health care is a right essay

Exploring what works, what doesn’t, and why.

Healthcare is a human right – but not in the United States

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The Supreme Court’s ruling on Dobbs v. Jackson in June is just the latest blow to health rights in the United States. National medical associations in the U.S. agree that abortion is essential to reproductive healthcare. So why would abortion not be protected as such? Because the U.S. does not, and never has, protected a right to health.  

Good health is the foundation of a person’s life and liberty. Injury and disease are always disruptive, and sometimes crippling. We might have to stop working, cancel plans, quarantine, hire help, and in cases of long-term disability, build whole new support systems to accommodate a new normal.

The U.S. remains the only high-income nation in the world without universal access to healthcare. However, the U.S. has signed and ratified one of the most widely adopted international treaties that includes the duty to protect the right to life. Under international law, the right to life simply means that humans have a right to live, and that nobody can try to kill another. Healthcare, the United Nations says, is an essential part of that duty. In 2018, the U.N. Committee on Civil and Political Rights said the right to life cannot exist without equal access to affordable healthcare services (including in prisons), mental health services, and notably, access to abortion. The U.N. committee mentioned health more than a dozen times in its statement on the right to life.

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The bottom line is: the U.S. can’t claim to protect life if it fails to protect health. And it has consistently failed on all three of the U.N.’s measures— the latest being access to abortion.

In the U.S., our debates around healthcare, and especially abortion, are hampered by a lack of right to health. Instead, the Supreme Court in 1973 protected access to abortion through the rights to privacy and due process, not health. Privacy is mentioned only twice by the U.N. committee commentary on the right to life.

Since Dobbs, several state legislatures have declared it fair game to criminalize abortion procedures even in cases where pregnancy threatens maternal health or life. Despite ample evidence that restrictive abortion laws lead to spikes in maternal mortality and morbidity—core public health indicators—the Court prior to the Dobb’s decision has defended abortion as merely a matter of privacy, not health or life. We know this is a myth. Abortion is deeply tied to the ability to stay healthy and in some cases, alive.

Regardless, our political parties remain deeply polarized on access to healthcare, including abortion. But lawmakers should know there is historical backing in the U.S. for elevating a right to health. None other than U.S. president Franklin D. Roosevelt, first proposed healthcare as a human right in his State of the Union address in 1944, as part of his ‘Second Bill of Rights.’ His list featured aspirational economic and social guarantees to the American people, like the right to a decent home and, of course, the right to adequate medical care.

Eleanor Roosevelt later took the Second Bill of Rights to the U.N., where it contributed to the right to health being included in the Universal Declaration of Human Rights in 1948. The right to health is now accepted international law, and is part of numerous treaties, none of which the U.S. Senate has seen fit to ratify. The U.S. conservative movement has historically declared itself averse to adopting rights that might expand government function and responsibility. In contrast, state legislatures in red states are keen to expand government responsibility when it comes to abortion. The conservative movement condemns government interference in the delivery of healthcare—except when it comes to reproductive health. The American Medical Association has called abortion bans a “direct attack” on medicine, and a “brazen violation of patients’ rights to evidence-based reproductive health services.”

Excepting access to abortion, U.S. lawmakers have largely left healthcare to the markets, rather than government. True, the government funds programs like Medicaid and Medicare but these programs vary significantly in quality and access by state, falling far short of providing fair, equitable, universal access to good healthcare.

The only two places where the U.S. government accepts some responsibility for the provision of healthcare are 1) in prisons and mental health facilities; and 2) in the military. While healthcare services in the U.S. prison system are notoriously deficient, they nevertheless exist and are recognized as an entitlement, underpinning the right to life. As an example, in 2005 a federal court seized control of the failing healthcare system in California’s Department of Corrections citing preventable deaths. In the military, free healthcare is an entitlement, and the quality of that care is deemed good enough even for the U.S. president.

So why doesn’t everyone in the U.S. have the same rights?

It is an uphill battle in a country that sees health and healthcare as a private matter for markets and individuals to navigate. But if we want to improve public health in the U.S. we need to start legislating healthcare as a right—and recognize that achieving the highest possible standards of public health is a legitimate government function.

photo: Tony Gutierrez / AP Photo

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“If you have your health, you have everything,” the classic saying goes. This is obviously not perfectly accurate, as many healthy people certainly do not have everything. However, it does reflect the connection that the right to health has to other human rights, and the interdependency that all human rights have with each other. Poor health can keep us from going to school or to work, caring for our families, or fully participating in our communities. States are responsible for respecting, protecting and fulfilling their human rights obligations, with international, regional, national and local actors supporting states and holding them accountable. The right to health exists, distinct from traditional political and civil rights, and there is an entire global apparatus built around making the right meaningful and real. I will spend this year exploring and evaluating these systems and human rights frameworks, seeking to understand how to best implement the human right to health.

So what does the right to health mean? States are obligated to fulfill the right through the provision of access to health care and hospitals, safe drinking water and sanitation, and food and housing. It entitles people to a system of disease prevention, treatment and control with access to essential medicines. It extends beyond these entitlements to people’s freedoms, such as the freedom to say no to medical treatment. It relates to a range of health determinants , including gender equality, healthy working conditions, and health-related education. The right to health is not the right to be healthy, which is outside of states’ direct control. This is why it is referred to as the right to the “highest attainable standard” of health. UN bodies, specialized agencies, the private sector, and even health professionals have responsibilities related to the right to health. The nature of businesses’ specific obligations are a bit unclear, and states are ultimately accountable for human rights violations, but there is a growing effort to define human rights standards that are applicable to businesses.

The right to health is idealistic in many ways, but it can be monitored and enforced. Accountability and monitoring take place at national, regional and international levels with involvement from states, NGOs, national human rights institutions, international treaty bodies and UN Special Rapporteurs. At the national level, administrative and political mechanisms contribute to accountability, such as national health policies and budgets. National judicial mechanisms can provide legal remedies to individuals when their rights are violated. Incorporating the right to health into national or subnational laws allows courts to judge violations with direct reference to the ICESCR. For example, Argentinian courts have ruled that the state must guarantee an available supply of antiretroviral drugs to people who are HIV-positive. Additionally, the Treatment Action Campaign in South Africa illustrates the ability of NGOs to use advocacy and social mobilization to fight for the right to health in its work for equal access to HIV treatment. In 2001, the Pretoria High Court ruled in favor of the Treatment Action Campaign and held that government restrictions on the drug nevirapine were unconstitutional, since the drug was proven to be effective but the government decided that it could only be distributed at two research sites. The Constitutional Court upheld the Pretoria ruling, stating that the government’s policy did not meet South Africa’s constitutional obligations to provide access to health care that “takes account of pressing social needs.” The government then removed nevirapine restrictions at public hospitals and clinics and created a comprehensive program to progressively realize the rights of pregnant women to prevent mother-to-child HIV transmission.

Through this series of blog posts, I will write about the usefulness of the human rights framework to global health endeavors. I strongly believe that, as the UN High Commissioner on Human Rights and WHO have stated , “The right to health is a fundamental part of our human rights and of our understanding of a life in dignity.” Physical and mental health allow adults to work and children to learn. The right to health cannot be realized without the realization of other rights that exist at the root of poverty, such as the rights to food, housing and water. Through exploring victories and pitfalls, I want to improve our understanding of how to best implement the right to health in practice. Achieving health equity worldwide requires innovative and interdisciplinary work, which necessitates a comprehensive understanding of international human rights law and governance.

Julia Kaufman is a T’18 Alumna and a 17′-18′ Human Rights Scholar at the Institute.

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Is Health Care a Right?

By Atul Gawande

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right. The responses were always interesting.

A friend had put me in touch with a forty-seven-year-old woman I’ll call Maria Dutton. She lived with her husband, Joe, down a long gravel driveway that snaked into the woods off a rural road. “You may feel like you are in the movie ‘Deliverance,’ ” she said, but it wasn’t like that at all. They had a tidy, double-wide modular home with flowered wallpaper, family pictures on every surface, a vase of cut roses on a sideboard, and an absurdly friendly hound in the yard. Maria told me her story sitting at the kitchen table with Joe.

She had joined the Army out of high school and married her recruiter—Joe is eleven years older—but after a year she had to take a medical discharge. She had developed severe fatigue, double vision, joint and neck pains, and muscle weakness. At first, doctors thought that she had multiple sclerosis. When that was ruled out, they were at a loss. After Joe left the military, he found steady, secure work as an electrical technician at an industrial plant nearby. Maria did secretarial and office-manager jobs and had a daughter. But her condition worsened, and soon she became too ill to work.

“I didn’t even have enough energy to fry a pound of hamburger,” she said. “I’d have to fry half of it and then sit down, rest, and get up and fry the rest. I didn’t have enough energy to vacuum one room of the house.” Eventually, she was diagnosed with chronic-fatigue syndrome and depression. She became addicted to the opioids prescribed for her joint pains and was started on methadone. Her liver began to fail. In 2014, she was sent two hundred miles away to the Cleveland Clinic for a liver-transplant evaluation. There, after more than two decades of Maria’s deteriorating health, doctors figured out what the problem was: sarcoidosis, an inflammatory condition that produces hardened nodules in organs throughout the body. The doctors gave her immunosuppressive medication, and the nodules shrank away. Within a year, she had weaned herself off the methadone.

“It was miraculous,” she said. In middle age, with her daughter grown up and in the Army Reserves herself, Maria got her life back and returned to school. All along, she’d had coverage through her husband’s work. “They have amazing insurance,” she said. “I think one year the insurance paid out two hundred thousand dollars. But we paid out, too.”

This was an understatement. Between a six-thousand-dollar deductible and hefty co-pays and premiums, the Duttons’ annual costs reached fifteen thousand dollars. They were barely getting by. Then one day in 2001 Joe blacked out, for no apparent reason, at a Girl Scout meeting for their daughter and fell down two flights of stairs, resulting in a severe concussion. It put him out of work for six months. Given the health-care costs and his loss of income, the couple ran out of money.

