Given the weekend failure of the Republican push to repeal/replace/modify Obamacare, it’s appropriate and timely that my first-ever blog effort be devoted to the topic of health care policy. But it quickly became clear to me that some background and context, all too often missing in today’s public discourse, are first required. So this will be a three-parter with the first two blogs devoted to addressing threshold health care policy questions.
The most fundamental threshold question of all is both straightforward and essential to ask: Should health care be a right in a modern, civilized society? In a classic but very readable 1975 book entitled Equality and Efficiency: The Big Tradeoff, economist Arthur Okun laid out the core source of tension inherent in a modern capitalist democracy – the interface between what he calls “the domain of dollars” (the marketplace) and “the domain of rights” (universally distributed entitlements and privileges that cannot be bought and sold). In the US the latter includes basic freedoms like speech and assembly, but also resource-using entitlements such as police and fire protection and public education that are paid for collectively through taxation. Every society must decide where to draw the boundary lines between the domain of rights and that of the marketplace.
So on which side of the boundary line should health care fall? The answer has economic, political and even philosophical dimensions, and reasonable (as well as unreasonable!) people obviously can disagree on the details. Almost no one today of any political persuasion argues that the unconstrained marketplace should determine life, death or survival when individuals are confronted with serious illness or injury. Yet unlike most industrialized countries, American public policy has still stopped well short of formally declaring a right to quality health care for all. It’s tempting to conclude that what Okun noted in 1975 would still seem largely true today in the US, namely that the right to quality health care “has been kept fuzzy, because its fulfillment could be very expensive.”
But I’m not so sure that conclusion would be valid. After all, almost a decade before Okun wrote Equality and Efficiency the US adopted a national health insurance program for senior citizens and some others. Soon thereafter the Medicaid program of health insurance for those with lower incomes was added. Eligibility and benefits for both programs have generally expanded over time, especially in the case of Medicare in 2006 and Medicaid under the Affordable Care Act of 2010. Medicare and Medicaid each now enrolls more than 55 million Americans (there are some dual enrollees). In addition, in 2014 66% of nonelderly US workers received an offer of health insurance coverage from their employer. And especially noteworthy for the question at hand although less well-known, the Emergency Medical and Treatment Labor Act of 1986 (EMTALA) expressly forbids denial of care by hospitals of indigent or uninsured patients based on inability to pay. Finally, the recent failure to repeal Obamacare provides further confirmation that, as David Leonhardt notes in today’s New York Times, “Americans are generally not willing to go backwards on matters of basic economic decency.” Even conservative commentator Jennifer Rubin concluded the following after the Obamacare repeal failure: “Americans now think government should help guarantee coverage for just about everyone.”
So where does that leave us on the fundamental question of should health care be a right in the US, substantially removed from Okun’s domain of dollars? Of course this oversimplified question masks important complexities regarding the minimum quality of care deemed socially necessary. But putting that complication aside for now, the public policy activity of the last 50 years seems to indicate a pretty clear emerging consensus that the answer is Yes, even if rarely asked or answered this explicitly.* But that’s just the first threshold question, and the affirmative answer now requires us to ask further questions about the nature of the health care and health insurance markets in the US. On to Universal Health Care Part 2!
*Edit: Some are beginning to ask and answer explicitly. Having apparently read this blog entry 😋, on April 1 respected conservative commentator Charles Krauthammer stated “A broad national consensus is developing that health care is indeed a right. This is historically new. And it carries immense implications for the future.”
Garygrams 
Well written and carefully considered. I look forward to reading the subsequent posts.
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