Is Healthcare a Right? A Privilege? Something Entirely Different?

Election Day 2016 should have been Christmas morning for Republicans. Long awaited control of the White House and both houses of Congress. A chance to deliver on an every two-year election cycle promise to repeal and replace Obamacare. In 2010 Republicans needed the House. They got it. In 2014, it was the Senate. Delivered. But we still need the White House they said. Asked and answered with President Donald Trump.

So, what happened a few weeks ago when the House bill fizzled like a North Korean missile launch? Disparate factions within the House couldn’t unify behind Speaker Paul Ryan’s plan, despite pressure from the White House. For some it wasn’t a repeal, only a rearranging of the deck chairs on the sinking Obamacare ship. Others in the GOP were happy with the status quo, preferring to rail against Obamacare in campaign speeches rather delivering on empty campaign promises. Still others, #NeverTrumpers, knowing that President Trump was behind the House bill, preferred to see the bill, and Trump, fail.

Kudos to the Democrats. When they ran the show in 2008, they herded their cats and passed Obamacare. No Statist Caucus on one side or a Tuesday (or Thursday or Friday) group on the other side, each wanting their own version of healthcare reform.

The GOP will likely regroup and take another bite of the apple. What the final product will look like is anyone’s guess. Will it get through the Senate? Can it be passed via reconciliation or will the filibuster have to be nuked?

First, the GOP must answer a fundamental question. Is healthcare a right or a privilege? I don’t mean a discussion at a think tank or in a university classroom. But here and now in the United States based on what we as a country want. A recent Pew Research Center poll shows 60 percent of Americans favor universal coverage, meaning healthcare as a right.

Free market conservatives want the government out of healthcare. Certainly the federal government. Turn it over to the states via the Tenth Amendment or leave it to the market, like purchasing and insuring a home.

If healthcare is a privilege, not a right, what about the 10-year-old with leukemia whose family can’t afford six-figure cancer care? Or the working diabetic needing a $2000 per dose drug injected into each eye once a month so that he can maintain his vision, work, drive and support his family? How about the 20-year-old who fractured her leg on the ski slopes but doesn’t have insurance, savings or family support to pay the medical bill?

On the other hand, if healthcare is a right, an entitlement, then how much is enough? How much healthcare can society, meaning taxpayers, be expected to fund? What medicines and treatments are covered? What’s the free meal? Meatloaf and mashed potatoes or filet mignon and lobster? With a limited supply and unlimited demand, some form of rationing will be necessary.

Until these two competing concepts are reconciled, healthcare reform goes nowhere, just a patchwork attempting to satisfy both sides of the argument, but in the end satisfying neither.

Most developed countries have parallel public and private healthcare systems. A public option covering everyone, with minimal or no out-of-pocket expense to patients, but with long wait times for care and limited treatment options. And a private option allowing individuals to purchase the healthcare or insurance they want and need, paying for it themselves, without subsidies, tax breaks or any government assistance. One option a right, the other a privilege.

For an analogy, think of K-12 schools. A public option available without cost to students. For most, a good and more than adequate education. And a free-market private school option for those who desire and have the means. Shop around, pay as much as you want, or default to the public option.

Each system has its pros and cons, but they are separate and distinct. Instead we are trying to combine both into a single scheme — Obamacare, Ryancare or whatever finally emerges from Congress. We get the worst of both systems – bureaucracy and high cost. And the best of neither – no universal coverage and limited freedom of choice.

Wouldn’t it make more sense to simply create the two-system approach here in the US? Then my question wouldn’t need answering. The public system would be the “right” and the private system would be the “privilege.” This difficult to answer question, which legislators won’t touch with a ten-foot pole, can be easily answered by choosing “both.”

Brian C. Joondeph, MD, MPS, a Denver based physician and writer. Follow him on Facebook  and Twitter.

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24 replies »

  1. This is one of the largest problems America faces right now, and it will only get worse without thoughtful action. I do agree that the central issue that must be addressed politically is the of if we want healthcare to be provided to everyone for only those can afford it. Another issue that has not really been addressed is the cost of healthcare in the United States is higher than anywhere else in the world. Yet, according to the World Health Organization, the quality of healthcare we receive, and outcomes based on life expectancy are less than many other industrial nations.

    There is much misinformation relating to healthcare in America coming from both political parties. One fact that cannot be ignored is the cost of healthcare is a large factor that corporations must consider when hiring. Many families simply cannot afford the cost of healthcare insurance without help.

    When healthcare costs rise at multiples of the average wage increase and continues for year after year, the problem becomes exacerbated. Addressing the actual costs of healthcare will be critical to any long-term solution for America.

