The liberal argument for the Democratic health care proposals currently before Congress depends for its force on the claim that health care is a right. The case for such reforms begins from the observation that some Americans cannot afford to purchase health insurance, which is important to getting health care. These bare facts, however, do little to make the current proposals seem compelling. After all, it can be said of many good things in life that many Americans—and indeed many people in any free economy—cannot afford them. Accordingly, liberals are forced to suggest that this factual situation presents an injustice because health care is a right.
The most obvious response available for those who oppose the proposals before Congress is to deny that health care is a right, or at least that it is a right in the sense implied by liberals. Opponents of Democratic health care reforms could contend that health care is not, as liberals imply, a positive right, a right that obligates society to take positive steps to provide something for those who cannot attain it by their own efforts. This argument might suggest that health care is properly understood only as a negative right, a right that obliges society to stand aside and not impede individuals in their pursuit of something by their own means. On this understanding, the argument would continue, the right to health care is already established in America. All Americans are free to seek health care without artificial restraint and to purchase as much as they can afford.
Such a response might at first appear attractive because of its clarity and simplicity, as well as its tendency to confine government to a strictly limited role. Nevertheless, these opponents should not embrace a wholesale denial that health care is a positive right. Taken to its logical conclusion, the insistence that health care is only a negative right would lead us to conclude that nothing wrong happens when someone is denied life-saving medical care simply because he cannot afford to pay for it. Most Americans—even those who are most committed to individualism and strictly limited government—sense that there is an intrinsic dignity in the human person that requires society to render him some positive aid, at least in his necessities, when society can afford to do so. It would be ridiculous to deny, however, that health care is in many cases a necessity, or to overlook the fact that America, as one of the world’s most prosperous nations, is able to render such assistance. In this light, it would be difficult to deny that health care is, at least to some extent, a positive right.
Nevertheless, even the understanding that health care is a positive right does little to justify the changes that the Democrats are proposing—changes admitted on all sides to require a serious extension of government control over the health care system, and hence over a large sector of the American economy and over an important aspect of every American’s life. The weakness in the case for the Democratic proposals stems, in the first place, from the fact that some positive right to health care is undoubtedly being largely secured under existing conditions. In the United States, hospital emergency rooms may not lawfully refuse to treat patients who cannot pay. In addition, American federal and state governments offer a program, Medicaid, to provide health care for the poor. Moreover, American society provides at least some additional free access to health care through clinics established specifically to serve the poor. If we understand the “right to health care” as a positive right to at least some minimal medical services, then the right is currently being respected.
Proponents of liberal health reforms, as a result, must argue that the right to health care should be understood as a right to “adequate” or “decent” health care, and that an adequate or decent standard is not currently being achieved. This claim raises the question: how are we to determine what is adequate or decent? Stripped of the normative terminology, the case for reform depends on the factual observation that some Americans are not getting as much access to healthcare as they want, even though the health services they seek do exist and could be provided. Most Americans would agree that this situation should be considered not only empirically but also morally, in light of a concern with what is owed to human dignity.
Nevertheless, if we consider the situation only in light of the facts as stated above, we see that the Democratic health care proposals will effect no uniform improvement. Instead, they will simply rearrange the distribution of dissatisfactions. If the extension of access to the health care system is not to bankrupt the country, it must involve some effort to control costs and therefore to limit the amount of health care that is provided. Since it is beyond even the power of Congress to repeal the laws of supply and demand, it is economically impossible simultaneously to increase the use of a service and keep prices down, without generating some kind of compensating scarcity. This is admitted, more or less openly, by the more candid advocates of the Democratic proposals. The end result of their reforms will be that many Americans will still not be getting as much access to health care as they want. Some will have to endure longer waits for services—delays that in some cases may result in irreversible damage to their health. In other cases a government provider will have to rule out some treatments for some patients because they are too costly. If, then, such proposals will generate nothing more than a variation on the situation that now exists, but with different people who are underserved, we seem not to have advanced the positive right to health care at all.
