This was my final paper (only paper… only assignment PERIOD) for a graduate course I accidentally signed up for: Economic Justice. This particular paper is a variant of a thing I’ve done often, and it was a lot more of a bet-hedging than the “THERE IS NO SUCH THING AS ECONOMIC JUSTICE” Marxist critique I wanted to do. But, alas, I think you’re only allowed to do that once during college.
Currently, in the United States there are forty-five to fifty million people lacking basic preventative health care. This fact, a fact seemingly head and shoulders above any other in its sobering quality, is the clearest point at which any rational citizen of the United States would begin an analysis of the ills inherent in our health care system. Though there are many auxiliary and ancillary problems that plague the system, the mere fact that—amongst western nations—the United States government stands alone in not providing baseline care to tens of millions is a sad assessment of our national ethical schema. Indeed, I will argue that the most just and positively applicable solution to the problems of health care in the United States is the federal government providing health care to its citizens.
It is important, before arguing for a universal, federal system, to point out that the status quo under the Affordable Care Act is a marked improvement over the true free market that existed before it. However, the fact that the system is more or less a public-private hybrid wherein citizens are compelled to purchase insurance plans raises the critique that—for all of the waste and forced consumption in an ACA status quo—perhaps a true universal system would be preferable. It is from the end of this critique that the argument begins: yes, the status quo is improved from twenty years prior, but in no way shape or form are the health care-provision-based problems of the United States close to being solved.
Before outlining the argument for providing health care, the definitional bounds of the argument must be made. For the duration of the argument, the term “health care” must come to mean more than the simple syntactical definition—especially once one considers the large array of market and government methods of providing health care; the definition must be specifically targeted toward the United States by displaying characteristics unique to them. Being that the United States currently provides emergency ambulatory care to all of its citizens and preventative care (through Medicare and Medicaid) to the elderly and poverty-stricken, the distinction in “health care” in this argument comes with regard to prevention. The “health care” being considered in this argument is a form of preventative care directly provided to the citizen by the federal government. This care is not contingent on employment or social standing, but rather on citizenship, alone; placing this proposed right in American political jargon, health care can be considered a civil right under the umbrella of this argument.
Being that the intention of this paper is to make an argument for the normative and positive effects and benefits of changing the health care status quo, the current economic situation relating to health care must be addressed and related to the topic.
The practical fiscal bounds of the United States will require that this “health care” be paid for—inasmuch as it would create additional deficits—through some degree of progressive capitalistic redistribution—most likely though taxation.
Taxation is a strange thing to view through a normative lens when crafting policy, and luckily, the positive effects have been addressed, and even predicted by our own government. The Congressional Budget Office, several times during the 1990’s and 2000’s, put together reports outlining the costs and benefits of the implementation of various national health care systems. Their findings show how fiscally possible a true national health care system is.
“Under a single payer system with co-payments …on average, people would have an additional $54 to spend…more specifically, the increase in taxes… would be about $856 per capita…private-sector costs would decrease by $910 per capita….The net cost of achieving universal insurance coverage under this single payer system would be negative…. Under a single payer system without co-payments people would have $144 a year less to spend than they have now, on average…consumer payments for health would fall by $1,118 per capita, but taxes would have to increase by $1,261 per capita to finance this plan.”
Clearly, the option of providing a universal preventative health care to citizens is possible for the United States, if in the sense that it can be done with an uptick in taxes. The fact that it can be implemented—and at a cost that appears manageable for the vast supermajority of Americans—proves that it is a live, implementable, positive solution to the problem of lacking health care.
Another key element of the system being proposed for argument is the continued existence of a private insurance market. Though it may seem counter-intuitive when considering the harms and ills that private insurance conglomerates spawn in the status quo, if a baseline level of preventative care is provided by the federal government, then the idea of additional premium insurance packages and programs for the wealthy becomes tenable—much as is the case in France.
France has—as common knowledge and right-tending political vitriol would relay—a nationalized and federally provided system of distributing health care services. The system, a holdover from distinctly European views on the role of government, relies on conditions that, at first glance, put up significant roadbloacks to cross-application in the United States:
“Beginning with German legislation in 1881, governments have encouraged and structured these systems…. In France about 80 percent of the population is in one fund for salaried employees, but there are a number of smaller funds, for example for agricultural workers…. The sickness fund systems differ in the roles they leave to private insurance. In France, about 80 percent of the population has private insurance that supplements the sickness fund benefits, somewhat like U.S. Medigap policies.”
