Is Health Care a Right?
The United States' current debate over healthcare has led to the question of whether healthcare is a fundamental right. The high cost of healthcare, even with insurance, is prohibitive for many Americans. However, some see healthcare access as a right, but the cost is a burden that individuals should pay, rather than the taxpayer. A right to healthcare, from a conservative standpoint, would allow both the deserving and the undeserving to benefit. A more liberal approach sees healthcare as a necessity, much like the potable water that the government must provide. The balance must be found over maintenance of the belief that collective action results in collective benefit. Medicare, as a system where everyone pays in, is perceived more favorably to Medicaid, as all Americans benefit from the system past age 65. 

No other country in the world has built its health-care system this way, and, in the era of the gig economy, it’s becoming only more problematic. Between 2005 and 2015, according to analysis by the economists Alan Krueger and Lawrence Katz, ninety-four per cent of net job growth has been in “alternative work arrangements”—freelancing, independent contracting, temping, and the like—which typically offer no health benefits. And we’ve all found ourselves battling over who deserves less and who deserves more.

The Berkeley sociologist Arlie Russell Hochschild spent five years listening to Tea Party supporters in Louisiana, and in her masterly book “Strangers in Their Own Land” she identifies what she calls the deep story that they lived and felt. Visualize a long line of people snaking up a hill, she says. Just over the hill is the American Dream. You are somewhere in the middle of that line. But instead of moving forward you find that you are falling back. Ahead of you, people are cutting in line. You see immigrants and shirkers among them. It’s not hard to imagine how infuriating this could be to some, how it could fuel an America First ideal, aiming to give pride of place to “real” Americans and demoting those who would undermine that identity—foreigners, Muslims, Black Lives Matter supporters, feminists, “snowflakes.”

Our political debates seem to focus on what the rules should be for our place in line. Should the most highly educated get to move up to the front? The most talented? Does seniority matter? What about people whose ancestors were cheated and mistreated?

The mistake is accepting the line, and its dismal conception of life as a zero-sum proposition. It gives up on the more encompassing possibilities of shared belonging, mutual loyalty, and collective gains. America’s founders believed these possibilities to be fundamental. They held life, liberty, and the pursuit of happiness to be “unalienable rights” possessed equally by all members of their new nation. The terms of membership have had to be rewritten a few times since, sometimes in blood. But the aspiration has endured, even as what we need to fulfill it has changed.

When the new country embarked on its experiment in democracy, health care was too primitive to matter to life or liberty. The average citizen was a hardscrabble rural farmer who lived just forty years. People mainly needed government to insure physical security and the rule of law. Knowledge and technology, however, expanded the prospects of life and liberty, and, accordingly, the requirements of government. During the next two centuries, we relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

Health care has been the cavernous exception. Medical discoveries have enabled the average American to live eighty years or longer, and with a higher quality of life than ever before. Achieving this requires access not only to emergency care but also, crucially, to routine care and medicines, which is how we stave off and manage the series of chronic health issues that accumulate with long life. We get high blood pressure and hepatitis, diabetes and depression, cholesterol problems and colon cancer. Those who can’t afford the requisite care get sicker and die sooner. Yet, in a country where pretty much everyone has trash pickup and K-12 schooling for the kids, we’ve been reluctant to address our Second World War mistake and establish a basic system of health-care coverage that’s open to all. Some even argue that such a system is un-American, stepping beyond the powers the Founders envisioned for our government.

In fact, in a largely forgotten episode in American history, Thomas Jefferson found himself confronting this very matter, shortly after his Inauguration as our third President, in 1801. Edward Jenner, in England, had recently developed a smallpox vaccine—a momentous medical breakthrough. Investigating the lore that milkmaids never got smallpox, he discovered that material from scabs produced by cowpox, a similar condition that afflicts cattle, induced a mild illness in people that left them immune to smallpox. Smallpox epidemics came with a mortality rate of thirty per cent or higher, and wiped out upward of five per cent of the population of cities like Boston and New York. Jefferson read Jenner’s report and arranged for the vaccination of two hundred relatives, neighbors, and slaves at Monticello. The President soon became vaccination’s preëminent American champion.

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But supplies were difficult to produce, and the market price was beyond the means of most families. Jefferson, along with his successor, James Madison, believed in a limited role for the federal government. They did not take expanding its power and its commitments lightly. By the time Jefferson finished his two terms as President, however, city and state governments had almost entirely failed to establish programs to provide vaccines for their citizens. Thousands of lives continued to be lost to smallpox outbreaks. Meanwhile, vaccination programs in England, France, and Denmark had dramatically curbed the disease and measurably raised the national life expectancy. So, at Jefferson’s prompting, and with Madison’s unhesitating support, Congress passed the Vaccine Act of 1813 with virtually no opposition. A National Vaccine Agent was appointed to maintain stocks of vaccine and supply it to any American who requested it. The government was soon providing free vaccine for tens of thousands of people each year. It was the country’s first health-care entitlement for the general population. And its passage wasn’t in the least controversial.