  2. If access to quality healthcare is to remain a privilege enjoyed by only those who can afford it, I think that says something about the limits of our ambitions as humans. Surely the species that put rovers on mars and super-computers in the pockets of nearly every member of society can figure out a way to make sure that people who are suffering can get adequate medical care in their time of need.

  3. Hank, how does a two tier system help more Americans get the health care they need? The system described by Dr. Joondeph would allow providers to opt into the upper tier so removing them from access to the rest of those needing treatment.

    All Dr. Joondeph’s plan does is protect high earners access to faster service and better care. His plan does nothing to expand access – only restricts access.

  4. Thank you Dr. Joondeph for the measured, sober take on our nation’s heathcare debate. I think that most people are compassionate enough to understand that people who are poor don’t deserve to die because they can’t afford the minimum care that they require. At the same time, people are rational and understand that resources are limited. Universal heathcare would simply require more resources than are currently available. Fully covering all Americans with premium healthcare coverage would mean a massive change to our tax laws in order to fund such an endeavor, and many see this as either impractical, or against their political ideology.

    Your proposed dual-approach is something that ought to be seriously considered if the real goal is to help more Americans get the healthcare they need. If the goal remains for politicians to score political points, I fear this type of solution will never come to pass.

  5. “Best of all, we want Peter to pay for all of this because we all feel that healthcare is our right!”

    Not exactly. I want taxes on harmful habits/choices to pay for the medical costs. Cigarette taxes should go to health care expanses not the general fund. I want a tax on your Aunt Susie’s sugar/fat craving to pay for her health care, and alcohol taxes should be dedicated to societal problems that booze creates. I think we should remove subsidies on corn (which gives you cheap food) and transfer them to fresh fruits and vegetables.

    Responsibility comes with a price tag.

    As for your knee, is it needing to be replaced because your too fat and too lazy to exercise? The moles are not a life altering condition – live with them, maybe even the one on the end of your nose.

    Why wouldn’t your wife’s insurance pay for her painful varicose veins – or do you just want her to live with it.

    Let’s see how you view health care when you get to Medicare age.

  6. I want a new knee and some moles removed. My wife wants her varicose veins removed since they are painful and look bad. Each of my four kids wants a boat load of services. My uncle, life long smoker, wants new lungs. Aunt Susie, who’s never passed a pound cake she couldn’t eat, wants bariatric surgery. My neighbor who has a drinking problem wants to go through inpatient rehab again (he’s already been through it five times)

    Best of all, we want Peter to pay for all of this because we all feel that healthcare is our right!

  7. Right on Jwood! I agree with you 100%! I too am part of the sucker middle class and I am growing increasingly angry with all this wealth transfer garbage pushed on us suckers by 1- those who receive direct benefit from it or 2-rich people who apparently have some guilt trip going on. I wonder which camp this Peter fellow lies in?

  8. Thank you for your balanced insight and opinion Dr. Joondeph. People that claim healthcare is a right without acknowledging/addressing the issue of limited resources may as well claim the moon is made of cheese and demand a free ride to moon to eat that cheese. Ain’t gonna happen! Claiming healthcare is a right is a silly, meaningless, platonic catchphrase meant to make people feel good about themselves.

    I am firmly in the camp that healthcare is a privilege. Perhaps your right to emergency care to stabilize yourself from death is a right but nothing more is your ‘right.’ I’ve tried to address this question many times and wrote two blog posts about this:

    Why is Health Care Considered a Right? Someone Please Explain.

    Are your ‘rights’ met if you get just a little healthcare?

    You should see some of the tweets I get that claim I’m a heartless, privileged old white guy. smh

  9. I visited the two largest VA hospitals in MN when my dad was a patient, and they are fine.

    But America is a physically enormous country. There are not even remotely enough VA hospitals to form a complete public network.

    We have to find some way to pay local hospitals to act as pubiic institutions. Some form of Medicare expansion will be the answer.

  10. More confusion from you about spin and the difference between facts and op-ed. Even if one looks at the references of the altlantic acticle you cite one sees the left wing Politifact saying the following about the claims of high quality care in Cuba,

    ” There is pressure to falsify statistics.”

    You are a pure ideolgue similar to those that could never give up their love for Stalin even after the Stalin papers were opened to the public.

  11. Thanks for the comments. The idea of using the VA infrastructure as a public hospital system makes sense. Hospitals and clinics already exist. Give the vets Medicare and let them get a higher quality of care without the hassles and waits at the VA. Other countries have a public hospital system that functions much like our VA system. And is free to legal residents without copays or any out of pocket expense.