“We had to file for bankruptcy,” Joe said. He told me this reluctantly. It took them more than five years to dig out of the hole. He considered the bankruptcy “pretty shameful,” he said, and had told almost no one about it, not even his family. (This was why they didn’t want me to use their names.) He saw it as a personal failure—not the government’s. In fact, the whole idea that government would get involved in the financing of health care bothered him. One person’s right to health care becomes another person’s burden to pay for it, he said. Taking other people’s money had to be justified, and he didn’t see how it could be in cases like this.

“Everybody has a right to access health care,” he allowed, “but they should be contributing to the cost.” He pointed out that anyone could walk into a hospital with an emergency condition, get treated, and be billed afterward. “Yes, they may have collectors coming after them,” he said. “But I believe everybody should contribute for the treatment they receive.”

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Like her husband, Maria leans conservative. In the 2016 election, Joe voted for Donald Trump. Maria voted for Gary Johnson, the Libertarian candidate. But on health care she was torn. Joe wanted Obamacare repealed. She didn’t.

“I am becoming more liberal,” she said. “I believe that people should be judged by how they treat the least of our society.” At her sickest, she had been one of them. But she was reluctant to say that health care is a right. “There’s where the conservative side comes in and says, ‘You know what? I work really hard. I deserve a little more than the guy who sits around.’ ”

A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe. They both told me about people they know who don’t work and yet get Medicaid coverage with no premiums, no deductibles, no co-pays, no costs at all—coverage that the Duttons couldn’t dream of.

“I see people on the same road I live on who have never worked a lick in their life,” Joe said, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.” Maria described a relative who got disability payments and a Medicaid card for a supposedly bad back, while taking off-the-books roofing jobs.

“Frankly, it annoys the crap out of me—they’re nothing but grasshoppers in the system,” Joe said, recalling the fable about the thriftless grasshopper and the provident ant.

The Duttons were doing all they could to earn a living and pay their taxes—taxes that helped provide free health care for people who did nothing to earn it. Meanwhile, they faced thousands of dollars in medical bills themselves. That seemed wrong. And in their view government involvement had only made matters worse.

“My personal opinion is that anytime the government steps in and says, ‘You must do this,’ it’s overstepping its boundaries,” Joe said. “A father, mother, two kids working their asses off—they’re making minimum wage and are barely getting by—I have no problem helping them. If I have someone who’s spent his whole life a drunk and a wastrel, no, I have no desire to help. That’s just the basics.”

Such feelings are widely shared. They’re what brought the country within a single vote of repealing major parts of President Obama’s expansion of health-care coverage. Some people see rights as protections provided by government. But others, like the Duttons, see rights as protections from government.

Tim Williams, one of my closest childhood friends, disagreed with the Duttons. Tim is a quiet fifty-two-year-old with the physique of a bodybuilder—he once bench-pressed me when we were in high school—and tightly cropped gray hair that used to be flame red. He survived metastatic melanoma, in the nineties, and losing his job selling motorcycles, during the great recession. He went through a year of chemotherapy and, later, three years without a job. He can figure out how to fix and build almost anything, but, without a college degree, he had few employment options. Hundreds of job applications later, though, he was hired as an operator at our town’s water-treatment plant, where I visited him.

The plant was built in the nineteen-fifties. We walked among giant pipes and valves and consoles that controlled the flow of water from local ground wells through a series of huge pools for filtration, softening, and chlorination, and out to the water towers on the tallest ridges surrounding the town. The low hum of the pump motors churned in the background.

People don’t think about their water, Tim said, but we can’t live without it. It is not a luxury; it’s a necessity of human existence. An essential function of government, therefore, is to insure that people have clean water. And that’s the way he sees health care. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together.

Before I entered the field of public health, where it’s a given that health care is a right and not a privilege, I had grown up steeped in a set of core Midwestern beliefs: that you can’t get something for nothing, and that you should be reluctant to impose on others and, likewise, to be imposed upon. Here self-reliance is a totemic value. Athens, Ohio, is a place where people brew their own beer, shoot their own deer, fix their own cars (also grow their own weed, fight their own fights, get their own revenge). People here are survivors.

Monna French was one. She was fifty-three years old and the librarian at Athens Middle School. She’d been through a lot in life. She had started a local taxi company with her first husband, but they couldn’t afford health insurance. When she gave birth to her daughter Maggie and then to her son, Mac, the couple had to pay cash, pray that there’d be no unaffordable complications, and try to leave the hospital the next morning to avoid extra charges. When Monna and her husband divorced, litigation over the business left her with no income or assets.

“I had twenty-six dollars, two kids, and a cat,” she said.

She held down five part-time jobs, working as a teaching assistant for three different schools during the day, bartending at night, and selling furniture at Odd Lots department store on weekends, while her parents helped with the kids. Finally, she got the librarian job. It was classified as clerical work and didn’t pay well. But it meant that her family had health insurance, and a roof over their heads. She also met Larry, an iron worker and Vietnam veteran, who became her second husband. He had two children, but he was older and they were grown. Together, Monna and Larry had a child of their own, named Macie. Then, thirteen years ago, Maggie, at age sixteen, was killed in a car accident. Seven years ago, Larry’s son, Eric, who had spina bifida and multiple medical needs, died suddenly in his sleep, at the age of forty.

After twenty-two years as a librarian, Monna still makes only sixteen dollars and fifty cents an hour. Her take-home pay is less than a thousand dollars a month, after taxes and health-insurance contributions. Her annual deductible is three thousand dollars. Larry, now seventy-four, has retired, and his pension, military benefits, and Medicare helped keep them afloat.

For all her struggles, though, Monna is the kind of person who is always ready to offer a helping hand. When I visited her, there were stacks of posters on her porch, printed for a fund-raiser she was organizing for her daughter’s high-school marching band. She raised money for her township’s volunteer fire brigade. She was the vice-president of her local union, one of the largest in the county, which represents school-bus drivers, clerical staff, custodians, and other non-certified workers. She’d been deeply involved in contract negotiations to try to hold on to their wages and health benefits in the face of cutbacks.

“I don’t know anything about health care,” she protested when I asked her for her thoughts on the subject. In fact, she knew a lot. And, as she spoke, I thought I glimpsed a place where the health-care divide might just allow a bridge.

Monna considered herself a conservative. The notion of health care as a right struck her as another way of undermining work and responsibility: “Would I love to have health insurance provided to me and be able to stay home?” Of course, she said. “But I guess I’m going to be honest and tell you that I’m old school, and I’m not really good at accepting anything I don’t work for.”

She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. “They have a card that comes in the mail, and they get everything they need!” she said. “Where does it end? I mean, how much responsibility do tax-paying people like me have? How much is too much?” She went on, “I understand that there’s going to be a percentage of the population that we are going to have to provide for.” When she was a young mother with two children and no home, she’d had to fall back on welfare and Medicaid for three months. Her stepson, Eric, had been on Medicaid and Social Security Disability Insurance before he died. Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid. “If you’re disabled, if you’re mentally ill, fine, I get it,” Monna said. “But I know so many folks on Medicaid that just don’t work. They’re lazy.” Like the Duttons, she felt that those people didn’t deserve what they were getting.

But then we talked about Medicare, which provided much of her husband’s health care and would one day provide hers. That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it.

I asked her what made it different.

“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.

“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.

Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.

The Oxford political philosopher Henry Shue observed that our typical way of looking at rights is incomplete. People are used to thinking of rights as moral trump cards, near-absolute requirements that all of us can demand. But, Shue argued, rights are as much about our duties as about our freedoms. Even the basic right to physical security—to be free of threats or harm—has no meaning without a vast system of police departments, courts, and prisons, a system that requires extracting large amounts of money and effort from others. Once costs and mechanisms of implementation enter the picture, things get complicated. Trade-offs now have to be considered. And saying that something is a basic right starts to seem the equivalent of saying only, “It is very, very important.”

Shue held that what we really mean by “basic rights” are those which are necessary in order for us to enjoy any rights or privileges at all. In his analysis, basic rights include physical security, water, shelter, and health care. Meeting these basics is, he maintained, among government’s highest purposes and priorities. But how much aid and protection a society should provide, given the costs, is ultimately a complex choice for democracies. Debate often becomes focussed on the scale of the benefits conferred and the costs extracted. Yet the critical question may be how widely shared these benefits and costs are.

Arnold Jonas is another childhood friend of mine. Blond, ruddy-faced, and sporting a paunch at fifty-two, he has rarely had a nine-to-five job and isn’t looking for one. The work he loves is in art and design—he once designed a project for the Smithsonian—but what usually pays the bills is physical labor or mechanical work. He lives from paycheck to paycheck. (“Retirement savings? Ha! You’re funny, Atul.”) Still, he has always known how to take care of himself. “I own my house,” he told me. “I have no debts.”

This is a guy who’s so handy that the cars he drives are rehabbed wrecks rebuilt from spare parts—including the old Volvo that he drove to the strip-mall Mexican restaurant near my family’s house, where we were catching up. But when I asked him about health care he could only shake his head.

“I just try not to think about it,” he said. He hadn’t seen a doctor in at least a decade. He got a health-care plan through an insurance-agent friend, but could only afford one with minimal benefits. He wasn’t sure whether he’d got an Obamacare subsidy. “I don’t read the fine print, because it’s going to be completely confusing anyway.” All he knew was that the plan cost him a hundred and ten dollars a month, and the high deductible (however many thousands of dollars it was, it was well beyond his savings account) made doctors’ visits almost out of the question.

“I am lucky I can get my teeth looked at because I’m dating a dental hygienist. But”—here he showed me his white-toothed grin—“I can’t date a dental hygienist and a cardiologist.”

Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life. But here was one that was beyond his control. “The biggest worry I have would be some sort of health-care need,” he said. A serious medical issue would cost him his income. As an independent contractor, he isn’t eligible for unemployment benefits. And, having passed the age of fifty, he was just waiting for some health problem to happen.

So did he feel that he had a right to health care? No. “I never thought about it as a matter of rights,” he said. “A lot of these things we think are rights, we actually end up paying for.” He thinks that the left typically plays down the reality of the costs, which drives him crazy. But the right typically plays down the reality of the needs, which drives him crazy, too.

In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care.

“I think the goal should be security,” he said of health care. “Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here.’ ” He went on, “Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.”

He told me about a friend who’d undergone an emergency appendectomy. “She panicked when she woke up in the hospital realizing it would cost her a fortune,” he said. “Think about that. A lot of people will take a crappy job just to get the health benefits rather than start an entrepreneurial idea. If we’re talking about tax breaks for rich people to create jobs and entrepreneurialism, why not health care to allow regular people to do the same thing?”

As he saw it, government existed to provide basic services like trash pickup, a sewer system, roadways, police and fire protection, schools, and health care. Do people have a right to trash pickup? It seemed odd to say so, and largely irrelevant. The key point was that these necessities can be provided only through collective effort and shared costs. When people get very different deals on these things, the pact breaks down. And that’s what has happened with American health care.

The reason goes back to a seemingly innocuous decision made during the Second World War, when a huge part of the workforce was sent off to fight. To keep labor costs from skyrocketing, the Roosevelt Administration imposed a wage freeze. Employers and unions wanted some flexibility, in order to attract desired employees, so the Administration permitted increases in health-insurance benefits, and made them tax-exempt. It didn’t seem a big thing. But, ever since, we’ve been trying to figure out how to cover the vast portion of the country that doesn’t have employer-provided health insurance: low-wage workers, children, retirees, the unemployed, small-business owners, the self-employed, the disabled. We’ve had to stitch together different rules and systems for each of these categories, and the result is an unholy, expensive mess that leaves millions unprotected.

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.

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.

“They put me in a bed, and eight minutes later I’m out,” he recalled. “I’m dying.” Someone started chest compressions. A defibrillator was wheeled in, and his heart was given a series of shocks. When he woke up, he learned that he’d suffered cardiac arrest. “They said, ‘Well, you’re going to Riverside’ ”—a larger hospital, in Columbus, eighty miles away. “And I went back out again.”

He’d had a second cardiac arrest, but doctors were able to shock him back to life once more. An electrocardiogram showed that he’d had a massive heart attack. If he was going to survive, he needed to get to Columbus immediately for emergency cardiac catheterization. The hospital got him a life-flight helicopter, but high winds made it unsafe to fly. So they took him by ground as fast as an ambulance could go. On the procedure table, a cardiologist found a blockage in the left main artery to his heart—a “widow-maker,” doctors call it—and stented it open.

“The medicine is just crazy good,” Mark said. “By twelve-thirty, I was fixed.”

After that, he needed five days in the hospital and several weeks at home to recover. Although he had to take a pile of drugs to reduce the chance of a recurrence, he got his strength back. He was able to resume work, hang out with his buddies, live his life.

It was only after this experience that Mark realized what the A.C.A. had given him. Like twenty-seven per cent of adults under sixty-five, he now had a preëxisting condition that would have made him uninsurable on the individual market before health-care reform went into effect. But the A.C.A. requires insurers to accept everyone, regardless of health history, and to charge the healthy and the less healthy the same community rate.

“This would have been a bad story for Mark,” he said. “Because the same time you’re being life-flighted is the same time you lose value to an employer. Your income is done.”

He no longer opposed the requirement that people get insurance coverage. Fire insurance wouldn’t work if people paid for it only when their house was on fire, and health insurance wouldn’t work if people bought it only when they needed it. He was no longer interested in repealing protections for people like him.

In this, he was like a lot of others. In 2013, before the implementation of the A.C.A., Americans were asked whether it was the government’s responsibility to make sure that everyone had health-care coverage, and fifty-six per cent said no. Four years after implementation, sixty per cent say yes.

“But that doesn’t mean I have to sign on for full-blown socialism—cradle-to-grave everything,” Mark said. “It’s a balance.” Our willingness to trust in efforts like health reform can be built on experience, as happened with Mark, though we must recognize how tenuous that trust remains. Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and the vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise.

Eight years after the passage of the Vaccine Act of 1813, a terrible mistake occurred. The Agent accidentally sent to North Carolina samples containing smallpox, instead of cowpox, causing an outbreak around the town of Tarboro that, in the next few months, claimed ten lives. The outrage over the “Tarboro Tragedy” spurred Congress to repeal the program, rather than to repair it, despite its considerable success. As a consequence, the United States probably lost hundreds of thousands of lives to a disease that several European programs had made vanishingly rare. It was eighty years before Congress again acted to insure safe, effective supplies of smallpox vaccine.

When I told this story to people in Athens, everyone took the repeal to be a clear mistake. But some could understand how such things happen. One conservative thought that the people in North Carolina might wonder whether the reports of lives saved by the vaccine were fake news. They saw the lives lost from the supposed accident. They knew the victims’ names. As for the lives supposedly saved because of outbreaks that didn’t occur—if you don’t trust the government’s vaccines, you don’t necessarily trust the government’s statistics, either.

These days, trust in our major professions—in politicians, journalists, business leaders—is at a low ebb. Members of the medical profession are an exception; they still command relatively high levels of trust. It does not seem a coincidence that medical centers are commonly the most culturally, politically, economically, and racially diverse institutions you will find in a community. These are places devoted to making sure that all lives have equal worth. But they also pride themselves on having some of the hardest-working, best-trained, and most innovative people in society. This isn’t to say that doctors, nurses, and others in health care fully live up to the values they profess. We can be condescending and heedless of the costs we impose on patients’ lives and bank accounts. We still often fail in our commitment to treating equally everyone who comes through our doors. But we’re embarrassed by this. We are expected to do better every day.

The repeal of the Vaccine Act of 1813 represented a basic failure of government to deliver on its duty to protect the life and liberty of all. But the fact that public vaccination programs eventually became ubiquitous (even if it took generations) might tell us something about the ultimate direction of our history—the direction in which we are still slowly, fitfully creeping.

On Mark’s last day in the hospital, the whole team came in to see him. He thanked them. “But I didn’t thank them for taking care of me,” he said. “I thanked them for when I was smoking, drinking, and eating chicken wings. They were all here working and studying, and I appreciated it.”

“That’s what you thanked them for?”

“Yeah,” he said. “Because if Mark wasn’t going to stop this, they were going to have to keep working hard. Something had to happen because Mark was clogging up.” And those people did keep working hard. They were there getting ready for Mark, regardless of who he would turn out to be—rich or poor, spendthrift or provident, wise or foolish. “I said, I am glad they do this every day, but I’m hoping to do it only once.” ♦

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By Malcolm Gladwell

By André Alexis

Is health care a human right?

• Published: 13 August 2016
• Volume 37 , pages 249–257, ( 2016 )

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• Daniel Brudney 1  

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Few things in human life seem as important as health. Without it, one’s projects are likely to flag and falter, one’s experiences may darken, one’s life be less than it could be. In an era that invokes human rights for many phenomena that are less crucial than health, it seems natural to assert a human right to health. In the last few decades this assertion has been made by activists, by politicians, by the United Nations. The rhetoric of a human right to health has become a rallying cry. And because the talk of such a human right is so widespread, it is important that philosophers now do what they are good at doing: analyzing and assessing this sort of claim.

It is easy to see what might concern a philosopher. Take Article 12 of the International Covenant on Economic, Social and Cultural Rights. It proclaims a “right of everyone to the enjoyment of the highest attainable standard of physical and mental health” [ 1 ]. Can this be correct? Can there be a right to health? Rights usually correspond to duties, and duties obtain only if some duty-bearer has the power to do some particular thing. But can there be a duty-bearer who has the power to make everyone healthy ? It seems possible at most to provide health care , with the hope that this will lead to health. And even if the right is not to health but to health care, can everyone be given “the highest attainable standard” of health care? Should we neglect all other good things in order to procure the maximum health for the maximum number of people? Surely, health care is only one important good among others (e.g., education, safety from violence), and in a world of scarce resources, everyone cannot have all good things. Should we then construe a human right to health as a right to health care and attempt to specify it in some reasonably clear way?

Doing so will generate plenty of questions. What are the grounds for thinking that there is in fact such a human right? If the right exists, what is its content and what are its limits? Can the right be justified by linking it to other things that are already widely accepted as human rights? Who are the duty-bearers of the right? Does the right depend on accepting some picture of human flourishing, even if only a broad and general one? How does the right fit with the common belief that governments have an obligation to provide many of the material conditions for a healthy life, many of the so-called social determinants of health, such as clean air and water?

The contributors to this special issue develop these topics from a variety of perspectives. There is, I think, no basic agreement among the contributors. That is all to the good. What emerges are reasons to support the claim that there is a human right to health care, but also reasons to be mindful of that right’s limits, and even reasons to be skeptical about the claim that there is such a right. As I say, such differences are welcome. They are what one gets when one applies seven first-class philosophical minds to a deep and difficult topic.

