Health Insurance Social Justice and Rights

The concept of justice is the second major ethical theme associated with health insurance. Concerns about justice and health insurance derive from the question whether it is fair for some, but not all, citizens to have insured access to healthcare. Originally, health insurance was viewed as required by social justice not for everyone, but only for those made vulnerable by the conditions of wage labor. Compulsory insurance schemes were designed to help capitalism by making the working class more secure. The U.S. middle class broadly committed itself to the voluntary purchase of health insurance when, as a means of winning better fringe benefits through collective bargaining (intensified under wage and price controls during World War II), getting health insurance as a benefit became a normative expectation of workers.

Once the idea of health insurance takes hold in a society and is widely believed to give access to a fundamental benefit of social existence, it comes to be seen as the way members of the society purchase their healthcare, not merely the way they protect themselves from potential financial loss. Having insurance and getting needed healthcare become closely linked in the logic of justice. (For an account of how social expectations give rise to the perception of entitlement and societal obligation, see the work of Michael Walzer.)

The idea of a right to healthcare as a requirement of social justice is intimately connected to the practice of collectively financed healthcare. The notion that healthcare might count among positive human rights derives from the widespread belief that healthcare successfully meets fundamental human needs, such as security, relief from suffering, prevention of premature death, and maintenance of functional capacity. (For a philosophical argument about the grounds and limits of universal entitlement, see Norman Daniels's work and Charles J. Dougherty's publication.) Creating legal protections for that right becomes a problem of political will.

The injection of rights language into political arguments about health insurance is itself evidence of the evolution of the concept and expansion of its original limited goal of protecting wage laborers from the effects of major illness. In the absence of a constitutional or statutory declaration of a right to healthcare, opinion leaders use human rights language to motivate members of society and to provoke legislative action aimed at helping persons whose needs are being ignored. While specific contractual rights to healthcare exist between insured persons and their insurance carriers, that is not what advocates of a right to healthcare have in mind. When reformers argue for a right to healthcare, they mean that basic relationships of solidarity and interdependence among all members of society create a societal obligation to ensure access to healthcare for all. (For a discussion of issues raised by rights discourse in relation to health insurance and access to healthcare, see the U.S. President's Commission Report, and the 1994 work edited by Audrey Chapman.)

During the second half of the twentieth century, aggregate expenditures for healthcare rose at such a dramatic rate that by the 1980s, cost control in healthcare became a central issue for reformers. However, the question of setting limits makes debate about a right to healthcare politically difficult. Unlike rights to liberty or the pursuit of happiness, which entail noninterference by others, a right to healthcare entails paying someone to provide costly services. By 1990, the need to speak of a limited right was clear to many leaders, although negative reaction to the idea of rationing healthcare led many to deny its necessity, and how to define limits was hotly debated (Strosberg). In 1989, the state of Oregon intensified the debate when it organized a unique social experiment to guarantee coverage to uninsured persons while setting limits on what would be covered based on a prioritized list of healthcare services (Garland, 1992, 1994, 2001).

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