  12. “Cuba actually has a pretty good health care”

    Quality healthcare might be in Cuba’s Constitution, but that is meaningless from a real perspective because the data is not open to independent verification. I seem to remember a comment made by a former advisor to the Cuban government on healthcare policy stating that at some of their favorable statistics were falsely created for ideological reasons. Pictures of Cuban hospitals, reports, etc. that were shown in the US demonstrate quite the opposite opinion of what you believe.

    Thanks for informing us that you don’t bother with verification of facts. It makes many of your Peterisms more understandable since you try not to confuse yourself with facts.

  13. “I have a crappy $7,500 deductible plan through my employer”

    That plan is tax deductible (subsidy) by your employer and I doubt you pay much if anything in premiums. The deductible is similar to plans in the ACA. But that “crappy” plan is a private market plan that you seem to idolize.

    Cuba actually has a pretty good health care based on extensive primary care doctors, but primary care access in the U.S. is hard for many people and I support more pay for primary care taken from specialists. Goggle RUC and see how the system is rigged in favor of specialists.

    Canada has no deductibles or co-pays and no networks.

    “I don’t want anything from the government, but if I needed anything, I would expect it to be sub-par quality, not feel entitled to get the same as someone who pays.”

    I guess that would include Medicare when you get there – “Gov’t run hospitals, limited networks, waiting periods, death panels, older equipment, etc.”

  14. All I’m saying is that there should be levels of quality. Pay nothing, get something but just not as good as people who pay. Worse health care would be Gov’t run hospitals, limited networks, waiting periods, death panels, older equipment, etc. You know like all those countries you idolize who have socialized medicine. I’m thinking Cuba type health care quality.

    I receive no subsidy, I’m part of the sucker middle class. I have a crappy $7,500 deductible plan through my employer, that I can’t use unless I’m dying. Co-insurance for ER Visits. We use urgent care for the small stuff that we basically pay out of pocket for, or use Tele-medicine. I tried to get a primary doctor and the admin who answered the phone laughed at me because the doctor (who my buddy recommended) hasn’t taken new patients, “in years.” The system is now flooded with too many people in the wagon and not enough people pulling the wagon.

    No, public education stinks too. My kids go to a private school that I can’t afford because its important to me and I invest in it, thankfully I can do that with education, I can’t avoid the masses in healthcare.

    I pay taxes for all sorts of things I don’t use, Public Schools, Medicaid, CHIP, Medicare, terrible roads in bad condition, etc. The police and Fire resources are utilized 80% in one small part of town. My trash is a private company, and they actually do a great job. I don’t want anything from the government, but if I needed anything, I would expect it to be sub-par quality, not feel entitled to get the same as someone who pays.

  15. “But if they want to give-away Cheese or some form of direct health care that is worse than what I can pay for, I’m okay with that.”

    How do you get your health insurance paid for J? Any subsidy?

    What would be “worse” health care?

    So is education a right or a privilege? Would you be happy with public “worse” education?

  16. Thank you Dr. Joondeph, yes, I agree! Please read my article on this same idea.


    The idea is to convert the current VA into the “health care for the poor” plan. The framework is already built with hospitals and docs. They spend about $180 billion the VA, (only the DOD has a larger budget) and they only cover about 15 million people. About the same as the total uninsured, around 5% of the population. So let the Veterans have private market access and convert the current VA system be the default for those who “fall through the cracks”.

    It’s not that I even believe that healthcare is a right, but I do think it would solve the economic and social problem. I believe that our country was founded only to give us Life, Liberty, and the Pursuit of Happiness, and all others must pay cash. Isn’t that enough? Something you can’t truly get anywhere else in the world. The government should not be allowed to give-away insurance, or EBT cards. But if they want to give-away Cheese or some form of direct health care that is worse than what I can pay for, I’m okay with that.

    I’m with Ben on this topic…

    “I am for doing good to the poor, but…I think the best way of doing good to the poor, is not making them easy in poverty, but leading or driving them out of it. I observed…that the more public provisions were made for the poor, the less they provided for themselves, and of course became poorer. And, on the contrary, the less was done for them, the more they did for themselves, and became richer.”
    -Ben Franklin

    You can’t give the same quality to all. That’s why you can’t ‘give-away’ insurance. With socialism, either the quality goes down for all or the cost goes up for all (unsustainable), it’s simple economics.