Matthew Liao argues for a human right to health care on the ground that health care is a fundamental condition for the pursuit of a good life. Here is his argument for the fundamental conditions approach :

(1) Human beings have human rights to the fundamental conditions for pursuing a good life. (2) Basic health is a fundamental condition for pursuing a good life. (3) Therefore, human beings have a human right to basic health. (4) A human right to basic health implies a human right to those essential resources for maintaining and promoting basic health. (5) Basic health care is an essential resource for maintaining and promoting basic health. (6) Therefore, there is a human right to basic health care.[ 2 ]

Liao’s central thought is that there are some activities such “that if a human life did not involve the pursuit of any of them, then that life could not be a good life.” A condition of the good life involves being able to pursue an adequate range of these activities (e.g., deep personal relationships; active pleasures such as creative work and play). What Liao calls “the fundamental capacities” are those capacities required to pursue the basic activities. These include, e.g., “the capacity to think, to be motivated by facts, to know, to choose an act freely … to develop interpersonal relationships, and to have control of the direction of one’s life.” The ground for a human right to health care is its relation to the fundamental capacities, and this relation goes through the fact that, in general, health care is crucial to sustaining these capacities.

Now, Liao accepts (1) that there can be no right to health but at most a right to some of the social determinants of health, among them being health care, and (2) that health care is unlikely to be the most important social determinant of health. Nevertheless, he argues, “if we have a right to X, and Y is an essential means to X, it seems that we should have a right to Y”; we do have a right to health; health care is an essential means to health (even if other things are as well); therefore, we have a right to health care.

Many issues remain. For instance, who has the duty to make good on that right? Here, Liao distinguishes between primary and associate duty-bearers of rights. Primary duty-bearers are those who are at the levers of power. With health care, primary duty-bearers have the duty to set up institutions such that basic health care is available to all. Secondary duty-bearers must merely do what is needed to enable the primary duty-bearers to do their job. Secondary duty-bearers might be merely obliged to pay the taxes that support the institutions that make health care available.

Liao finishes by asking whether, in practice, the duty to make health care available to all could be so demanding as to call the human right into question. This goes to the more general question of the limits to the demandingness of morality. In a world of scarce resources and vast human needs, we are likely to have to adjust what can be demanded of us in one sphere to what can be demanded in another. Liao’s thought is that any such adjustment ought to be framed in terms of the thesis that there is a human right to the fundamental conditions for pursuing a good life. Health care is not the only such condition; however, it is an important condition and any balancing of duties will have to find an important place for it.

Jennifer Prah Ruger [ 3 ] begins by noting four features of current American health care. First, in terms of the United States constitution, health care rights are purely negative rights, e.g., the state may not prevent a woman from having an early-term abortion. Second, a patchwork of statutes (among them EMTALA, Medicare, Medicaid, SCHIP, ACA) has created a patchwork of positive legal rights to health care. Third, this patchwork of legal rights is fundamentally inadequate and needs to be replaced. Finally, fourth, as part of replacing it, a morally proper standard for health care provision is needed.

The standard that Ruger proposes is the health capability paradigm (HCP). Based on the capabilities approach pioneered by Amartya Sen and Martha Nussbaum, the “HCP provides a standard for health and health care toward which we can strive in our social and political organization, and a yardstick against which to measure our progress…. [It] is rooted in the Aristotelian view of the good life as human flourishing.” (One can see an overlap with Matthew Liao’s view.)

A couple of things should be noted about the HCP. First, it is different from an equality of opportunity approach to access to health care. Footnote 1 The latter has no independent standard for health care’s contribution to a good human life; rather, it stresses that access to health care is a condition for having an equal opportunity to attain the things that a modern society makes available. Such equal opportunity is assumed to be a requirement of fairness, independent of any substantive view of human flourishing. By contrast, the HCP builds in an outline of human flourishing through its specification of what it takes to be the key human capacities. Second, for policy purposes that outline needs to be made more precise, but in a diverse society it is important that no detailed account of human flourishing be built into health care legislation. Here, as a way to find useable content for such legislation, Ruger appeals to the idea of an incompletely theorized agreement. The hope is that, although we might have reasonable disagreements about many details, we can accept some basic goals for health care legislation, for instance, “preventing premature death and preventable morbidity…. These central elements represent universally valued elements of health capability.”

This might seem anodyne. In fact, in Ruger’s hands it becomes radical because it is coupled with a commitment to equality. “The HCP employs ‘shortfall equality,’ used in welfare economics, to assess health policies and health inequalities…. Inequalities in health capabilities are unjust if they represent a shortfall from the optimal standard and can be prevented, avoided, or ameliorated.” It is easy to move from the standard of shortfall equality to the conclusion that, at least in terms of the distribution of health capabilities, many existing societies, almost certainly including the United States, are unjust.

Ultimately, Ruger argues, a just and stable distribution of health capabilities will depend upon the widespread internalization of an appropriate social norm with regard to such things. Citizens must come to regard health care as a positive right and so come to see inequality in health care as a basic injustice that must be remedied. In this regard, achieving just health care in the United States will require much transformation of our public norms.

In his contribution, James Nickel [ 5 ] takes on the topic of linkage arguments. Such arguments are popular in the human rights literature. They move from a right of some kind that is widely accepted—widely accepted as a right—to another right that is claimed to be, in some sense, a condition of realizing the widely accepted right. However, as Nickel shows, the structure of this sort of argument is not simple. Nickel’s claim, made in careful and subtle detail, is that there are many ways in which one right Alpha might have another right Beta as its condition, that most of these ways come in degrees, and that, in the end, whether a given Beta is a sufficiently crucial condition of a given Alpha so as itself to count as a right will depend on a variety of empirical facts.

Here are a few of the many complexities that Nickel details. Beta might reduce the cost of realizing Alpha, thus making Alpha’s realization more likely; Beta might promote “acceptance, knowledge, and use” of Alpha (suppose there is a right to political participation; a population of adequately educated citizens might avail themselves more often and easily of that right); or Beta might promote “the willingness and ability of dutybearers to meet their responsibilities” (suppose there is a right to political participation; adequately educated officials might be more adept at making sure that citizens can avail themselves of this right).

The complexities also include ways in which it might be a mistake to think that Beta is a needed support of Alpha. For instance, a given Beta might be needed for a complete realization of right Alpha but not for its sufficient realization, in which case there may not be a compelling defense of Beta as a right.

Focused more particularly on a right to health care (RHC), Nickel asks “whether or not the full realization of RHC is indispensable or very useful to the realization of other [important] rights.” Nickel’s conclusion is complex, specific, and remarkable for its carefulness. He argues that there are ways in which RHC contributes to other rights. For example, it is less costly to educate healthy children; moreover, good health care reduces the likelihood of epidemics with their associated threat to such rights as freedom of movement and association. There are other ways in which Nickel believes RHC supports other rights (although he also notes that there might be ways in which RHC undermines other rights). However, he finds, and perhaps this is not surprising, the strongest linkage argument to be between RHC and a right to life. “The availability to all of an adequate basket of health care services and products will save lives from injuries and diseases that are amenable to medical treatment. Full realization of RHC is arguably indispensable to blocking some important threats to the right to life of many residents of [a] country.” Thus, Nickel concludes, a linkage argument does in fact ground RHC in its support of other rights, and it strongly grounds RHC in support of a right to life. Such conclusions, Nickel notes, “are not spectacular, but neither are they insignificant.”

Sarah Conly [ 6 ] accepts the existence of a right to health care but stresses that, like any right, its scope is limited by facts about scarce resources and human psychological tendencies. Rights are constrained by context, and, Conly argues, context involves considering costs and benefits. “How important is the exercise of a particular practice or the provision of a particular good? And, how costly is it to others? … [W]hat one can claim as a right will be sensitive to social costs, individual benefits, and the ratio of the two.”

There are real world limits to the supply of health care. Without beggaring other needs—in effect, other human rights, e.g., the right to education or to be safe from crime—we cannot supply health care to the max. But if health care is a great benefit, and yet, sadly, we cannot supply it to the max, then we ought to reduce the demand for it. This consideration naturally leads Conly to preventive health care. An obvious tack is health education, and Conly supports it. However, health education alone is insufficient. Incentives are needed. “We need to make it much more difficult to engage in behaviors that are bad for us.” There are many possibilities: taxing fast food or soda, prohibiting ads for such things, imposing portion limits in restaurants. Conly calls for creative ways to get us to adhere to a healthier form of living. At the limit, harmful foods and other things could be banned.

Conly knows that talk of taxes and prohibitions will raise hackles. “The right to health care is typically taken to expand our options, not to reduce them.” But if rights are sensitive to costs, then we must think about reducing the cost of a right to health care. Moreover, rights come with obligations: “the recipients of health care, in claiming their right, also place themselves under some obligations.”

An opponent might urge that lifestyle changes, although desirable, ought to be voluntary. And those who fail to adopt healthy lifestyles have only themselves to blame, and so ought to have no claim to health care resources. Conly thinks this “ignores too many realities of human psychology.” People are weak of will. They will predictably often take the course of least resistance, i.e., poor self-care. Conly thinks that such realities are sufficiently pervasive that institutions must play a role in guiding our choices. Nevertheless, Conly acknowledges that there is a difference between a person who engages in an unhealthy lifestyle because of limited alternatives (e.g., living in a food desert), difficult-to-avoid flaws in rationality, or other excusing conditions and a person who does so with full knowledge and unimpaired rationality. She thinks that the first retains a right to health care while the second does not. However, she goes on to note both that few people will fit into the second category and that society might still have a duty not to let such people suffer. That someone has no rights claim to health care does not entail that society has no duty to provide it. (Of course, the duty must then be justified in a different way.)

Overall, Conly’s essay is a plea to approach the issue of a right to health care with realism as well as with a willingness to make hard choices. Health care is resource intensive. We cannot all have all of it that we want; perhaps all of us cannot even have all of it that we need. Therefore, we must recognize our duty to conserve the resource and to find rules (legal and otherwise) to ensure that we do so.

In his essay, David Reidy [ 7 ] argues for a “cautious and circumspect use of human rights language within deliberation over and advocacy for improved health and health care policies around the world.” Reidy reaches this conclusion in an unusual way: by focusing on the moral status of the international treaties that guarantee a right to health care (e.g., the International Covenant on Economic, Social and Cultural Rights (ICESCR)). These are often regarded as signal international achievements. They seem to be proper responses to the fact, as Reidy emphasizes, that our moral rights often need institutional embodiment for their effective exercise. To “provide persons … with specific, targeted high-priority normative direction,” he notes, “rights typically require some measure of conventional or institutional embodiment or social recognition.”

