has been a major political topic in the United States for many years now. Should the government be in charge of providing the citizens with the basic necessity of healthcare? Or should it stay private with insurance companies handling the reigns? One argues that the citizens have the right to choose who their physicians are and that the government does not know what is best for them. The other ‘extreme’ side, who would support a socialized healthcare system, says that healthcare is a social issue that a government needs to provide for their citizens. They believe that all deserve the right to the same healthcare at an equal opportunity; that none deserve quicker or better treatment than anyone else. We are all equal, and something as basic as healthcare should be available to everyone, no matter their social or economic status. Thomas Jefferson’s quote on the necessity of a government at the signing of the Declaration of Independence said, “We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness –That to secure these Rights, Governments are instituted among Men…” Whether or not healthcare is a right, and governments are needed to secure these rights should be the debated issue. However, in the complex times we live in today, there is more to be considered in this decision than the simple moral concern of whether healthcare should be provided by the government or not. But if it is, the system should be fair for all citizens. On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) was signed in by President Obama as a compromised reform on our healthcare system that he believed would make some progress on finding a happy medium between both sides of the complex debacle of a system we previously had. This paper will ethically evaluate whether or not this is ethical for American citizens.
Many questions arise when discussing this issue, like: What will bring the most good to the most people (utilitarian)? What fulfills the government’s duties, obligations, and responsibilities to the people? Basically, what is fair for our society as a whole? We are in a strategic position now in determining what the best healthcare system is for us. We are the only developed country without a national healthcare system, so we have the chance to evaluate what is best. By looking at the benefits and failures of our system, and comparing it to the several national systems in other countries, we have the knowledge and power to create the best system in the world (as long as lobbyist and greedy politicians do not corrupt the decision making process) (Ink, 2006).
United States Healthcare:
The money that we spend on healthcare has been getting out of control. It is far surpassing other country’s expenditures on healthcare, yet in 2001, half of bankruptcy filings were medically related (Inks). According to the World Health Organization, the United States is the third largest average spender on healthcare per capita after Luxembourg and Norway as of 2009 (see Appendix A), yet we are ranked 31st in the world for life expectancy. Luxembourg and Norway still beat us by two years for men and women’s average (WHO, 2011). The mortality rate rankings for children under the age of five are even worse. How can we be spending so much money on health care, yet not be on the top of the lists?
The medical treatment one may get in the United States is related to the type of health insurance that they are under. If approximately 46 million people are uninsured, 9 million of which are children, how can we say our system is fine (Huebner)? This statistic is rising steadily according to the World Health Organization (see Figure 1).
Figure 1: Total Health Expenditure per capita (Peterson, 2010).
In addition to the health of our citizens, the increasing rate of healthcare is also affecting our economy. Businesses cannot afford to provide their employees company healthcare, so some are moving their offices out of the country (Ink, 2006). Obviously there is much concern of changing our system. In 2002, 770 medical students (freshmen and seniors) from the American Medical Association Masterfile were surveyed to see their views on medical reform (see Appendix B). Problems such as medical student debt, patient out-of-pocket costs, physician paperwork, and access to care for everyone were apparent problems with our system compared to other countries.
So why are the costs so expensive? There are many reasons, but the PPACA aims to eliminate them. The mast amount of unorganized paperwork that is needed for insurance purposes require a lot time and money. Our system encourages doctors to order tests and interventions because of the service fee doctors get from it. This is very inefficient for the patients that need care. Doctors will waste their time checking things unnecessarily because they make more money that way. PPACA encourages electronic health records with incentives so that decisions are made more informative decisions. It also helps preventative care for patients to keep chronically ill ones out of the hospital. The PPACA also forces everyone to have some type of insurance of the four different pools; this is called the “individual mandate” (Baker, 2011). These are just a few of the numerous changes being made over the next few years, and I do not want to get into all of them. Many argue over the pros, cons, and costs of the changes, but I would like to identify whether the overall goals of the PPACA are ethical.
One of the main goals of the PPACA is to make healthcare more affordable. But how does the system organize this? The out-of-pocket premiums are designed to be more affordable to the poor and more expensive for the rich. Medicaid is there to take care of those below the poverty level. Obama’s big argument that may have won him the election is to take care of those middle-class Americans just above the poverty line, but still have trouble affording healthcare (good strategy to campaign to this class). Figure 2 depicts the price reductions.
Figure 2: Premium Reductions (Peterson, 2010)
If those who do not make a lot of money aren’t covering these costs, who is?…I wonder. Figure 3 shows how this equalizes the burden of healthcare has on families’ income.
Figure 3: Premiums Income Percentage (Peterson, 2010)
These savings are in addition to the Medicaid extension to 133% of poverty. People with preexisting conditions are better protected by giving them more opportunities and no longer able to be denied (under certain conditions). People’s coverage will not be dropped when they get sick (rescission) and children will be able to stay under their parents care until they are 26. I don’t want to list all the changes of this Act, but I do want to concentrate on where and how medicine will now be financed.
Is it fair that those who make more money support those who do not? It is fair to say that not everyone is presented with the same opportunity as others to be able to make such a living as others. But that is far too complex to organize a measure for that. Some work very hard for their income, whether it is large or small, some are lazy and do not make the effort that could earn them a higher salary, and some weren’t given the opportunity to do so. It is hard to make generalizations on how fair people’s incomes are, but it does not give the government the right to penalize those who make a lot of money. They could have been given their fortune on a silver platter undeservingly, but that doesn’t mean it should be chipped away at more aggressively than those who do not make as much to support them.