  17. I have always thought of it as a moral obligation rather than a right. A two tiered system is a good and workable idea. No one knows how to make health care cheaper, with better quality and more access. We need to pick the tradeoffs we are willing to accept. A system where we have in essence Canadian or NHS health care for everyone, but the ability to buy better care if you can afford it is probably affordable for the country. It means those in the public system sometimes wait a bit longer for elective care, but that is, IMO, an acceptable tradeoff to guarantee needed care. Of course, the devil will be in the details.


  18. Health insurance because of the benefits to Americans should be regulated, no one wants to go back to a time when insurance companies deny coverage even when people make their monthly payments,simply because they are sick. When we remove ideology from healthcare then we can begin to reform the entire system.
    The public system Obama Care should remain with some reform. Allow lower to middle income Americans to buy coverage using a subsidy. Create a private option for middle income to upper middle income people to buy coverage from insurance companies and use tax credit to reduce taxable income. The third option would be the current Medicaid program but people should contribute to the cost even 1-2% of income base on a sliding scale. The idea every one will be contributing to the system. The tax penalty for people who refuse to buy coverage should remain with a increase surcharge paid to insurance companies. Extend open enrollment for 6 month first year,second year 3 months,and 60 days there after allowing every one to get covered. Apply surcharge there after for people who refuse to follow the law plus tax penalty.

  19. A two tier system would look like “Separate but Equal” education did prior to desegregation.

    The public system will get increasingly starved of money with the sicker, poorer having no choice. And how do you allocate the same providers who have a choice of high reimbursements from private and low reimbursements from public. That’s what Medicaid is, a basic public system that gets starved of resources with high rationing. Everyone wants rationing for the other guy.

    As the Repugs turn more and more to vouchers for education, public education will be even more limited in what it can do from lack of adequate funding, which will lead voucher supporters to justify even more money to private facilities because the public system continues to fail in their self fulfilling prophecy. The same fate will come of a two tier health system – and it will not solve the cost problem.

    Private schools succeed because they don’t take all comers and attract the best, most supportive parents with the most resources to spend on their kids. A private health system will look the same.

  20. I agree with MommyDoc, I think a two tiered system would probably work best in the US. We are used to first class and coach, public / private schools, etc. As said in other comments, right now its is a nightmare. Remember, Medicaid does not pay us enough to even keep the lights on. So all this Medicaid expansion, is not care by the way, its very crappy insurance…it would be impossible to pay an electric bill with the tiny amounts Medicaid pays and all the denial hurdles thrown at us for ridiculous reasons. Remember, current regulations and program are driving MDs out in droves, and a real crisis is looming, if not here already. So don’t think that I will be working for free, I work very hard and I’m pretty sure I can find something outside front line medicine to do. So CMS ACA etc needs to be VERY gentle with those of us left actually doing the work of medicine. We are at a breaking point.

  21. * The ‘short answer’ is: the availability and accessibility by each citizen to HEALTHCARE was functionally guaranteed by the Federal EMTALA legislation passed by Congress in 1986. Although there is no formal basis, i.e., Constitutional Amendment or Congressional legislation, to specifically declare healthcare as a ‘right,’ the underlying concept continues to be useful to hopefully guide our national priorities.
    * The long answer is: HEALTH CARE, rather than healthcare, should be considered as one of the “clusters of benefits” that each community institutes for its Common Good to serve the needs its citizens. What makes it unusually complex, among many issues, is that many of the causes of each person’s Unstable Health are driven by forces not amenable to health care mitigation: homelessness, pandemics, highway safety, poverty, violence, family fragmentation, child neglect, illicit substance addiction… Mobilizing each community’s Social Capital asset would be required to promote the collaboration among its local institutions and their legitimate vested interests to augment the resiliency of its own Common Good, community by community. I would define a community for management of its Common Good as representing, on average, 400,000 Citizens (800 nationally).
    I propose that we spend one dollar per citizen, annually, for ten years to fix it. A new Congressional Chartered institution would be necessary to assist each locally supported collective thrust efforts.
    Universal Health Insurance would be a starting point. Over-all, a distributed risk management process would be necessary. A baseline concept might be characterized by
    * Citizen co-payments defined by each citizen’s disposable income,
    * Adequately capitated Primary Healthcare,
    * Complex Healthcare risk pools (Specialists and Hospitals) protected by sensible stop-loss coverage from payer,
    * Payer risk protected by State risk pool, and
    * State-risk pool covered by the Federal government.

  22. Dr. Joondeph, I like your posts and agree with you. I believe the two-tier system is probably the best way to go. Many countries have a similar framework and it allows for the “right” ie basic healthcare and the “privilege” pulling out all the stops healthcare. Nicely done!