It is precisely for this reason that one might applaud treaties such as the ICESCR. Here at last, one might think, is the needed institutional embodiment. Yet Reidy points out that there is a normative gap between the existence of such treaties and their moral force to bind individuals. The problem is not that the treaty signatories might have signed unwillingly. Even if they were willing signers, the internal structure of a signing state might not provide it with the moral power to bind individuals in its territory. Reidy asks the reader to consider a treaty between Syria and North Korea. Even if the various leaders signed it with enthusiasm, its content would hardly be morally binding on individual Syrians and North Koreans. Reidy’s point is that the content of a treaty is not morally binding unless the entity that signs the treaty is morally entitled to impose obligations upon those under its jurisdiction—and in many actual cases, including with some states that signed the ICESCR, the signatory does not hold legitimate power and so does not have such an entitlement. A treaty could thus be legally binding under international law but fail morally to bind individuals to act in accordance with it.

Reidy argues that valid legal obligations are also valid moral obligations only if they “arise out of a law-making process that satisfies certain substantive conditions of legitimacy.” He presses that it is “the nature of domestic law-making processes [that] determines whether states have the standing or status necessary for the international legal obligations and legal reasons created by their voluntary or consensual undertakings to have prima facie moral force.” Reidy develops this point by urging that only a “constitutional, rule of law, republic,” one that already protects “the most basic of human rights,” can generate moral obligations that bind its citizens.

The implication of Reidy’s argument is startling. Rights need duty-bearers to make them effective. But who counts as a moral—not merely a legal—duty-bearer for a human right to health care turns out to be far from straightforward. The mere fact that, say, the ICESCR is valid international law is not enough. According to Reidy, there can be no proper international moral structure for the human right to health care until the states that are signatories to the relevant treaties are internally structured in a morally adequate way. Perhaps all individuals do have a human right to health care, and perhaps such rights require institutional embodiment to be effective. Still, for such international arrangements to be morally binding on the individuals subject to them, the states involved must have met an appropriate standard of political legitimacy.

Gopal Sreenivasan [ 8 ] notes the following common claims:

There can be no human right to health because achieving health is beyond what social institutions can accomplish.

If there is a human right in this neighborhood, it is a two-pronged right: a right to an adequate provision of the social determinants of health (e.g., clean water) and a right to health care, for such things are within the purview of social institutions.

Sreenivasan challenges both of these claims. Against the claim that there is a human right to the social determinants of health, he presses that a human right is an individual right, something due the individual, but that the social determinants of health often require large-scale state action that affects and might even place duties upon many people. He concludes that such state action cannot be due an individual as her human right. His example is herd immunity from a disease. Jack cannot have a human right to such immunity because achieving it would require vaccinating millions of people. This might be good to do, but Jack, merely as one human being among others, cannot have a human right that millions of people be vaccinated. The burden is too great. It is one thing to claim that one has a right that the state do X with respect to oneself; it is quite another to claim that one has a right that the state do X (or Y or Z) to millions of others.

This tosses the ball back to whether there is a human right to health care. That looks as if its focus is properly individual. Here, Sreenivasan makes a different point. The appeal to health care rather than to the general provision of what makes for health (health care plus the social determinants of health) seems arbitrary because, in the end, what we care about is that social institutions facilitate citizens’ health to the extent that existing technology and resources permit. But if what makes for health are two instruments for achieving what we care about, namely, health, and if there is no human right (no individual right) to one of them (the social determinants), then it is unclear that what we care about, namely, health, can ground a human right to the other instrument. Consider that both instruments are focused on attaining the same goal. Now, given that health resources are finite, any sensible health bureaucrat must trade off resources allotted to one instrument against those allotted to the other. If one instrument is a human right while the other is not, it would seem that individual health care (the alleged human right) ought generally to win out over the social determinants of health (a goal, not a right). But the social determinants of health are far and away the more important instrument for attaining citizens’ health—the thing we care about. It would be a pyrrhic victory to gain a human right at the cost of losing the point of the right. It seems conceptually more sensible, Sreenivasan argues, to concede that there is no human right to health care.

Sreenivasan has further ingenious arguments against the claim that there is a human right to health care. As with the argument above, they target the common thought that one can get a human right to health care by subtracting from the claim of a human right to health. One concedes the absence of a right to the latter but asserts the seemingly more straightforward right to the former. Sreenivasan shows that this move requires far more defense than it has been given.

John Tasioulas and Effy Vayena [ 9 ] stress the need to distinguish between a claim of individual right to health care and the general social duty (incumbent upon governments, multi-national companies, perhaps even individuals) to remedy health shortfalls. Even were all human rights met, there could still be such shortfalls. This could be due to many things, e.g., unhealthy choices by individuals, problematic social determinants of health. Unlike other contributors to this issue, Tasioulas and Vayena accept that there is a right to health but they insist that it has two components: “health policy … has to be responsive both to human rights, including prominently the right to health, and to global common goods that bear on health.”

Many issues now need resolution. For instance, there is the problem of distinguishing what falls under the right to health from what falls under other rights (or is not a right at all). Health is clearly connected to many things but Tasioulas and Vayena argue that mere connection does not entail inclusion in a human right to health. It is both misleading and a hindrance to useful policy to put “entitlements to food, housing, life, education, privacy” and many other things under a right to health. (Here, Tasioulas and Vayena seem to agree with James Nickel that we should be very careful about linkage arguments.) Tasioulas and Vayena urge that the right to health includes only such other rights as serve “one’s interest in health as [their] primary and direct objective, as in the case of clean air and water.”

A second issue concerns the determination of when a health interest becomes a health right. Tasioulas and Vayena press that duty-bearers who are supposed to act in such a way as to realize the purported right must actually be able to do so (e.g., at present it is not a practical possibility for all human beings to have “the highest attainable standard of physical and mental health”). Moreover, even if it is possible to realize an alleged health right, there is a threshold of burdensomeness on the duty-bearer that would remove the duty and thus forestall the claim of right. In practice, applying the standards of possibility and burden to determine what is and is not a health right will surely be difficult; still, these are the key standards to apply.

Finally, Tasioulas and Vayena address the issue of global common goods. These differ from rights but can be of profound importance. An individual might not have a right to a new kidney but it would be a great common good for there to be “a social ethos that … helps maintain an adequate supply of organs for transplant.” Both the state and individuals might have a duty to promote such an ethos.

Although they press the distinction between individual rights and common goods, Tasioulas and Vayena also stress that the distinction can be complicated. In some cases, they argue, individual rights do entail a common good. “[T]he relationship between human rights and common goods is not mutually exclusive.” Here, they disagree with Gopal Sreenivasan. In particular, they argue that herd immunity is a human right although each individual’s rights claim is not to make millions of others be vaccinated but to “a proportionate share” of what is involved “in a vaccination programme aimed at securing” herd immunity. Tasioulas and Vayena draw the inference that “some aspects of the common good are rights-based, in the sense that they include elements to which we have a right; and what these rights confer is a right to benefit from the common good in question.” This disputed issue—whether or how far a health care common good can be rooted in a claim of individual human right—is clearly among the most important to resolve.

In a vague and general way all the writers in this special issue and, indeed, most people believe that it would be a good thing if everyone were able to avail herself of adequate health care. Yet public policy requires that choices be made, and making policy choices usually involves setting up a moral hierarchy. The frequent claim that health care is a human right is a way to assert that it belongs near the top of any moral hierarchy. But of course not every claim is justified, so we need to know whether health care truly is a human right. It will be clear from reading the contributions to this special issue that there is ongoing disagreement about whether there is indeed a human right to health care; and if there is, what grounds such a right as well as how, in a morally defensible way, limits can be set to it. There is, then, plenty of work still to be done.

An equal opportunity approach is associated especially with the work of Norman Daniels; see [ 4 ].

United Nations. General Assembly. 1966. International covenant on economic, social and cultural rights . Resolution 2200A (XXI) of December 16, 1966. Entered into force January 3, 1976. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx . Accessed July 14, 2016.

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Acknowledgments

These papers were initially given at a symposium, “Is Health Care a Human Right?” presented by the Neubauer Collegium for Culture and Society and the Pozen Family Center for Human Rights at the University of Chicago on October 10–11, 2014. I am very grateful to both the Neubauer Collegium and the Pozen Center for their help. I want also to thank the Franke Institute for the Humanities for its support of the symposium.

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Brudney, D. Is health care a human right?. Theor Med Bioeth 37 , 249–257 (2016). https://doi.org/10.1007/s11017-016-9376-6

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This I Believe

Health is a human right.

Paul Farmer

Dr. Paul Farmer is a founding director of Partners In Health, an international organization that provides health care to people living in poverty. Above, Farmer examines a child at a mobile clinic in Haiti. Mark Rosenberg/Partners In Health hide caption

Dr. Paul Farmer is a founding director of Partners In Health, an international organization that provides health care to people living in poverty. Above, Farmer examines a child at a mobile clinic in Haiti.

Partners In Health

I believe in health care as a human right. I've worked as a doctor in many places, and I've seen where to be poor means to be bereft of rights.

I saw early on, still just a medical student, the panicky dead-end faced by so many of the destitute sick: a young woman dying in childbirth; a child writhing in the spasms of a terrible disease for which a vaccine has existed — for more than a century; a friend whose guts were irreparably shredded by bacteria from impure water; an 8 year old caught in cross-fire. Li mouri bet — what a stupid death, goes one Haitian response.

