Updated: Oct 3, 2019
By Leon Galis
Donald Trump is as mesmerizing as a 50-vehicle pileup. But now and again Democrats manage to disenthrall themselves, remember that they’re the party of government and say something on policy. A favorite on those occasions is health care, with most of the focus centering on the proposed universal-coverage, single-payer system candidates are calling “Medicare-for-all.”
The rallying cry among proponents of a universal, single-payer health-care system is, “Health care is a right, not a privilege!” It’s a reasonable guess that vindicating the principle is so urgent to many people because they think that, if true, it would settle all the outstanding health-care policy issues at a stroke. But it hasn’t and it won’t. It turns out that getting straight about the principle leaves us about where we are now on policy.
It’s obvious why advocates of Medicare-for-all think that the health-care-is-a-right principle gives them leverage in policy debates. Rights are very strong moral claims. If I have a right to something, then you have corresponding duties toward me. That’s why we’re all eager to claim rights to one thing and another. If they weren’t moral chits that we could call in against other people, nobody would care about them.
A lot of conservatives seize on the Declaration of Independence rights to “life, liberty and the pursuit of happiness” as paradigm cases because the duties corresponding to those rights are duties of forbearance, of mere non-interference. I can respect your rights to life, liberty and the pursuit of happiness just by leaving you alone. Among people who make it their business to think about stuff like this, rights like that are called ‘negative rights.’
A right to health care, though, isn’t like that. If I have a right to health care, then you have toward me a performance duty—not just to stay out of my hair, but to actually do something that delivers health care. That’s what’s called a ‘positive right.’ It’s because a right to health care entails burdensome performance duties that conservatives don’t want to hear about any such right. At least, they think they don’t.
If a right to health care imposes a corresponding performance duty, who exactly has that right? Some would say “everybody.” But is that true?
Amazon’s Jeff Bezos is worth upwards of $100 billion. If he needs a heart transplant, in about 30 minutes last year he earned enough to cover the cost. I don’t know about you, but I certainly don’t think I have a duty to kick in for his replacement heart, because he can self-insure for any conceivable health care he might need and still have eye-popping wealth left to indulge his every whim.
My intuitions about Bezos-type cases tell me that we don’t have an unqualified right to health care. We have only a right to health care that we need and can’t afford. In other words, we have a means-tested right to health care.
But that qualified right to health care has been embedded in government policy since Medicaid was established in 1965. We’re at one another’s throats about where to fix the qualifying income level, what services should be covered, how much providers should be paid and a host of other vexing issues, but there’s a broad consensus favoring a means-tested right to health care.
If political morality gets us no further than this qualified right to health care, how do we get to a single-payer system of universal coverage? Not just by saying “Health care is a right, not a privilege!” over and over. To see why, consider Bezos again.
I don’t think I have a positive duty to help Bezos get a heart transplant or even a bottle of aspirin. But if I have a means-tested right to a heart transplant, he has a duty to help me get one if I need it and can’t afford it. And as we found out with the Affordable Care Act, people deeply resent being taxed to fund a public benefit that they don’t themselves qualify for or want. The program was so toxic politically because people who didn’t qualify for its premium subsidies were furious over being taxed to fund subsidies for people who did.
So if the only right we have in this area is to healthcare we need and can’t afford, that puts us squarely atop one of the most active fault lines in American political life, where there’s unremitting conflict about who really “needs” healthcare, who really “can’t afford” it and who should pay for it. We shouldn’t be surprised then that while all twenty Democratic candidates (Is that where we are now? Twenty? I’ve lost count.) embrace the principle that healthcare is a right, the policies they think would operationalize it are all over the map.
Leon Galis is an Athens native who returned to town in 1999 after retiring from the faculty of Franklin and Marshall College in Lancaster, PA. Since 2008, he has written dozens of columns for local Athens media. Galis is a professor of philosophy emeritus, with broad interests in current events and cultural commentary. You may read additional works by Galis at https://medium.com/@leongalis