Is health care a right or a privilege? - Health Policy

Physician Executive, Jan-Feb, 2003 by Howard Haft

"THE BIGHT TO BASIC HEALTH CARE IS AFFORDED TO EVERY CITIZEN OF TILE UNITED STATES."

Amendment (XXVIII) (2003)

Constitution of the United States of America

Of course there is no 28th Amendment to the Constitution. As a matter of fact, health care is not a right afforded to every citizen in our country.

Health care is a privilege attainable by the wealthy, a benefit provided solely at the discretion of an employer, a government subsidized insurance plan for the elderly or a charitable gift provided based on the goodwill of others.

The Founding Fathers declared that we are "endowed with unalienable rights, among them are Life, Liberty and the pursuit of Happiness." (1) There is no question that in order to have life we must have health. Yet there has been only limited constitutional language specific to this right.

The "cruel and unusual punishment" clause of the 8th Amendment to the Constitution has been interpreted by the Supreme Court to require prisoners, as part of their humane treatment during detention, to be guaranteed the right to health care. (2)

Currently prisoners are the only group who are specifically granted the right to health care. It is probable that the founders of our country, if they could have predicted the importance of health care, would have granted that the same standard of humane treatment be extended to every citizen.

At the time of the framing of the Constitution--though meager in its scope compared to today's standards--health care was generally available to all citizens. There was no major issue of lack of affordability or lack of access to care.

Framers of the Constitution, such as Thomas Jefferson, were heavily influenced by their personal experiences. Thomas Jefferson's personal physician, Robley Duglison, was aware of his patient's general distrust of medicine. Duglison wrote, "(Mr. Jefferson) has often told me he would rather trust to the unaided or uninterfered with efforts of nature than to physicians in general." (3)

Based on a realistic view of the impotent and poorly organized health care as it existed in the 1700s, Jefferson and the Founding Fathers probably found no reason to include health care as a specific right in the Constitution. They had no way to predict that health care would grow to be an integral part of the fabric of modern life and essential to the pursuit of life and happiness.

Value and cost

Our country and its health care system are radically different now than at the time of the Revolutionary War.

We are now blessed with a system that has enormous potential for the improving the quality and quantity of life. Life expectancy at birth has jumped from 39 years in 1850 to over 76 years in 2001. (4)

There have been enormous numbers of health care interventions that improved the quality of life. However, the improvements in quantity and quality of life occurred in concert with costs that increased both absolutely and relative to the wealth of the country.

Our health care system is now extremely expensive, costing us over a trillion dollars a year and consuming 13.2 percent of our gross domestic product in 2000. (5)

Over the years as the costs and complexity of health care rose, we responded by developing interim methods to fund health care for most of the citizens. Now, even as the capability to relieve suffering and prolong life is growing, the financial ability to provide these services to all of our citizens is steadily declining.

The disconnection between valuable health care and the financial ability of every citizen to access that healthcare brings into focus the essential question of health care as a right or a privilege.

Health care funding

How did we manage to avoid directly addressing this issue until now?

The answer is found in a series of interesting and temporary solutions to funding health care that developed over the past 100 years. It is helpful to review these events to better understand how we accept the current hodge podge of health care finance as a viable payment system.

Prior to the turn of the century, health care was almost exclusively paid for directly by cash by the consumer. Fortunately, health care was very affordable and accessible to virtually everyone. Physician office visits were 25 cents and house calls 50 cents.

It wasn't until after World War I that the costs associated with significant health problems exceeded affordability by the average person. Because of relatively low wages and rising costs for hospitalization, it was possible for a long hospital stay to have a serious personal financial impact.

In response, the not-for-profit Baylor Plan in Texas was developed in which a monthly payment of 50 cents indemnified school teacher enrollees from the costs associated with 21 days of hospitalization annually. This program later became the Blue Cross insurance plan. (6)

Soon after, Blue Shield was born creating similar indemnifications for physician's fees. Both of these schemes spread the costs of health care between those that needed services and those that remained without need. This method of funding was sufficient as long as the overall costs were low and everyone didn't use the services funded by the system.