AMA Journal of Ethics^®

At the 1992 Republican National Convention in Houston I marched down the main street of the Texas Medical Center with a group chanting "Health care is a right." In those days it seemed as if the US would adopt a universal health plan. Thirty-seven million people were uninsured and millions more lived in danger of losing benefits. Something would happen, surely. But, as Daniel Callahan has reflected, "Surely nothing, it turned out. No plan made it through Congress then—not a single bill, not a single reform. By 1997, the 37 million uninsured had grown to 41 million and only one other bill had been passed; the 2 presidential candidates in 1996 had all but ignored the issue"¹ While no universal coverage came out of Clinton's plan, it inadvertently galvanized the private sector in an unsurpassed way. Today, 12 years and 2 convention seasons later, health care reform seems low on the policy radar in comparison to 1992 and there are 45 million uninsured Americans. Does this mean that it is time to claim health care as a right again? For me, the idealism of marching days are replaced with worry—degrees of separation between me and the problem have narrowed as people close to me lose jobs and benefits, and I wonder how to keep them healthy. For many today, issue-specific discussions are replacing philosophical claims. At the 2004 Republican Convention it is unlikely that there will be a health care rights march.

Framing the Need for Reform

In the United States health care is not a right. Most Americans access health care through workplace benefits or public sector programs such as Medicare, Medicaid, and the Veterans Administration. There are post World War II Western democracies with state welfare systems that incrementally installed health care as a national right, however they are struggling with difficult decisions determined by technology and inflation as well.¹ Framing a public problem too broadly can inhibit a dialogue for change. Start, for example, with the question: "What is health?" Answers vary from the narrow, such as "the absence of disease," to the very broad, "harmony between a human organism and his or her physical and emotional environment." Now consider "What is health care?" Answers could vary from "systemic delivery of clinical services" to "an essential civil right for all Americans." While the premise that health care is a right can be argued on moral and philosophical grounds, it also has the ability to alienate solution-driven policy action. Equating health care with inalienable rights—that is to say that health care is a part of the pursuit of life, liberty and happiness—runs the risk of instigating a broad dialogue on national culture and individual rights that distracts policy initiatives from immediate problems. What sounds ideally good to some leads others to fear legal mandates encouraging abuse of a system already in crisis. The impetus for health care reform may be better construed on commonsense, rather than philosophical, grounds. When times are tough, experience trumps idealism. Among the many practical reasons why the US must initiate substantial health care reform are (1) to remain economically competitive in a global economy and (2) to maintain essential public infrastructure in emergency services and medical education.

Rising Health Care Costs and Global Competition

The patchwork approach to access is becoming dangerously vulnerable as the United States is forced to compete in a global economy. US job growth is slowing, and the impact of rising health care costs on employers is considered a significant factor. Competition for cheaper labor has extended itself to white collar jobs in the Internet age. The New York Times² reports that corporate decision makers must factor in health care costs that rise at a pace 3 or 4 times the rate of inflation, and this increases labor costs as wages remain stagnant. In a standoff between health care benefits and wages, health care impacts the entire economic system. As the cost of health care benefits rises, fewer and fewer people have them. US Bureau of Labor Statistics data indicate that, in the last decade, the percentage of employees in private industry enrolled in company health plans has dropped from over 60 percent to just over 40 percent.² Couple this with the fact that many Americans are transitionally uninsured if they lose or change jobs, and the numbers rise.³ If these trends continue, the burden on workplace benefits will drive up both labor costs and ultimately put the US at a competitive disadvantage internationally.

Essential Public Safety

The federal Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) established the right to emergency medical treatment. This is the only common law annexing a right to health care in the US. Consequently, the cost of covering those with no insurance is being shifted to the most vulnerable links in the health care sector—public hospital emergency rooms. Emergency systems all over the US are crashing. In California, 70 hospital emergency rooms have closed since 1990. Dr. Jack Lewin, President of the California Medical Association reports that 500 hospitals in the state are "on the verge of a whole series of unraveling events. Uncompensated health care affects everyone in the system. No place is safe when you have large volumes of people who need care, but there's no one to pay for it."⁴ Every state is facing the burden of charity care, with the ER as a focal point. How then would the country deal with a major emergency? The vulnerability of the health sector is inherently linked to national security. Public sector hospitals are also the backbone of resident training programs. If the country is to keep its vital infrastructure intact, it must move primary care out of the ER.

In summary, the impetus for health care reform has to begin with a commonsense approach to problem solving. Claiming health care as a right is valid philosophically—life, liberty, and happiness are contingent upon health in the abstract. However, US policy problems are specific and should be discussed with particular solutions in mind. As Michael Walzer contends, civil society is a project within projects and the "devil is in the details."⁵