Two centuries later, the Affordable Care Act was passed to serve a similar purpose: to provide all Americans with access to the life-preserving breakthroughs of our own generation. The law narrowed the yawning disparities in access to care, levied the taxes needed to pay for it, and measurably improved the health of tens of millions. But, to win passage, the A.C.A. postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth. The prospects and costs for health care in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)? Any of these can work. Each has been made to work universally somewhere in the world. They all have their supporters and their opponents. We disagree about which benefits should be covered, how generous the financial protection should be, and how we should pay for it. We disagree, as well, about the trade-offs we will accept: for instance, between increasing simplicity and increasing choice; or between advancing innovation and reducing costs.

What we agree on, broadly, is that the rules should apply to everyone. But we’ve yet to put this moral principle into practice. The challenge for any plan is to avoid the political perils of a big, overnight switch that could leave many people with higher costs and lower benefits. There are, however, many options for a gradual transition. Just this June, the Nevada legislature passed a bill that would have allowed residents to buy into the state’s Medicaid plan—if the governor hadn’t vetoed it. A similar bill to allow people to buy into Medicare was recently introduced in Congress. We need to push such options forward. Maintaining the link between health coverage and jobs is growing increasingly difficult, expensive, and self-defeating. But deciding to build on what’s currently working requires overcoming a well of mistrust about whether such investments will really serve a shared benefit.

My friend Betsy Anderson, who taught eighth-grade English at Athens Middle School for fifteen years, told me something that made me see how deep that well is. When she first started out as a teacher, she said, her most satisfying experiences came from working with eager, talented kids who were hungry for her help in preparing them for a path to college and success. But she soon realized that her class, like America as a whole, would see fewer than half of its students earn a bachelor’s degree. Her job was therefore to try to help all of her students reach their potential—to contribute in their own way and to pursue happiness on their own terms.

But, she said, by eighth grade profound divisions had already been cemented. The honors kids—the Hillary Clintons and Mitt Romneys of the school—sat at the top of the meritocratic heap, getting attention and encouragement. The kids with the greatest needs had special-education support. But, across America, the large mass of kids in the middle—the ones without money, book smarts, or athletic prowess—were outsiders in their own schools. Few others cared about what they felt or believed or experienced. They were the unspecial and unpromising, looked down upon by and almost completely separated from the college-bound crowd. Life was already understood to be a game of winners and losers; they were the designated losers, and they resented it. The most consistent message these students had received was that their lives were of less value than others’. Is it so surprising that some of them find satisfaction in a politics that says, essentially, Screw ’em all?

I met with Mark, a friend of Arnold’s, at the Union Street Diner, uptown near the campus of Ohio University, which makes Athens its home. The diner was a low-key place that stayed open twenty-four hours, with Formica tables and plastic cups, and a late-night clientele that was a mixture of townies and drunken students. I ordered a cheeseburger and onion rings. Mark ordered something healthier. (He asked me not to use his last name.) The son of a state highway patrolman, he had graduated from Athens High School five years ahead of me. Afterward, he worked as a cable installer, and got married at twenty-three. His wife worked at the Super Duper grocery store. Their pay was meagre and they were at the mercy of their bosses. So, the next year, they decided to buy a convenience store on the edge of town.

Mark’s father-in-law was a builder, and he helped them secure a bank loan. They manned the register day and night, and figured out how to make a decent living. It was never a lot of money, but over time they built up the business, opening gas pumps, and hiring college students to work the counter part time. They were able to make a life of it.

They adopted a child, a boy who was now a twenty-five-year-old graduate of the local university. Mark turned fifty-seven and remained a lifelong conservative. In general, he didn’t trust politicians. But he felt that Democrats in particular didn’t seem to recognize when they were pushing taxes and regulations too far. Health-care reform was a prime example. “It’s just the whole time they were coming up with this idea from copying some European model,” he said. “And I’m going, ‘Oh shit. This is not going to end up good for Mark.’ ” (Yes, he sometimes talks about himself in the third person.)

For his health coverage, Mark trusted his insurance agent, whom he’d known for decades, more than he trusted the government. He’d always chosen the minimum necessary, a bare-bones, high-deductible plan. He and his wife weren’t able to conceive, so they didn’t have to buy maternity or contraceptive coverage. With Obamacare, though, he felt forced to pay extra to help others get benefits that he’d never had or needed. “I thought, Well, here we go, I guess I’m now kicking in for Bill Gates’s daughter’s pregnancy, too.” He wanted to keep government small and taxes low. He was opposed to Obamacare.

Then, one morning a year ago, Mark’s back started to hurt. “It was a workday. I grabbed a Tylenol and I go, ‘No, this isn’t going to work, the pain’s too weird.’ ” It got worse, and when the pain began to affect his breathing he asked his wife to drive him to the emergency room.