What Are the Bounds on the Right to Healthcare?

2 August 2009 at 10:10 pm RussCoff 8 comments

| Russ Coff |

My last blog dealt with the efforts to reform U.S. healthcare to reduce costs. Now I turn to the other key objective of achieving universal coverage. This seems at odds with lowering costs since covering 46 million uninsured people would not come cheap.

As Karl points out in his comment to my earlier post, many believe that healthcare is a right. Certainly there is an ethical and moral obligation to help those who are ill: it is part of the oath to which all physicians pledge as well as the UN charter.

But how far does this right extend? What level of healthcare is a human right and what level becomes a luxury? This is a very practical question. Currently there is a proposal for a luxury tax on insurance plans that offer too much coverage (Listen on NPR). Clearly some believe it is no longer a human right at that level. . . .

But let’s unpack the 46 million uninsured. A Kaiser commission report estimates that about 10 million of the uninsured are illegal aliens. This is conservative — it suggests that quite a few illegal aliens actually are covered. An NCHC report uses a similar estimate. Should they get free coverage? I’ll tip my hand here, I’m not opposed to covering illegal aliens if they are on a path to citizenship (which I also would support under the right conditions). However, it seems implausible to do either without first securing borders. Imagine the cost to taxpayers if sick people all over the world have incentives to enter the U.S. illegally? Even if this is desirable as a policy objective, is it sustainable?

Another issue is what portion of the uninsured could actually afford insurance but choose not to buy it? A paper by Bundorf and Pauly uses multiple methods to assess whether people can pay. The conclusion is that 25–75% of the uninsured can afford to buy at least basic coverage. In the same vein, the NCHC reports that nearly 40% of the uninsured reside in households that earn $50,000 or more.

Using conservative estimates, then, 50% of the uninsured are either illegal aliens or choose not to buy insurance. Probably another 25% are temporarily uninsured because they are between jobs or changing insurance vendors. As such, one can imagine that reasonable and ethical people may question whether the taxpayer should foot the bill for all of the uninsured.

Taxes (that would fund universal coverage) are not optional so the fact that people may legitimately differ in their beliefs is important. It is therefore a worthy effort to put some clarity around the extent and nature of the moral and ethical responsibilities. From a practical standpoint, since at least 90% of voters are insured, it is important to know how much they are willing to pay for the remaining 10%.

Let me close with a rather unscientific poll. Which types of uninsured would you be willing to pay for?

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8 Comments Add your own

1. Per Bylund | 3 August 2009 at 9:07 am

Imagine the cost to taxpayers if sick people all over the world have incentives to enter the U.S. illegally?

I think you assume too much in this statement. There may be an increase in sick people living very close to the border to try to enter the U.S. illegally if they automatically gain the right to health care. But I doubt we would see a great increase. There are many reasons for people to stay at home, and they are often stronger than the availability of health care.

I also doubt sick people in general would travel to the U.S. for health care when they are sick. “Free” health care has been supplied in e.g. the Scandinavian welfare states for decades without any noticeable “social tourism” and the quality of health care there is about the same as in the U.S.

My own experience (non-quantifiable and still untested) is that welfare benefits tend to create demand, meaning that people in welfare state systems seem to place greater value in welfare benefits than people in non-welfare states. A Swede, for instance, would find it much more “necessary” to have certain welfare benefits in order to lead a good life than e.g. a Taiwanese. Whether this is a result of a created dependence on welfare in welfare systems I do not know, but it seems a plausible explanation.
2. Eric | 4 August 2009 at 7:34 am

As a grad student, I’ve been uninsured (in the past) because I can’t afford it. So, I don’t understand, why would those who can afford it choose not to be uninsured?
3. russcoff | 4 August 2009 at 7:37 am

Per, you point is well-taken. One would not expect large numbers of people to come from all over the world especially if they have closer places with solid healthcare alternatives. However, there is ample evidence (as you point out) that people will at least cross the southern border to gain opportunities…

Here are some tentative results (from 40 voters) in the most unscientific poll. There is not an overwhelming willingness to increase taxes to cover most categories (not even children):
* Illegal aliens 18% (7 votes)
* Those who choose not to buy insurance 15% (6 votes)
* Employed but have no insurance 20% (8 votes)
* Uninsured children (8 million) 25% (10 votes)
* Temporarily uninsured 20% (8 votes)

So I ask again, what is the extent of the moral and ethical responsibility to provide universal healthcare?
4. Steve Phelan | 4 August 2009 at 11:16 am

It has already been decided that we have an ethical responsibilty to treat people in an emergency.

These “categories” currently crowd the emergency rooms of our hospitals leading to budget over runs and long waits for those with genuine emergencies. Emergency room care is more expensive than an office visit or even urgent care. Not to mention the benefits of preventative medicine in reducing costs.

So…what if universal health care actually reduces the amount of money spent on these categories?

P.S. I’m sure the polls would reveal the same results for public education.
5. M Lee | 4 August 2009 at 6:28 pm

Eric,
Probably below posting may explain why.

http://krugman.blogs.nytimes.com/2009/08/04/insurers-only-pull-your-coverage-when-it-hurts/
6. jeremy hunsinger | 5 August 2009 at 12:21 pm

I think we also have an ethical responsibility beyond emergency, and into preventative medicine, which follows in relation to limited right to learn/be educated that people have. Preventative medicine is in part the ongoing dialogue between physicians and their patients, that bring them greater knowledge of each other, which in turn improves the quality of life of everyone involved. I do not know if the right to health extends to the level of luxury, as i don’t know what that would be, perhaps voluntary surgery for appearances, or something, but then on occasion even such surgery may be necessary to the life and wellbeing of the person and it certainly is necessary for the surgeons that specialize in that sort of thing. One thing that i’m pretty sure we don’t have though… is a right to life in the u.s. at least, as there are death penalties, and that would clearly conflict, and parallelly we do not have the right necessarily to be secure in our bodies from which follows certain forms of privacy, as that has basically been given up to doctors in some circumstances.
7. russcoff | 6 August 2009 at 9:42 am

Steve, you are absolutely correct that, while most people do not wish to pay for these categories, they do crowd emergency rooms. They are getting very costly care now. What is the best and most efficient solution to that problem? Is it Universal coverage or are there cheaper ways to get healthcare to these populations?

Jeremy, we do have a responsibility. I personally give blood 4-6 times a year. The question is, what responsibility should be forced on taxpayers? It is very much a practical question since at least 90% of taxpayers have coverage and may not be economically better off with universal coverage. Unfortunately, nothing gets through if taxpayers oppose it…

Eric, it may be irrational but some people underestimate the likelihood of getting sick and allocate resources to other things that seem more valuable (like cell phones). Why do people use food stamps to buy food that lacks any nutritional value? Other people may correctly estimate a low likelihood of illness and choose to self-insure.
8. Steve Phelan | 7 August 2009 at 2:52 pm

Hi, Russ, some interesting ideas over at Harvard (of all places):

http://hbswk.hbs.edu/item/6245.html