Clearly, the United States never had the large-scale trade-union and community-syndical organization that provided the funding basis for the original European systems. This is not to say, however, that nothing can be gleaned from the example of France. It is in that last portion—the supplemental private insurance—that its relevance to the United States system can be seen.
France’s system is unique—and in this uniqueness, quite applicable to the American capitalist sentiment—due to its hybrid health care market. Like the rest of the western European nations, France holds health care to be a civil right. However, their differences in implementation and regulation provide an option for implementation in the United States—owing largely to American leery-ness of completely nationalizing an industry. The French system allows affluent people to purchase additional supplemental coverage to expedite or allow greater choice in medical care. This may seem to be an unequal system, and one that would potentially lead to the same sort of abuses regarding variance in care such as in the United States, but according to Joseph White,
“…[other nations] must accept the standard fees if they wish to deal with public or sickness-fund patients… France allow(s) extra billing. That creates more inequality and probably does more to transfer costs to patients than to limit total spending. But France limits the number of doctors who can charge more, and most insurance does not pay the difference…. These measures and some competition among doctors mean that the proportion of the public that pays more is small enough to ensure that most providers are available to citizens who can pay only the standard amounts.”
Essentially, France uses the best portions of the US private model, but controls and regulates it in tandem with the publicly provided insurance, allowing tor the two to exist in the same market at the same time.
In summation, then, the health care model being proposed for argument is most likenable to the national health services of France: a baseline amount of preventative care provided by the federal government, with an additional premium market functioning for the benefit of those who might afford it.
The second supposition of this paper the regards the methodology behind the argument. Though there are certainly a number of related temperaments and viewpoints that can help to paint a holistic picture of the general positions of the modern American left and right, in order to draw a true distinction for a concrete examination something must be done for argument’s sake. Owing to the lack of concrete or monolithic definitions for American political factions, a synthetic definition of “United States Left and Right qualities” must be created before this particular analysis of healthcare can begin. Two sources—used in concert—can help to paint a picture of a traditionally “American” Left/Right divide for modern times.
The first source, Alexis de Tocqueville’s Democracy in America is instructive in helping to define the American political temperament. Written during the Age of Jackson—a rapidly democratizing era in American politics—de Tocqueville used his French outsider’s perspective to great effect, studying the Americans in the manner of a scientist. In his polemic, he comes to the conclusion that Americans are essentially hardwired to promote one of two qualities, liberty or equality. He further goes on to theorize that Americans, owing to their lack of an established aristocracy and having their positive rights guaranteed to a level unheard of in contemporary politics, will gravitate toward equality as “their idol.” If updated to regard contemporary issues on the role of government, his theory on American political psychology essentially holds that Americans are amenable to a growing role for the federal government, so long as this growth did not overpower the perceived overall liberty of the nation. Because American political society was a balancing act between the competing ideals of liberty and equality, de Tocqueville believed that, from time to time, there would be spurts of extreme pluralistic and aristocratic sentiment, serving to balance one another out. That said, sporadic, incremental corrections for liberty, in de Tocqueville’s eyes, were subordinate to the constant push toward equality exhibited by Americans.
The second source, the modern Italian political philosopher Noberto Bobbio’s Left and Right: The Significance of a Political Distinction shall be used to provide modern definitions and applications of the traditional and historical Left/Right divide. Bobbio, in observing the working of early 90’s Italian politics, as well as New Labour and the later New Democrats, devised a modern four-axis definition for the age-old political distinction. Using poles of egalitarianism, libertarianism, extremism, and moderation, Bobbio sorts the modern distinction in to extreme left, center left, center right, and extreme right—with the extremes being called as such owing to their propensity for authoritarianism in policy implementation.Equality and freedom, for Bobbio, become cleavage points between the left and right, and authoritarianism and libertarianism, respectively. Considering that through de Tocqueville’s analysis, America is uniquely anti-authoritarian, the “American” definition of left and right must come from Bobbio’s center parties, and thus equality becomes the point of distinction.
Equality, then, becomes the criterion of judging just action within a modern American democracy, having met the definitional qualities of the first political scientist to holistically analyze the United States as well as the most modern to write on the Left/Right distinction as a matter of temperament and philosophical qualia. Any policy proposal or theory must promote this defined modern American equality in order to be considered as the normative or positive solution to the problem of health care.
Now that health care and the American political status quo have been defined, the clear choice in providing a case for government-provided health care in the American status quo—the contractarian viewpoint of John Rawls—shall be addressed. Though it may be obtuse to justify the usage of Rawls in this instance, it is important to the component of the argument that deals with essential modern American characteristics. Rawls and his variant on contractarianism are the most modern and pluralistic of the philosophers and philosophies that can address this problem. The very fact that Rawls wrote his masterpiece, A Theory of Justice, in the modern United States, with full knowledge of the social and political ills of the nation, gives his work an added sheen of applicability.