Fighting such "stupid deaths" is never the work of one, or even of a small group. I've had the privilege of joining many others providing medical care to people who would otherwise not be able to get it. The number of those eager to serve is impressive, and so is the amount that can be accomplished. I believe that stupid deaths can be averted; we've done it again and again. But this hard and painful work has never yet been an urgent global priority.

The fight for health as a human right, a fight with real promise, has so far been plagued by failures. Failure because we are chronically short of resources. Failure because we are too often at the mercy of those with the power and money to decide the fates of hundreds of millions. Failure because ill health, as we have learned again and again, is more often than not a symptom of poverty and violence and inequality — and we do little to fight those when we provide just vaccines, or only treatment for one disease or another. Every premature death, and there are millions of these each year, should be considered a rebuke.

Farmer, shown above making a presentation to a community in Haiti, is also a professor in the Department of Global Health and Social Medicine at Harvard Medical School. Gilles Peress/Partners In Health hide caption

Farmer, shown above making a presentation to a community in Haiti, is also a professor in the Department of Global Health and Social Medicine at Harvard Medical School.

Questions Or Comments?

I know it's not enough to attend only to the immediate needs of the patient in front of me. We must also call attention to the failures and inadequacy of our own best efforts. The goal of preventing human suffering must be linked to the task of bringing others, many others, into a movement for basic rights.

The most vulnerable — those whose rights are trampled, those rarely invited to summarize their convictions for a radio audience — still believe in human rights, in spite of — or perhaps because of — their own troubles. Seeing this in Haiti and elsewhere has moved me deeply and taught me a great deal.

I move uneasily between the obligation to intervene and the troubling knowledge that much of the work we do, praised as "humanitarian" or "charitable," does not always lead us closer to our goal. That goal is nothing less than the refashioning of our world into one in which no one starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended.

Of course such a world is a utopia, and most of us know that we live in a dystopia. But all of us carry somewhere within us the belief that moving away from dystopia moves us towards something better and more humane. I still believe this.

Independently produced for Weekend Edition Sunday by Jay Allison and Dan Gediman with John Gregory and Viki Merrick.

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Healthcare Debates: Is Healthcare a Right or Privilege?

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The debate in the United States over whether or not healthcare is a right or a privilege has been raging for over a century . Do all U.S. citizens have a right to access healthcare, regardless of their position in a free market system? Or, as healthcare services are a limited resource requiring money to operate, is access to healthcare just like every other commodity—a privilege reserved for those who are competitive in the free market?

As there is real-life evidence to support both outlooks, the debate over whether healthcare is a right or a privilege ultimately is a values-based debate. Where someone stands on this debate comes down to how they view rights, the role they believe the government has in enforcing these rights, whether or not they believe healthcare is something every individual deserves, and whether they believe we are connected or separate.

Keep reading to learn more about the fundamental questions we must ask ourselves as individuals and what our nation must answer as a collective to come to a consensus around whether or not healthcare is a right or a privilege.

Positive Rights vs. Negative Rights

When the healthcare debate rages, one of the dialectics that fuels the debate is the semantic meaning of the word “rights.” While we all have a generalized sense of what this means—something we are entitled to simply because we exist—the debates over healthcare arise from differing ideas regarding how rights are idealized and from these idealizations: how they should be enforced.

Parties who believe that healthcare is a right often operate from the rhetoric of positive rights, whereas those who believe health care is a privilege often operate from the rhetoric of negative rights.

Those who see healthcare as a privilege will often use the rhetoric of negative rights . In a negative-rights framework , rights are restraints on actions rather than an obligation to act. In the case of the constitutional decree that we have the right to life, liberty, and the pursuit of happiness, a negative rights outlook would mean that you have no obligation to help another person to attain life, liberty, or happiness—but you do have a duty not to get in their way.

In the case of healthcare, those who believe in a negative rights framework believe that you cannot have healthcare as a right because it places a positive obligation on others to provide access through the nonconsensual surrender of income to the state. From a negative rights perspective, the only duty or obligation we have to one another in regard to healthcare is not to threaten choice or bar access, but we should not be forced to contribute to the care of others.

Parties who see rights from this perspective believe that helping with healthcare needs to be voluntary (i.e., free-market decisions or healthcare charities run on voluntary donations). The government’s role in healthcare is to protect this individual’s right to choose. Simply put, in a negative rights framework, healthcare can be available through the mechanisms of a free market system, but it is not a right.

Those who advocate greater governmental responsibility in healthcare are often working from a positive rights perspective —a framework where a positive duty is imposed on us to sustain the welfare of those in need.

There is a major global consensus that health—and all the circumstances that mediate health—is a fundamental human right (see the UN Universal Declaration of Human Rights and the World Health Organization’s Constitution ). Healthcare is often a necessary tool for the attainment of access to health and, from a positive rights perspective, it is something that should be provided to everyone, whether or not they can participate meaningfully in a free market system.

From this point of view, marginalized populations who struggle to find adequate work or cannot work (e.g., the young, the poor, the elderly, those with debilitating chronic diseases, the disabled) should have a right to healthcare. In this framework, it is the government’s duty to ensure that the conditions that mediate fundamental human rights are attainable, regardless of the lottery of the birth. Therefore, the government has a right to impose taxes that will help those for whom the free market system imposes an undue burden.

In a positive rights framework, healthcare is a tool to attain the basic human right of health, and it is the duty of the people to ensure access to it.

Does Everyone Deserve Healthcare?

As a result of an unequal system of healthcare that began during World War II, the idea of healthcare as a basic entitlement that we all contribute to—much like clean water, garbage collection, roads, etc.—has experienced a complete breakdown in American cultural consciousness.

In linking health insurance to employment and thereby intrinsically linking access to care to employment, the U.S. became the land of an inequitable system whereby different people with varying circumstances became subject to different rules for healthcare. This history is integral to the way we speak about whether or not people deserve healthcare.

For parties who believe that healthcare is a privilege , one of the key beliefs is that rights do not distinguish between the deserving and the undeserving . Within this framework, narratives of self-reliance and hard work are key rhetorical cornerstones. Those who do not believe healthcare is a right often assert that work is the key that opens the door to healthcare all throughout the lifecycle. Earning money, saving for health, and choosing employment with health coverage is what hardworking, self-reliant individuals should do in their productive working years to ensure access to the privilege of healthcare for themselves and for their children.

As these individuals work, they pay into Medicare, and this is the system that ensures that hardworking, self-reliant individuals will retain access to health care when they are no longer capable of work.

For those who are working hard and earning wages that do not cover the cost of healthcare, access to government assistance or charity is an earned privilege. However, from this point of view, those who are not productive members of society do not deserve access to care—nor to collective pools of money paid into by those who are productive. Supporting those who cannot contribute is seen as detrimental to the system, opening the door for abuse of the system.

Parties that believe healthcare is a right tend to use rhetorical frameworks that demonstrate all lives have equal value and that access to healthcare for all is necessary for a prosperous society .

Because of these centralized beliefs, those who believe that everyone deserves healthcare argue that it should not be linked to one’s capacities to work. There are many people who—through no fault of their own—are born with physical or mental disorders that bar them from work and many who, despite having some productive years, develop chronic conditions that prohibit them from working.

There are also those who do work—like the estimated 35 percent of the adult workforce in the United States who are in the gig economy—who do not have access to healthcare because of lack of access to employer coverage. Those who believe healthcare is a right state that investing in the health of all these people is essential because, with healthcare, these humans have the capacity to live up to their greatest potentials and may contribute to our communities in a way that cannot always be measured within a framework of contribution to a GDP.

Overall, supporting those who cannot work can lead to abuses in the system, but this is a small price to pay for opening the door to all citizens to live up to their greatest human potential.

Are We Separate or Connected?

Ultimately, all the questions that come before connect to one penultimate question around whether our fates are connected or if they are separate.

Those who believe healthcare is a right utilize the rhetoric of the connected . What impacts one of us impacts all of us —both in the realm of the negative and the in the realm of the positive. Healthcare, therefore, needs to be a right because if the most vulnerable member of our society is not cared for, it means that we—as a collective—are not cared for.

The real-world implications of this are seen in a healthcare system that is the most expensive, least effective, and least accessible in the western world. Those who see healthcare as a right argue that improving access to healthcare saves us money, heals people, and creates a more engaged citizenry.

Those who believe healthcare is a privilege utilize the rhetoric of the separate . It is the belief that we have a duty only to our own freedoms and to reap the benefits of the work we have done. Being forced to use what we have earned against our will to help another is akin to theft .

By putting the responsibility for healthcare on the shoulders of the individuals in need, we will ultimately save money because prices will become more competitive, and the citizenry will become more engaged if they wish for healing. They believe that our healthcare system is the most expensive and least effective in the western world because there is too much assistance on which people are becoming dependent.

In Conclusion: Is Healthcare a Right or a Privilege?

The debate over whether healthcare is a right or a privilege has more questions than answers—and the answers to these questions are not straightforward. If they were, this debate wouldn’t have a century-old history. What individuals believe about healthcare comes down to a complex mixture of:

• Life experience – Did they have a work-ending condition?
• Values – Do all human lives have equal value?
• Ideologies – Are rights negative or positive?

When debating in the realm of ideals, it is challenging to come to a conclusion as the values underlying the belief are often antithetical and irreconcilable. This begs one more question: can we come up with a system of healthcare that blends both ideologies so that we can move into a healthcare system that costs less, is more effective, and is a win-win for our ideals and the health of our citizenry?

Becca Brewer, MEd

Becca Brewer is building a better future on a thriving earth by healing herself into wholeness, divesting from separation, and walking the path of the loving heart. Previously to her journey as an adventurer for a just, meaningful, and regenerative world, Becca was a formally trained sexuality educator with a master of education.

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Is Health Care a Right? Health Reforms in the USA and their Impact Upon the Concept of Care

Mahiben maruthappu.

