Health Care Is a Right, but Who Deserves a Subsidy?

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 left over from Bernie Sanders’ presidential campaign.

The rallying cry among proponents of a universal, single-payer health-care system is, “Health care is a right, not a privilege!” They seem to think that there’s a short inferential path from the principle to the policy. But there isn’t.

The moral principle that proponents of universal health care appeal to is that it’s a right, not a privilege. It’s an indication of how freighted the principle is that Atul Gawande, a highly regarded commentator on health care, devoted a New Yorker article last fall to the question of whether the principle is true. It’s also a measure of how hard it is to say anything useful about this that Gawande punted, settling for just reporting some ordinary health-care consumers’ befuddled, incoherent musings on the subject.

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. Sanders Democrats famously seem to think that there’s a short inferential path from the principle to the policy. But there isn’t. So instead of doing what Gawande couldn’t or wouldn’t, I’m just going to stipulate, as the lawyers say, that health care is a right, and try to figure out where that leaves us at the policy level.

It’s obvious why advocates of Medicare for everyone, as they call it, 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.

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. 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.

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 performance 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 on a reasonable understanding of the principle that if health care is a right, not everybody has that right. Only people who need health care and can’t afford it have a right to it. Those are the only people toward whom society has a corresponding performance duty.

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” health care and who really “can’t afford” it. So even if health care is a right, that seems to leave us about where we are now on the policy front.

If there’s a case for Medicare for everybody, then it’s based less on political morality than on the tactical benefit of means-testing nobody, to spare us the prospect of endless debilitating warfare over who does and doesn’t deserve it.