Liberals will respond that this statement of the case ignores important differences between the two sets of dissatisfactions involved. The currently underserved are largely the lower class, but this will not be the case under the system to be established. Under that system, they may sometimes still be denied, if what they seek is found to be too costly. They will not be denied, however, simply because of their inability to pay for what they seek. According to this view, under society’s existing health care arrangements some people are getting inadequate health care, while others are getting more than adequate health care. Thus the virtue of the new system will be that everyone will get at least adequate health care, even though this will involve the cost that some will not get as much as they used to under the old system. Hence the positive right to health care will be better fulfilled.
This returns us again, however, to the question: what is the standard according to which we are judging that the health care provided to lower class Americans under existing conditions is not adequate or decent? The complaint that the current system fails in this regard ignores the fact that the quality of health and medical services has increased dramatically over the last fifty years. Admittedly the lower class today does not have access to health care as good as that available to the rich and the middle class. Nevertheless, they today do have access to health care that is better—markedly better—than was available to the rich and middle class even a generation ago. On this view, even assuming (though not conceding) that the health care provided to the lower class by our current arrangements is not adequate, we have reason to hope it will become more and more adequate. Such considerations argue powerfully in favor of keeping the current system, which provides at least a minimum of care to all citizens but that also operates over time to raise the objective quality of that minimum.
This, I think, gets us to the core of the dispute. In arguing for a positive right to health care, the American Left does not in fact have in mind an objective standard, derived from human nature or from an understanding of genuine human needs, of what is adequate or decent in the realm of health care. Rather, what they find so intolerable about the current system is the mere existence of the differences it tolerates. Their objections are ultimately grounded in their egalitarianism. What is at work is not the need to provide humane conditions for human beings: the existing arrangements have been making conditions more and more humane already. Rather, what is at work is what Alexis de Tocqueville presents, in Democracy in America, as one of democratic society’s most powerful inclinations: the unreasoning desire for more and more equality. As Tocqueville observes, under aristocratic conditions, the most egregious inequalities pass unnoticed. When by birth one man rules and another serves, it will hardly be noted that the former can see a physician while the other cannot. Democracy, in contrast, abolishes such distinctions of rank and opens the way to all to rise according to the success of their own efforts. Once democracy establishes this fundamental equality, however, all remaining inequalities stand out all the more, irritating the democratic mind and calling for conquest.
Of course, Tocqueville’s account does not perfectly describe the most powerful intellectual reflexes of all Americans. Such egalitarian impulses are restrained in many Americans by their commitment to notions of individual responsibility that they derive from their religious traditions or from the Founding’s emphasis on individual rights. Tocqueville’s account does, however, offer a compellingly accurate description of the dominant inclinations of the American Left, the segment of society that is least committed to traditional religion or to the principles of the Founding, and which accordingly is most powerfully moved by the democratic social state’s egalitarian desires. This explains why American liberals can declaim so indignantly on the “right to health care” in a nation that provides all of its members with better health and medical services than have been available to almost all people in human history.
From the standpoint of a concern with what is owed to human beings as human beings, the liberal understanding of the positive right to health care appears groundless. They are not seeking to satisfy the requirements of human nature, but to satisfy an insatiable thirst for equality of conditions. This is why opponents of Democratic reforms are right to suspect that they are only a step on the way to fully socialized medicine. It is likely, as many have already observed, that a public-option health insurer will distort the market to the disadvantage of private health providers, rendering them less and less viable, and itself more and more the only alternative. It is, however, also almost certain, as Tocqueville teaches us, that whatever greater equality of conditions is generated by the proposed reforms, it will not be enough to satisfy the next generation of liberals, who will notice new inequalities against which to inveigh, new evidence that the ever expanding “right to health care” is being denied.
We have good reason to fear that Democratic health care reform will not only fail to satisfy the desires giving rise to it, but that it will also, in the long run, undermine the objective quality of health care for all Americans. If we are to attribute the half-century improvement in medical care to the existing balance of private enterprise and government assistance, then we must wonder whether such improvement will be slowed, stopped, or even reversed by reforms that undo that balance in favor of a much greater governmental role. Here again we may gain insight from Tocqueville. For, as he observes, the democratic demand for greater and greater equality more and more smothers all individual initiative, and hence the source of all social energy, under an oppressive blanket of government regulation and paternalism. There is no reason to think that this would be any less true in health care than in any field of human endeavor.