1 Green Templeton College, University of Oxford, Oxford, UK

Rele Ologunde

2 Imperial College London, London, UK

Ayinkeran Gunarajasingam

3 New York University, New York, USA

In 2008 United States President Barack Obama declared that health care “should be a right for every American”. 1 This statement, although noble, does not reflect US healthcare statistics in recent times, with the number of uninsured reaching over 50 million in 2010. 2 Such disparity has sparked a political drive towards change, and the introduction of the Patient Protection and Affordable Care Act (PPACA). 3 These changes have been highly polemical, raising the fundamental question of whether health care is a right; a contract between the nation and its inhabitants granted at birth, or an entitlement; a privilege that must be earned as opposed to universally provided.

Access to healthcare in the US is mediated by insurance coverage, either in the form of private or employer based cover, which may be government based for public sector employees or private for private sector employees. The majority of spending on healthcare however, comes from government expenditure on health programs such as Medicare, Medicaid, Tricare, and the State Children's Health Insurance Program (SCHIP). 4 Medicare is a federal government funded social insurance program that provides health insurance to people aged 65 and older, younger people with disabilities, and those with end stage renal failure requiring dialysis. Medicaid is a means tested insurance coverage program for individuals with low incomes and their families, and is jointly funded by state and federal governments. Tricare is a healthcare program that provides healthcare insurance for military personnel, retirees, and their dependents. The SCHIP provides states with federal government funding to provide health insurance to children from families with modest incomes that do not qualify for Medicaid. As such, although the majority of the US population is insured by federal, state, employer, or private health insurance, the remainders go uninsured.

A US census bureau report suggested that 16.3% of the population, 49.9 million people, did not have health insurance in 2010. 5 Households with an income of $25,000 or less made up the largest proportion of the uninsured. 6 Lack of access to healthcare has also been shown to be associated with increased mortality; a 2009 study found that there were 44,800 deaths annually in the US that were directly associated with lack of healthcare insurance. 7

This article presents the argument that health care should be a human right, drawing upon: i) the political grounds for health care provision, and ii) ethical and moral frameworks supporting its introduction. These points are illustrated using the Medicare, Medicaid and SCHIP programs, in addition to assessing the extent to which the PPACA will convert health care from an entitlement to a right in this USA.

Should Health Care Be Considered a Right?

When examining the concept of health care as a ‘right’, one may consider it as either a legal or a moral one. Few would object to the proposition that accessible healthcare for all is in essence a moral right, 8 however, less would be of the opinion that it is a universally legal one. In the buildup to the 2008 presidential election, when questioned about whether health care was a right, a privilege, or a responsibility, then-Senator Obama asserted that health care should be a right. In Obama's argument he cited the case of his mother's struggle with cancer, he suggested that there was a fundamental injustice with a country not entitling it's sick to healthcare due to their inability to pay. 1 The Affordable Care Act, discussed in the 2012 presidential campaign, is projected to substantially reduce the number of uninsured in every age, income group and state, and thus increase access to care. 9

A system that distributes healthcare unevenly, on the basis of any determining factor other than necessity, raises numerous questions about how ethical that system is. In a society where disparity in the level of care or access to care exists, inevitably there will be individuals who fail to receive the care for which they desperately need. Failure to access care early on will undoubtedly lead to individuals consuming a greater proportion of healthcare resources, should the degree of their morbidity escalate, and therefore increase the burden on health provision. 10

Some may suggest that enshrining health care as a right in law may lead to over-utilisation of healthcare resources, 11 however the consumption of these resources does not result in fiscal or otherwise measurable gain for the individual seeking them. Although, one could argue that there may be personal satisfaction in over-utilisation. Healthcare is an essential requirement for well-being, conferring on one the ability to do other activities; it is, therefore, a condition upon which many other factors are determined.

Another fundamental difficulty with considering healthcare as a right is that this right, unlike many others, is dependent upon the resources of a society, 12 and the ability to meet the demands of the population without disparity in distribution and allocation of medical care. As such, even if this right were to be upheld universally, there would still be a gulf in care provision for individuals between different societies. To address this apparent gulf we need to assess what exactly constitutes a fair system of distribution. 13 One could consider establishing a minimum level of health care provision. 10 However, given that the health needs of different communities and vulnerable groups vary, defining this minimal level is challenging.

The World Health Organisation (WHO) defines health as “a state of complete physical, mental and social well-being”. 14 Healthcare, in turn, can be described as the provision of services necessary to treat disease and promote health. Several lines of political evidence support the concept of health care as a right:

First, in 1943, President Roosevelt proposed a ‘Second Bill of Rights’ that included: “The right to adequate medical care and the opportunity to achieve and enjoy good health”. 15

Second, the Universal Declaration of Human Rights published by the United Nations provided: “Everyone has the right to a standard of living adequate for the health and well-being…including…medical care”. 16

Third, the International Covenant on Economic, Social, and Cultural Rights (signed by the US in 1977) stated that it is “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” in addition to: “the creation of conditions which would assure to all medical service”. 17

Undermining the utility of these statements is the unclear definition of healthcare that could include a wide range of social, economic, organisational, and scientific issues, making the allocation of responsibility challenging. 18 Moreover, the achievement and enjoyment of good health by all may be perceived as an unrealistic aspiration in the context of today's economic austerity, rising healthcare costs, and aging population.

Ethical frameworks further support the notion of healthcare as a human right; Peter Singer adopts a utilitarian standpoint – the greatest good for the greatest number, arguing that:

• i) Suffering from a lack of medical care is harmful.
• ii) If it is within our power to prevent something harmful from happening, without sacrificing anything nearly as important, it is wrong not to do so.
• iii) By improving health care, suffering can be prevented without making significant personal losses.
• iv) Therefore, by not improving health care, and to an extent, by not introducing health care as a right, we are doing something wrong. 19 , 20

There are limitations to this: it applies to individual actions rather than governmental change. Further, it assumes that health care can be improved without significant personal loss when in actual fact the introduction of, for example, the PPACA has been estimated by some to be of significant cost to the US, let alone the implementation of universal care. 21

Another supportive framework is the Capabilities Approach, 22 whereby health care is fundamental to the capacity of a person to conduct all other individual rights, making it of primary importance. However, it could be argued that although people need health care, food, and shelter, this does not necessarily obligate others to make such provisions available. 18 Food, for example, is not considered a right; companies are permitted to sell it, and it can be withheld from those who cannot afford it.

The difficulty in introducing health care as a right also lies in the fact that care, unlike other goods, cannot be simply quantified and allocated equally to members of a society. Thus, there comes a point where the lack of responsibility of one person must be compensated by an increase in another, where the healthy pay for the unhealthy.

We, therefore, find that the question of whether health care should be offered as a right is complex, with ethical, judicial and financial tensions.

Consequences of the PPACA

The PPACA was introduced in 2010, and included a number of changes to US healthcare such as reducing pre-existing condition exclusions, and restricting annual dollar limits on coverage, in turn expanding insurance coverage to over 30 million Americans. 23 This has moved the US towards offering universal care.

However, it must be noted that the quality of this care is worse compared with that received by the majority of the population. For example, although Medicaid has been expanded, it has been associated with the longest length of stay and the highest risk of deaths for a number of surgical procedures compared with those under private insurance. 24

Therefore, the health reform will simply rebrand those with poor access to care to those covered by Medicaid, Medicare, or SCHIP, whereby they still receive substandard health care.

When the PPACA was enacted by congress it was broadly received with skepticism. Many opponents of the act challenged the constitutionality of the individual mandate and the Medicaid expansion, citing that it is illegal, under US constitution, to require individuals to buy health insurance. 25 Indeed, twenty-six states and the National Federation of Independent Business opposed this act in federal district court. The case was taken to the US Supreme Court, which on 28 th June 2012 upheld the core of this new health care legislation that requires all US citizens to hold health insurance or be subject to a tax if failing to do so. The Supreme Court held that the tax levied on those who failed to provide minimum or adequate health coverage was permissible under congress's power to tax under article 1 of the US constitution. 26

Other health related stipulations require that health insurers can no longer discriminate the sale of insurance on the basis of health status, that individuals in the same age group are charged the same premium, and that organisations with a workforce of greater than 50 employees provide affordable health insurance. 27 The legislation also introduced a subsidy for low- to middle-income individuals and families in an effort to reduce the financial impact of accessible healthcare to those who can least afford it. 27

The successful supreme court ruling culminates the efforts by the US government to overhaul the nation's health care system. Most recent efforts to implement change to the US system have fallen victim to opposition, but this landmark ruling paves the way to improving accessibility of care to all on the basis of need. The US has some of the highest survival rates for diseases such as prostate and breast cancer, 28 yet despite advancements in medical treatment there has been significantly less progress in medical coverage, such that those suffering from simple treatable ailments elude care. Following this Supreme Court ruling however, the US is set to bring about a paradigm shift in their approach to healthcare.

Like the 2012 Supreme Court ruling, the 2012 presidential election represented a major milestone for the PPACA. President Obama's re-election ensures that the law's major provisions remain unscathed and will go into effect by January 2014. Despite the President's campaign promises to implement the PPACA, and his subsequent re-election, many Republican governors refuse to create the state-based health insurance exchanges required by the law. The PPACA, however, obviates such opposition. In the event that state governments refuse to create healthcare exchanges, the federal government has the right to create an exchange for it. Despite the specificity of its provisions, the full impact of the PPACA on the US healthcare system remains uncertain. The only certainty is the impact the PPACA will have in ameliorating the suffering of some of the most disadvantaged citizens in the United States. The PPACA will bring American health policy more in line with the access-for-all vision of European and Canadian health systems. In the wake of President Obama's re-election, it seems that the American people agree, despite its complex implications, with candidate Obama's declaration that “healthcare should be a right for every American”.