Rawls’ contractarianism is, in essence, a modern, revised version of the classical social contract that takes in to account the responsibilities and roles that a government must play in a civil society. Recognizing that the laws of the government are the most direct aspects of physically tangible justice, Rawls theorizes that justice must be promoted by the state itself. Justice, for Rawls, is the intrinsic good that a government provides; if it does not provide for justice, then it is an illegitimate or unjust government.
In terms of grappling with what exactly justice shall come to mean for Rawls, the most important source is undoubtedly A Theory of Justice. For a brief overview, Rawls, in his touchstone work, lays out his theory on how justice shall come to be defined as fairness. In the “justice as fairness” theory, there are two thought experiments used as cudgels to lead to a fairness-oriented definition. The first, the veil of ignorance, is a fairly simple concept. The basic idea is that, if one were in the position of the policy-maker but had no access to knowledge about one’s self or capabilities, one would craft policy that considers and provides for the needs of the least-well-off.
Utilizing the veil of ignorance, Rawls develops his magnum opus: original position theory. Rawls theorized that behind the veil of ignorance—during a time in which a social contract was being formed—two principles would be paramount. The first, liberty, is a simple maxim that all humans have an intrinsic right to basic liberties such as life, autonomy, and property. The second principle, equality, is a slightly more nuanced concept requiring a segmented definition. The first portion of the principle of equality, and the ontologically superior one, is fair equality of opportunity. This sub-principle holds that all individuals should have practical and realistic opportunities to hold any office or position. Once this sub-principle is established, the next—the difference principle—is added. The difference principle is a variation on maximin theory; it essentially holds that the least well-off should be protected and insulated the most from potential inequalities. This conclusion leads to the idea that justice, as a concept, should be more concerned with the distribution of what Rawls called “primary social goods.” These primary goods, in Rawls’ view, were basic rights as well as economic or social privileges.
Rawls believed that, once the original position has been established and the political actors can be placed behind the veil of ignorance, the positive application of justice as fairness can begin—in other words, the fair distribution of primary goods to all members of society would occur, in Rawls’ conception of the thought-experiment.
Having established the borders of Rawlsian justice as fairness, it just now be proved health care, itself, would qualify as a just and fair right in this Rawlsian schema. Though Rawls, himself, never makes any claims as to the status of health care in his own schema for justice, his argument regarding primary goods can easily be extended to cover health care.
In A Theory of Justice, Rawls lines out the purpose of justice as fairness as curbing “the accidents of natural endowment and the contingencies of social circumstance.” It can be seen, then, that the distribution of primary goods, vis-à-vis the difference principle must be targeted toward “those who have the lowest index of primary goods when their prospects are viewed over a complete life.”
The issue, then, becomes what a complete life is. Vacuously enough, a complete life should come to mean, at a very base level, a life that is not ended prematurely. In addition, freedom from debilitating disease or crippling conditions could be included in the definition. Through any of those metrics, health would be a primary mitigating concern to the least well-off—and thus the care of it, perhaps, a primary good.
The most compelling argument for including health care as a primary good, however, utilizes the definition of primary good as being that which “every rational man is presumed to want.”By this metric, health care would be a primary good if all rational agents came to the conclusion that basic care for the health of a populace would be desired by the difference principle-illuminated disadvantaged class. Seemingly vacuously, no rational agent could come to any other conclusion than to include health care in the number of primary goods behind the veil of ignorance.
If health care comes to be defined a primary good, then by Rawls’ definition of justice as fairness provides the answer to the normative, just path (as well as the positively-implementable path, recalling the CBO statistics) that the United States must take: health care must be a provided good to all citizens. Through Rawls’ re-imagined social contract, using justice as fairness, the modern American contractarian viewpoint provides the single best answer for the way forward in the problem of health care.
Recalling that the synthetic definition of American left and right tendencies provided by Bobbio and de Tocqueville requires a countervailing opposite, one must provide the most modern takes on American right-tending political thought for arguement. In direct opposition to Rawls’ modern take on the contractarian model of political ethics, the libertarian and free market conservative viewpoints can be found—though in varying and surprising degrees. The free market conservative viewpoint, best advanced perhaps by Adam Smith or Milton Friedman, is not actually the most searing critique of this brand of government encroachment on private enterprise. In fact, considering many of the inefficiencies and abuses of the private insurance and HMO system, Smith would perhaps be in favor or a radically different, more regulated market.
