby get a fixed percent of a bigger number). They did this by making the ACA provide mandated coverage certain “preventative” services, many of which have no evidence-basis that demonstrates need or efficacy. Consumers took advantage of these “free” services and drove up the cost of healthcare while total life expectancy in the United States actually dropped for the first time in history. Drug costs rose rampantly and market controls on costs throughout the industry were eradicated since payment was guaranteed by law.
It may sound like I am against a single-payer system; I am not. But a single-payer system is not something that the United States can afford under the current conditions. In countries where a single-payer system has thrived, such as Finland, there are significant cost controls in place and the population itself values many aspects of healthcare very differently than we do in the United States. They spend far less money on end-of-life care and, as a society, promote death with dignity. They have far cheaper prescription drug costs. They don’t promote over-utilization of tests and interventions. They practice medicine that is more evidence-based. These are the issues that need to be addressed in this country. If healthcare were cheaper, access would improve and costs could be cut in half. Combine this with higher rates of employment and a higher tax payer base, and then the problems quickly fix themselves. This requires economic policies that are pro-growth, and it requires physicians who are willing to fundamentally change the way they practice medicine in the United States.
Every time I hear a physician argue that we should have a single-payer system, I envision a comic book writer demanding that the government give everyone a copy of his comic book; the quality of care being delivered by physicians in the United States is, after all, truly comical. About 80% of physician-patient encounters involve substandard care. Screening tests and diagnostic tests are over-utilized. Expensive, branded prescription drugs are far overused; drugs in general are over-utilized. Far too many surgeries are performed. Patients are exploited at the end of life and not allowed to die with dignity. Healthcare in the United States is a big business, far more pernicious than, say, the auto industry. The Affordable Care Act was written by the insurance companies, hospitals, and pharmaceutical companies. It is not science-based and its recommendations and requirements are not science-based. It further promoted a system that profits on over-utilization of services.
There are lots of ways to improve our healthcare problems; none of them are being discussed by politicians on either side of the aisle in Washington, DC. I think most people realize this. What most people don’t realize is that the solutions aren’t being discussed either by the American Medical Association, The American Hospital Association, and other service organizations that are supposed to care about healthcare in the United States. These are special interest groups no better than those interest groups which serve other industries in the United States. In fact, they are worse than organizations like the Comic Book Industry Alliance, because they shroud their economic interests in pseudo-science and pseudo-moralistic self-righteousness.
It’s time for patients to start advocating for themselves and stop being abused by politicians and an industry that seeks to exploit them.