Conclusions

US health care has gained significant attention in recent years, with a strong drive towards a right-based system. This movement is not simple, but rather burdened with complexities of funding, logistics, ethics, and rationality. The US remains one of the few industrialised nations in the world that does not guarantee universal healthcare access. 29 In the current framework of healthcare provision, concerted efforts to ensure universal health insurance coverage or entitlement need to be made in order to achieve universal access to healthcare. Ensuring access to healthcare is a compulsory requirement of healthcare as a right. 30 Recent US healthcare reforms have gone some way to achieving this. However, continued concerted efforts are required in order to achieve a comprehensive solution. It is also important to continue to pursue the aspiration of rights-based health care, but it should also be appreciated that the journey will take time, persistence, and a deep understanding of the system to navigate its inherent complexities.

Ethical approval

No ethical approval required for this study.

Conflicts of interest

No conflicts of interest have been declared by the authors.

Author contributions

■■■.

No funding source declared by the author.

Provenance and Peer Review

Unsolicited and peer reviewed

The Case for Universal Healthcare: Ensuring Health as a Human Right

This essay is about the importance of universal healthcare and argues that healthcare should be accessible to everyone, regardless of financial status. It emphasizes that health is a basic human right and that universal healthcare promotes equality, economic benefits, and social cohesion. The essay highlights how universal healthcare can reduce overall healthcare costs through preventative care, alleviate medical debt, and address health disparities among different socio-economic groups. It also counters criticisms about increased government spending by pointing out the long-term economic gains and successful examples from countries with universal healthcare systems. The essay concludes that universal healthcare is essential for a just and prosperous society.

How it works

The domain of healthcare constitutes a quintessential facet of human existence, engendering a discourse spanning the global spectrum regarding its universal accessibility. The contention surrounding this issue remains fervent and pervasive. There exist compelling rationales advocating for the universality of healthcare, positing it as an entitlement irrespective of one’s pecuniary status. At the crux of this discourse lies the axiom that healthcare embodies an elemental human entitlement, indispensable for the sustenance and flourishing of individuals and collectives alike. This exposition shall delve into the imperative for the universal accessibility of healthcare, scrutinizing diverse vantages and ramifications.

Primarily and paramountly, the accessibility of healthcare epitomizes an inalienable human entitlement. The capacity to procure medical attention in times of exigency stands as a linchpin for leading a fruitful and gratifying existence. The deprivation of healthcare owing to fiscal constraints constitutes a transgression against this foundational entitlement. Across myriad societies, the chasms in healthcare access are glaring, with indigent individuals and households often precluded from availing themselves of indispensable medical amenities. This schism not only adversely impacts the individuals directly implicated but also begets broader societal repercussions. Robust individuals serve as societal assets, fostering positive contributions both economically and socially. Ensuring equitable access to healthcare stands as a stride toward actualizing parity and socio-judicial rectitude.

Moreover, the universality of healthcare holds the potential for substantial economic dividends. Prophylactic measures, which are more apt to be embraced in an environment where healthcare is universally accessible, harbor the potential to curtail the incidence of grave maladies necessitating exorbitant remediation. Preventative interventions, encompassing immunizations, routine check-ups, and timely interventions, epitomize cost-efficient modalities for nurturing public health. By preemptively addressing health maladies, individuals can forestall the onset of more severe health adversities, which are prodigiously dearer to rectify and manage. This not only mitigates aggregate healthcare expenditures but also alleviates the financial encumbrance borne by individuals and households. Additionally, a robust populace fosters heightened productivity, engendering augmented economic outputs and diminished absenteeism within occupational spheres. Nations espousing universal healthcare paradigms, such as Canada and the United Kingdom, frequently manifest superior health outcomes and reduced healthcare expenditures vis-à-vis nations bereft of analogous frameworks.

Another salient contention for universal healthcare pertains to its ameliorative impact on the specter of medical indebtedness. In nations devoid of universal healthcare, healthcare expenses can burgeon precipitously, precipitating fiscal destitution for myriad families. In the United States, for instance, medical indebtedness ranks among the preeminent triggers for insolvency. Families grappling with towering medical bills are frequently confronted with onerous choices, compelled to arbitrate between defraying healthcare expenses and attending to other imperative requisites, such as habitation, education, and sustenance. This fiscal exigency can engender enduring repercussions, perpetuating cycles of indigence and circumscribing prospects for economic ascension. By extending healthcare to all denizens, the onus of medical indebtedness is alleviated, endowing individuals with the latitude to concentrate on their health and well-being sans the augmented stressors borne of fiscal adversity.

Universal healthcare further assumes a pivotal mantle in mitigating health disparateness. Across sundry nations, yawning lacunae in health outcomes between disparate socio-economic cohorts are palpable. These disparages frequently stem from disparate access to healthcare amenities. Low-income denizens and marginalized communities are predisposed to deleterious health outcomes due to their incapacity to defray requisite medical expenses. By effectuating the universality of healthcare, these disparages can be attenuated, fostering more equanimous health outcomes. This assumes particular salience for susceptible demographics, such as the aged, juveniles, and those afflicted by chronic infirmities, who may be disproportionately impacted by the paucity of healthcare access. Ensuring equitable access to commensurate calibers of care fosters societal cohesion and undergirds the fortification of healthier communities.

Furthermore, universal healthcare engenders social equilibrium and engenders confidence in governance. When denizens perceive their cardinal exigencies to be met, they are more predisposed to vest their trust in and buttress their governance and societal apparatuses. This can usher in a milieu typified by stability and serenity, wherein individuals are predisposed to contribute to the commonweal. Conversely, when sizable cohorts of the populace are precluded from pivotal services like healthcare, it can foment societal tumult and schism. Universal healthcare can help efface these schisms, fostering a sense of solidarity and shared accountability.

Detractors of universal healthcare often propound that its instantiation augurs augmented governmental expenditures and amplified levies. While it holds veracity that endowing universal healthcare necessitates substantial investment, the concomitant longue durée boons frequently eclipse the outlays. By fostering a milieu of hale and hearty populace, abating medical indebtedness, and augmenting productivity, the economic dividends can offset the initial disbursements. Furthermore, myriad nations boasting universal healthcare frameworks manage to furnish superlative care sans extravagant outlays, attesting to the feasibility of striking an equilibrium between affordability and accessibility. Adroit management and apportionment of resources constitute cardinal tenets for rendering universal healthcare sustainable and efficacious.

Another focal point of contention pivots upon the caliber of care attendant upon universal healthcare paradigms. Certain quarters posit that the instantiation of universal healthcare might engender a debasement in the caliber of care, owing to the concomitant surge in demand and strain upon extant systems. Notwithstanding, empirical evidence gleaned from nations espousing entrenched universal healthcare systems proffers a contrarian narrative. Such nations oftentimes boast robust healthcare infrastructures, comprehensive training regimens for healthcare practitioners, and meticulously regulated benchmarks of care. By prioritizing preventative care and premature interventions, universal healthcare systems can sustain superlative care standards while efficaciously managing demand.

Universal healthcare, in addition, propounds a more holistic paradigm vis-à-vis health and well-being. When healthcare is rendered universally accessible, greater accentuation is accorded to preventative care, mental health services, and communal health initiatives. This comprehensive framework addresses the root causatives of health maladies and champions holistic well-being. By synthesizing corporeal, cerebral, and communal health amenities, universal healthcare can precipitate ameliorated health outcomes and a loftier quality of life for individuals and collectives.

The ethical rationale for universal healthcare is also compelling. In an equitable and just society, every denizen ought to be endowed with the opportunity to attain optimal health. The preclusion of healthcare predicated upon one’s fiscal prowess is fundamentally unjust, perpetuating inequity and undercutting the underpinnings of parity and human dignity. Universal healthcare constitutes a moral mandate, consonant with the tenets of benevolence, empathy, and societal responsibility.

The COVID-19 pandemic has additionally underscored the exigency for universal healthcare. The pandemic laid bare the vulnerabilities and lacunae entrenched within healthcare systems across the globe, particularly in jurisdictions bereft of universal healthcare frameworks. The accessibility of healthcare metamorphosed into a veritable matter of life and death, underscoring the import of having a system undergirding the capacity of all to receive medical care in epochs of crisis. Universal healthcare not only bolsters the resilience of healthcare infrastructures but also amplifies their responsiveness to exigent health crises. By provisioning comprehensive coverage, universal healthcare can better safeguard individuals and collectives from the repercussions of pandemics and sundry health exigencies.

In summation, the assertion for universal healthcare stands as robust and manifold. It constitutes a crucible of human rights, economic efficacy, societal equity, and societal stability. Guaranteeing universal access to healthcare is a sine qua non for cultivating healthier, more fecund, and more equitable societies. The long-range benefits of universal healthcare eclipse the tribulations thereof, rendering it an indispensable constituent of a fair and flourishing society. As we continue to broach the discourse apropos the future of healthcare, it behooves us to retain the fundamental dictum that health is an entitlement, not a privilege. By committing to universal healthcare, we can espouse a society that prizes the health and well-being of all its constituents, auguring a future wherein all are endowed with the opportunity to lead robust and gratifying lives.

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Health Care Is a Right, Not a Privilege: A New Series on US Health Care and Health Policy

Affiliations.

• 1 Editor in Chief, JAMA.
• 2 Executive Editor, JAMA.
• 3 Washington University School of Medicine in St Louis, St Louis, Missouri.
• 4 Associate Editor, JAMA.
• PMID: 33464321
• DOI: 10.1001/jama.2020.23915

Publication types

• Delivery of Health Care
• Health Care Reform*
• Health Facilities
• Health Policy*

Home / Essay Samples / Health / Health Care Policy / Healthcare: a Right or a Privilege

Healthcare: a Right or a Privilege

• Category: Government , Health
• Topic: Affordable Care Act , Health Care Policy , Medicare

Pages: 2 (967 words)

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