In essence, the negative externalities on the overall economy from sick days, chronic injury, and other medical maladies mitigated by universal preventative health care may reach a point where the cost of taxation is outweighed. Further, beyond the potential losses in an economy from infirmity, the HMO system in the United States is notorious for its wasteful business practices. The administrative middle-manning creates a gap of cost on the system—as compared to Medicare and Medicaid—but does not deliver better care as a result. True, efficiency-minded free market conservatives might balk at such a system. Because our system either has those above characteristics, or because it is possible to conceive of such a system where the cost of taxation is outweighed by externalities, the true free market conservative viewpoint on universal health care is difficult to pin down. Though it is pointless nonsense to guess as to what Smith would say about a phenomenon—institutionalized health care, in this case—that did not exist during his lifetime, it would be reasonable to categorize the true free market conservatives’ viewpoint on the matter of government as ambivalent.
However, remembering that we are dealing with the United States, we must make allowances for the distortion of political concepts and philosophies. While many of the critiques of a Rawlsian example of a “socialist” health care system come in the garb of free market conservatism, most right-tending arguments in favor of the status quo are made from a largely libertarian viewpoint. They are not concerned with market efficiency as much as they are the creeping influence and power of a centralized federal government. This libertarian bent that the right side of American politics has recently adopted may have found a much better mouthpiece than Ayn Rand or Milton Friedman; as well, the libertarian viewpoint provides the man who believes that he has the attacking answer to Rawls’ ideas.
Much as Rawls represents the most modern and American variant of contractarianism, Robert Nozick can be seen as the most modern and American variant of libertarianism. Nozick wrote his flawed masterpiece Anarchy, State, and Utopia largely as a response to his co-faculty member at Harvard, Rawls. Though there are many examples in philosophical history of a manuscript being published as a response to another prominent work, there are no current philosophical conflicts that attack each other as directly, or in a manner as relevant to United States citizens as the divide between Nozick and Rawls.
In the work, Nozick makes the most cogent and current argument for the maximization of autonomy as a principle of morality—the libertarian principle of note in this argument. Making the preservation of individual agency the primary good that all humans seek, Nozick puts forth the notion that redistribution of any kind is inherently unethical—the exact opposite of the position that Rawls took in his theories.
Nozick’s direct response to a Rawlsian justice-based government comes in the form of an alternative social contract theory wherein he settles on the concept of the “minimalist state.” In Nozick’s eyes the just state should do no more than mutually protect and enforce contracts. Assuming that humans have natural rights, Nozick then goes on to posit that “any state more extensive violates people’s rights.” He ends his polemic with the statement that “The minimalist state treats us as inviolate individuals, who may not be used in certain ways by others as means or tools or instruments or resources… How dare any state or group of individuals do more. Or less.” Clearly, the application of progressive taxation in order to achieve the Rawlsian end of providing health care is incompatible with Nozick’s conception of just action.
In terms of defining what exactly constitutes a just action of acquisition in regard to Nozick’s conception of justice, one must look to the entitlement theory. The two components of entitlement theory, “principle of justice in acquisition of holdings” and “principle of justice in transfer of holdings,” hold that resources originally obtained or transferred without violating anyone’s natural rights are entitled to the individual who possesses them. Original position theory, in this case, would be wholly incompatible, as the advantages of birth that some members of society receive and enjoy would be considered just due to the lacking case of deprivation of natural rights (though the mother might disagree). Further, the tax-aided redistribution of the fruits of luck’s labor would be unjust according to Nozick; the minimalist state would have no power to tax, and the acquisition of capital by the state would be unjust in the transfer of holdings owing to the natural rights of the taxed being infringed upon.
Clearly, if the mechanism of providing health care came through progressive taxation, Nozick would abhor it prima facie. However, making his view on the matter even more transparent, Nozick actually uses health care as an example in Chapter 8. He begins by referencing a paper by Bernard Williams: “The Idea of Equality.” Williams argues that health care should be subject to equality-based conceptions of justice, referencing the inherent irrationality of patients of different class receiving different levels of care for the same illness. Nozick responds by arguing that Williams:
“ignores the question of where the things or actions to be allocated and distributed come from. Consequently, he does not consider whether they come already tied to people who have entitlements over them (surely the case for service activities, which are people’s actions), people who therefore may decide for themselves to whom they will give the thing and on what grounds.”
Nozick’s clear opposition to the idea of necessity of government-provided health care is near-palpable in his screed.