Looking at this from Nozick’s “Entitlement Theory” perspective, a person who acquires a holding in accordance with the principle of justice is entitled to that holding (Nozick, 1974). Each person’s salary, or inheritance, was earned in an exchange for their work, or relative’s work. The employer is not obligated to pay them a certain amount and the employee does not have to work at a specific company, so this is a fair exchange between them. This person deserves this holding, and nobody should be able to take it away from them; Nozick says this is injustice if they do. Nozick also claims that taxing the rich to support social programs for the poor is unjust because the transaction is forced. “Only voluntary exchanges are just (Nozick, 1974).” The government should spend taxes on social programs for everyone like infrastructure and schooling that is available equally for everyone. These services cannot be abused to the point where it takes privileges away from others. Everyone can drive on the streets – abuse would be congestion for everyone. All children can go to public schools – abuse might distract others, but it can be handled by the faculty. But to burden the rich to support the poor’s healthcare is unjust. Why should only some get reduction in payments for the same healthcare? People could neglect their health, act irresponsibly and hurt themselves frequently, and act paranoid and consult doctors habitually. This abuse to a public health service would take privileges away from others. Their personal actions would use tax dollars (unfairly) and take time away from the region assigned doctors. Since this system would be first come first served, a long wait for others who need serious attention from doctors would seriously affect others’ privileges. The poorer class ordinarily needs more health care than upper class because of the higher cost of a healthy diet, safer traveling, safer environment, etc., so why should the poor get such reductions on healthcare costs.
For example, looking at figure 3 above, a family making $30,000 versus a same-sized family making $60,000 per year, the latter family has to pay approximately twice as much as a pre-tax premium under the PPACA. That is $2,400 versus $4,800. What about $40,000/year versus $45,000/year. The poorer family would pay $3,800 and the richer family would pay ~$5,400 for a premium. As Forrest Gump would say, “That’s all I have to say about that.”
From a utilitarian viewpoint, the PPACA would be ethically acceptable. The 46 million without health insurance and 31 million workers underinsured would definitely benefit from this plan (Huebner). Obviously giving the poor better access to healthcare would benefit the country more than the negatives of using the rich’s money involuntarily. More people would have better health, which is probably a higher factor than money on the general population’s weight scale. But with an increasingly growing population on an overpopulated planet, is that best for everyone in the long run? Would flooding the limited number of doctors with millions of poor sick people that could not afford health care actually help everyone? It is hard enough to get time with a doctor now when only a portion of our population can afford seeing them. Plus the millions flooding the system are the ones that are probably paying the minimum for the program. We cannot clog up the line at the doctor’s office to make it difficult for the ones paying the most for it.
Obama’s argument to this is known as one of his biggest lies. On July 15, 2009, Obama said, “If you like your health care plan, you can keep that too.” But according to the PPACA, in 2014, almost all Americans will be directed to enroll in health plans made by the Department of Health and Human Services. We might be able to keep our plan now, but not for long.
This evaluation is too complex to determine with a simple “who will bring the most good to the most people” approach. I sway towards Nozick’s rationalization of having entitlement to your holdings. Governments should use taxpayer’s money for the overall benefit of society that the private industry would not otherwise invest in, but healthcare should also be earned by a just transfer of holdings. Whether the government or private organizations are providing it (both is a viable option), every person should be able to acquire it fairly. Each person earned their salary through a just transaction, so healthcare should be exchanged in a just transaction. With the PPACA’s plan, healthcare is not acquired justly. To receive the same treatment for a poor person versus a richer person, the costs to them are not equal.
Baker, Tom (2011). “Health Insurance, Risk, and Responsibility after the Patient Protection and Affordable Care Act: Research Paper No. 11-03.” University of Pennsylvania Law School – Institute for Law and Economics. Vol. 159 No. 6. June 2011. <http://papers.ssrn.com/sol3/papers.cfm?abstract_ id=1759366>.
Huebner, Jeffrey MD. (2006). “Universal Health Care and Reform of the Health Care System: Views of Medical Students in the United States.” Academic Medicine: Journal of the Association of American Medical Colleges. Volume 81 – Issue 8 – pp 721-727. Aug. 2006. <http://journals. lww.com/academicmedicine/Fulltext/2006/08000/Universal_Health_Care_and_Reform_of_the_Health.8.aspx#>.
Ink, Melissa (2006). Reasons to Support Universal Health Care in the United States of America. Yahoo! Voices. Accessed April 2012. <http://voices.yahoo.com/reasons-support-universal-health-care-united-67743.html?cat=5>.
Nozick, R. (1974). “The Entitlement Theory.” Anarchy, State, and Utopia. BasicBooks, Inc.
Peterson, C. and Gabe, T. (2010). Health Insurance Premium Credits Under PPACA (P.L. 111-148). Congressional Research Service. April 6, 2010. <http://liberalarts.iupui.edu/economics/ uploads/docs/jeanabrahamcrscredits.pdf>.
WHO – World Health Organization. (2011). World Health Statistics Report 2011. Global Health Observatory Data Repository. < http://apps.who.int/ghodata/ >.
Appendix A:ask me if you really want to see it