Health Care in the U.S. Should Be a Basic Human Right, Not an Entitlement

By Greg H. Jones and Hagop M. Kantarjian, M.D.

“Mercy Killers” is a one-man show that describes the consequences of a major medical illness (breast cancer) in one family. This seemingly exaggerated fictional account is actually a daily occurrence in cancer care. The catastrophic consequences include loss of insurance due to technicalities; loss of savings and of homes because of the inability to pay mortgages; bankruptcy, humiliation and loss of dignity; divorcing spouses to become eligible for indigent care; compromising on ethics and principles to save one’s life; and often dying from lack of proper care that exists but is not affordable. “Mercy Killers” has a double meaning in the show: assisting the spouse to die when the cancer recurs, and the death of merciful interactions in modern health care. Profit is the killer of mercy in a for-profit health care industry that aims to maximize profits, even at the expense of patients’ lives.

The sad and shocking consequences of the lack of health care for millions of Americans bring up a critical question: Is health care a human right or is it a privilege?

All European nations have long-established national health insurance programs. These programs were initiated to ensure income stabilization and to protect against wage losses due to sickness, not to pay for medical expenses. These are in some ways analogous to the American Social Security program. Over time, European social insurance programs have evolved into flourishing universal health care systems. Both the European Union and the United Nations recognize health care as a basic human right; 38 percent of the constitutions of United Nations’ members guarantee medical care. The United States, Mexico, Korea and Turkey are the only nations in the Organization for Economic Cooperation and Development (OECD) that do not recognize universal health care as a basic human right. The Patient Protection and Affordable Care Act (ACA), implemented in 2014, is our first renewed attempt to develop universal health insurance coverage in more than 200 years.

The reluctance of the United States to embrace universal health care may be traced to earlier ideological movements, influenced by the writings of William Graham Sumner in the last three decades of the 19th century. His ideology of Darwinian evolution and Malthusian economic theory aligned with capitalism in many aspects and was accepted by most Americans. Sumner’s philosophy is summarized as follows: the world population is increasing geometrically but resources are increasing arithmetically. Thus, civilization has a simple choice: liberty, inequality and survival of the fittest, or no liberty, but equality and survival of the least fit. The former carries society forward and favors its most robust members; the latter carries society downward and favors its weakest members. His belief is that the pressure of a competitive system strengthens a society over generations. An implication of this principle was that government interventions interfere with natural selection and weaken societies.

Societal Darwinism influenced medical Darwinism (survival of the fittest) and encouraged the acceptance of unequal health care, or health care as an entitlement rather than a human right. The 20th century brought a shift toward the concepts of hard work, but also fairness and equal opportunities to reach the American Dream — hence, the need for social safety nets to protect Americans during periods of hardship. This evolution in thinking was not linear and has waxed and waned according to the ideologies of governments in power. In 2003, a Texas legislator said: “Where did this idea come from that everybody deserves free education? Free medical care? Free whatever? It comes from Moscow. From Russia. It comes straight out of the pit of hell.” Today, politicians do not profess or declare such statements in public because most Americans believe in equal access to health care, and that fairness in health care should be guaranteed. Eighty-three percent say health insurance is absolutely essential or very important; 70 percent say the United States should have universal health care coverage.

Since America believes in reward for hard work, but in fairness and equal opportunity, to have an equal opportunity, Americans need fair access to health care and education. Lack of good health care or education destines individuals to inevitable failure from childhood. Inequality leads to poverty, and to becoming a burden rather than a hope to our society.

If the United States is the richest country in the world, and we spend more on health care than any other nation (18 percent of our GDP, or 2-3 times more than other advanced nations), why do we rank poorly in objective measures of health care outcomes? This dichotomy between resources and outcome is related to the for-profit nature of the health care industry in the United States. In the European health care systems, most resources are spent on patient care. In the United States, less than one-third of the dollars are directed toward patient care; the rest is diverted as profits for the health care industry (e.g, high costs of hospital care, procedures, drugs and devices; physicians’ fees; excessive regulations and bureaucracy; high salaries and bonuses to health care associates and profits to investors). Also, large sums of money are spent by insurance companies to deny (rather than provide) health care, and by health care providers to receive a larger share of profits. Universal health care in the United States, if properly implemented, can be in the long run more efficient and more affordable than our current system.

American exceptionalism, the for-profit health-care industry, and physician concerns over income are the main factors that hindered progress toward universal health care. To this triad were added, at different times, varied sentiments and political opinions such as opposition to “socialized medicine,” anti-communism, fears of hospital desegregation, anti-welfarism and, more recently, unaffordable costs of universal health care.

The ACA, implemented 50 years after Medicare and Medicaid (signed into law by President Johnson in 1965), and our first attempt to make health care available and affordable to all Americans, is already making a difference. The rate of uninsured Americans fell from 18 percent to 10 percent (and it is even lower in states that accepted the ACA Medicaid expansion — 7 percent versus 14 percent). Health care spending is lower than estimated. More people approve of the ACA and 81 percent of individuals enrolled in ACA plans are satisfied with their coverage. And, it is already saving lives. None of the negative predictions concerning the ACA materialized (i.e., mass cancellation of existing insurance policies; increased cost of care; soaring insurance premiums; job destruction; “death panels”; the ACA death spiral).

The United States is unique among advanced nations in not guaranteeing basic health care. This is neither sound nor ethical in a nation that promulgates fairness, equal opportunity and the potential of the American Dream. Freedom does not imply denial of other human rights, including affordable health care to all. The American Dream is born from the premise of equal opportunity. Medical Darwinism is not consistent with fairness in a country that spends excessively on health care, but fails to distribute it justly or effectively. To live up to the ideals of our nation, equal access to health care is critical and health care should be a basic human right.

Gregory H. Jones is a first-year student at The University of Texas Medical School in Houston.

Hagop M. Kantarjian, M.D., is chairman of the Leukemia Department at The University of Texas MD Anderson Cancer Center and a Nonresident Fellow in Health Policy at the Baker Institute.

Note: A longer version of this commentary appears in the Annals of Oncology 2015, doi:10.1093/annonc/mdv321.

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