Unlike in other developed countries, health care is not an explicit legal right in the United States, nor is it guaranteed by our Constitution. But is it a moral right? What does our history tell us? Have our values as a nation changed? Will they change in the future? And what about those of us who work in health care? What is our obligation to those who cannot afford care?
I believe it’s time to discuss the moral issue of access to affordable health care in the United States — and our obligation as health care professionals to advocate for universal care.
Our Climate of Fear
The United States is unique among the developed nations as the only one without a national health insurance program or a guarantee of health care for all. Not coincidentally, the quality of health care in the United States is lowest among all developed nations and compared with many less developed nations as well.
The ongoing national debate about health care in the United States has many dimensions, but the main focus has been on the cost of care, insurance, and the role of government. Not surprisingly, the reason health care has become such a pressing issue in this country has everything to do with skyrocketing costs: The cost of health care is higher in the United States than anywhere else in the world.
Health care spending accounts for almost one-fifth of the U.S. economy — an amount that is, quite frankly, unhealthy. Some 40% of Americans rely on Medicare and Medicaid to receive health care, and tens of millions of Americans remain uninsured or underinsured. Serious illness remains the number one cause of personal bankruptcy in the United States. The extraordinarily high cost of health care forces chronically or seriously ill people to confront horrible choices, such as giving up everything they have in the hope of continuing to live or risking death by foregoing health care so that their loved ones will not suffer further financial hardship.
It is inconceivable that the amount of money currently spent on health care in this country, the most in the world, is not enough to provide health care for all. It isn’t really a question of money — the money is already being spent. The harsh reality is that health care in the United States is a rip-off, with outrageous costs and worsening quality. We are not getting our money’s worth, and the status quo is unsustainable.
To those who do not work in health care, it must seem strange that health care professionals and provider organizations have not historically been outspoken champions of health care for all. I have yet to meet anyone who works in health care who doesn’t truly believe in the benefit to others of what we do. Moreover, most people who work in health care consider it a calling — a part of their life’s mission.
If we feel so strongly about the necessity of what we do, then why wouldn’t we want everyone to have access to our care? Why would we deny it to anyone? To do so is to deny ourselves, to undermine our professions and thwart our life’s work. Yet throughout most of the 20th century the efforts to create a national health insurance program, even the creation of Medicare and Medicaid, have been largely opposed by the American Medical Association and other health care organizations.
Fear — the fear of a loss of power and control — has driven the opposition in the past. Although in recent years all the major physician organizations and most of the other provider organizations have supported the Affordable Care Act and the expansion of Medicaid, there has never been a steady drumbeat on the part of health care organizations, no national campaign to ensure that all Americans can get what we have to offer.
Likewise, that same fear continues to motivate many others, including our patients, to oppose health care for all. Too many fear that if millions of others gain access to care, they may be less likely to get the care they want and need — health care has become a zero-sum game.
Our Public Health
The foundational values of this nation, made explicit in documents such as the Declaration of Independence and the Constitution, hold that all are created equal, and that life, liberty, and the pursuit of happiness are inalienable, God-given rights. The history of this nation, however, has been a struggle to achieve these ideals. Women, African-Americans, and members of many ethnic and minority groups have historically been denied such rights, and they have been denied access to health care as well, often regardless of their ability to pay.
In the face of the historical discrimination against millions of Americans who have been denied access to adequate care, communities and religious organizations have developed and maintained a health care infrastructure that for centuries has striven to make health care potentially available to all, including the poor and destitute. Private religious organizations, benevolent societies, trade associations, and other groups, along with local and state governments, have built hospitals, nursing homes, clinics, and parish nurse programs with names calling on faith, hope, love, and charity — all descriptions of an underlying moral imperative.
As a matter of professional courtesy, physicians and others took pride in offering free services at their discretion to patients, and they worked with patients to avoid economic devastation caused by health care. Stories still abound from previous periods of national hardship such as the Great Depression, when sick people paid what they could for health care — be it a chicken, a dozen eggs, or a load of wood.
Today, it is almost shocking to imagine buying any amount of health care, even a few aspirins, for the price of a live chicken. Yet today’s skyrocketing health care costs have made it virtually impossible for any but the wealthiest to pay for health care out of pocket.
Nor can charitable health care organizations afford to provide services to all their patients from donations alone. All depend on payments from insurers or government grants in order to exist. Moreover, charity and charitable donations are discretionary — charitable giving is often highest during times of relative plenty and lowest during economic scarcity. Likewise, a health care system based on charity alone is driven by the priorities and preferences of its donors, not its patients. The recipients of charitable giving are often chosen — that is to say, they are judged based upon their perceived worthiness. And the stigma associated with receiving charity often prevents those in need from seeking or receiving it.
The public health and safety of this nation cannot be guaranteed based upon charity alone. Programs such as Social Security, Medicare, and Medicaid owe their creation to the failure of our combination of market-based health care and charitable giving to ensure access to affordable, high-quality health care to millions upon millions of Americans.
Not only does the sickness of individual Americans undermine their own life, liberty, and pursuit of happiness, but their inability to receive care for contagious illnesses makes others sick as well. When the right to life, liberty, and the pursuit of happiness for every American is compromised in this fashion, it is inconceivable that these inalienable rights can exist for anyone unless we have some right to health care for all.
From a public health as well as quality-of-care perspective, everyone suffers when health care of the kind we want for ourselves and our families is only available to some — and everyone benefits when we are able to always do our best for everyone. We cannot expect the quality of health care to improve in any meaningful way for anyone so long as different care is provided to different people based upon their different ability to pay (or their insurers’ willingness to pay for them).
Care and treatment are now determined by factors other than what we consider to be best practice. Such inconsistent care makes effective measurement of quality of care as well as performance improvement impossible. With so much variability in care provision, it’s impossible to evaluate the effectiveness of care or to implement effective change. Eliminating this undesirable variability is a basic prerequisite for quality assurance and performance improvement.
Our Moral Imperative
Beneficence, justice, and autonomy — the ethical underpinnings of health care and of every decent society — are undermined when some are made to suffer unnecessarily because of the condition of their birth or their health. It is unjust to judge people or discriminate against them based upon their health. It is unjust to punish someone because of a pre-existing medical condition, particularly one that was inherited.
Universal access to care and the pursuit of high quality care for everyone are moral imperatives for all of us. Health care providers and practitioners have a special obligation as well as a special interest in advocating strongly for this basic human right. We have a responsibility to help shape and guide a just, compassionate health care delivery system for all.
Arguing about the legitimacy of each persons’ right to life, liberty, health, and the pursuit of happiness is simply un-American. We need to say proudly that everyone deserves the best health care we can provide because everyone is worthy and always will be. It is both necessary and worthwhile that we discuss, debate, and continuously improve our public and private health care plans, policies, programs, and payment systems.
Dr. Evans is a full-time long-term care physician in Charlottesville, VA, and medical director of two skilled nursing facilities. A past Society president, he serves on the Caring for the Ages Editorial Advisory Board.