Though it would be tempting to immediately dismiss Nozick’s objections to Rawls in light of the prior arguments, his theories do have their finger on the pulse of a uniquely American sentiment of libertarian or capitalistic success. In a way, Nozick speaks to the id of American individualism in his analysis of justice—indeed, a tempting prospect for the greedy, capitalistic American citizen.
Actually attacking Nozick becomes very simple when one overlays the ideal worlds of he and Rawls against the status quo. In Nozick’s writings, he relies on a great deal of utopian thought and baseless claims (going so far as to start his introduction with a maxim that all humans have inviolate natural rights, and then proceeding to ignore the defense of that philosophically controversial claim for the next three-hundred pages), while Rawls relies on the self-interested rationality of the original position—an easy concept to prove the material effects of. A society structured around Nozick’s theories would be, as he himself acknowledges— even through the title, itself—an anarchic utopia. On the contrary, Rawls’ theory is applicable as a fiscal graft on to the status quo, immediately—if the prior definition of taxation as being the actor of justice as fairness is accepted. Further, playing in to the issue of taxation, the previously referenced CBO report proves the feasibility of implementation of a universal federal preventative health care system through taxation. So, in this regard, Rawls actually provides a more realistic and more just outcome, all while managing to provide health care, too.
This is not the only way in which Rawls’ justice is superior to the libertarian-dressed-in-free-market-conservatism opposition to single payer health care. Much of Nozick’s argumentation within his publication relies on the inviolate nature of human rights. This sounds well and good until one weighs Nozick’s right to inviolate rights against Rawls’ right to life. Accepting that health care can be included in primary goods, Rawls can be seen as being the better protector of individual life than Nozick, since the government would become an actor in prolonging the lives of its citizens. On the other hand, Nozick is essentially arguing for radical anarchic freedom as a matter of morality. Taken simply, Rawls’ defense of justice acts through the preservation and amelioration of life, and that should always be valued against the well-worded variation of “get off of my lawn” that Nozick provides. A government’s one duty to its citizens in the protection of life, and Nozick’s government—if it exists at all—simply would have no stake in providing health care.
Nozick’s flawed, albeit eloquent and thought-provoking, promotion of libertarian principles cannot be accepted as the solution to the problem of health care due to the fact that his minimalist state, in the ideal, would barely be a functioning government by our American conception of the thing. Despite our protestations to the contrary, Americans are fans of paternalistic and redistributive government, at least when presented with the alternative of utopian anarchy; after all, our government is closer to Rawls’ vision than Nozick’s.
That is why, in the end, there is no other option, as a just, modern, western civil society, other than to provide baseline preventative health care to its citizens. Rawls must be upheld in this case because justice as fairness is both the most practical and most just solution to the problem of health care; it fits the criterion of being both a live positive option as well as a—if not the most—morally defensible position. Recalling the starting point of the argument, that the large numbers of uninsured Americans is a moral failing of our nation, federally provided preventative health care is still left at the end, standing as an option. Rawls’ modern contractarianism, through justice as fairness, provides the best way forward for American society if it plans on continuing on as the “shining city on the hill.” But even besides Rawls, the earlier figures regarding the cost of implementation would hopefully give Nozick pause: is the range of a couple of hundred dollars on average in levied taxes truly worth the risked lives of fourty-some-odd million Americans? Despite Nozick’s intractability, the answer to that particular divide would hopefully be self-evident.
Works Cited
Bobbio, Norberto, and Allan Cameron. Left and Right: The Significance of a Political Distinction. Chicago: University of Chicago, 1996. Print.
Nozick, Robert. Anarchy, State, and Utopia. New York: Basic, 1974. Print.
Rawls, John. A Theory of Justice. Cambridge, MA: Belknap of Harvard UP, 1971. Print.
Rawls, John. Utilitarianism and beyond. Ed. Amartya Sen. Comp. Bernard Owen. Williams. Cambridge: Cambridge UP, 1982. Print.
Tocqueville, Alexis De, Richard D. Heffner, and Vartan Gregorian. Democracy in America. New York, NY: Signet Classics / New American Library, 2010. Print.
United States. US House of Representatives. Congressional Budget Office. Single-Payer and All-Payer Health Insurance Systems Using Medicare’s Payment Rates. By Sandra Christensen. N.p.: n.p., n.d. Print.
Wenz, Peter S. Beyond Red and Blue: How Twelve Political Philosophies Shape American Debates. Cambridge, MA: MIT, 2009. Print.
White, Joseph. “Health Care Reform the International Way.” Issues in Science and Technology 12.1 (1995): n. pag. Web.