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Healthcare is a human right – but not in the United States

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The Supreme Court’s ruling on Dobbs v. Jackson in June is just the latest blow to health rights in the United States. National medical associations in the U.S. agree that abortion is essential to reproductive healthcare. So why would abortion not be protected as such? Because the U.S. does not, and never has, protected a right to health.  

Good health is the foundation of a person’s life and liberty. Injury and disease are always disruptive, and sometimes crippling. We might have to stop working, cancel plans, quarantine, hire help, and in cases of long-term disability, build whole new support systems to accommodate a new normal.

The U.S. remains the only high-income nation in the world without universal access to healthcare. However, the U.S. has signed and ratified one of the most widely adopted international treaties that includes the duty to protect the right to life. Under international law, the right to life simply means that humans have a right to live, and that nobody can try to kill another. Healthcare, the United Nations says, is an essential part of that duty. In 2018, the U.N. Committee on Civil and Political Rights said the right to life cannot exist without equal access to affordable healthcare services (including in prisons), mental health services, and notably, access to abortion. The U.N. committee mentioned health more than a dozen times in its statement on the right to life.

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The bottom line is: the U.S. can’t claim to protect life if it fails to protect health. And it has consistently failed on all three of the U.N.’s measures— the latest being access to abortion.

In the U.S., our debates around healthcare, and especially abortion, are hampered by a lack of right to health. Instead, the Supreme Court in 1973 protected access to abortion through the rights to privacy and due process, not health. Privacy is mentioned only twice by the U.N. committee commentary on the right to life.

Since Dobbs, several state legislatures have declared it fair game to criminalize abortion procedures even in cases where pregnancy threatens maternal health or life. Despite ample evidence that restrictive abortion laws lead to spikes in maternal mortality and morbidity—core public health indicators—the Court prior to the Dobb’s decision has defended abortion as merely a matter of privacy, not health or life. We know this is a myth. Abortion is deeply tied to the ability to stay healthy and in some cases, alive.

Regardless, our political parties remain deeply polarized on access to healthcare, including abortion. But lawmakers should know there is historical backing in the U.S. for elevating a right to health. None other than U.S. president Franklin D. Roosevelt, first proposed healthcare as a human right in his State of the Union address in 1944, as part of his ‘Second Bill of Rights.’ His list featured aspirational economic and social guarantees to the American people, like the right to a decent home and, of course, the right to adequate medical care.

Eleanor Roosevelt later took the Second Bill of Rights to the U.N., where it contributed to the right to health being included in the Universal Declaration of Human Rights in 1948. The right to health is now accepted international law, and is part of numerous treaties, none of which the U.S. Senate has seen fit to ratify. The U.S. conservative movement has historically declared itself averse to adopting rights that might expand government function and responsibility. In contrast, state legislatures in red states are keen to expand government responsibility when it comes to abortion. The conservative movement condemns government interference in the delivery of healthcare—except when it comes to reproductive health. The American Medical Association has called abortion bans a “direct attack” on medicine, and a “brazen violation of patients’ rights to evidence-based reproductive health services.”

Excepting access to abortion, U.S. lawmakers have largely left healthcare to the markets, rather than government. True, the government funds programs like Medicaid and Medicare but these programs vary significantly in quality and access by state, falling far short of providing fair, equitable, universal access to good healthcare.

The only two places where the U.S. government accepts some responsibility for the provision of healthcare are 1) in prisons and mental health facilities; and 2) in the military. While healthcare services in the U.S. prison system are notoriously deficient, they nevertheless exist and are recognized as an entitlement, underpinning the right to life. As an example, in 2005 a federal court seized control of the failing healthcare system in California’s Department of Corrections citing preventable deaths. In the military, free healthcare is an entitlement, and the quality of that care is deemed good enough even for the U.S. president.

So why doesn’t everyone in the U.S. have the same rights?

It is an uphill battle in a country that sees health and healthcare as a private matter for markets and individuals to navigate. But if we want to improve public health in the U.S. we need to start legislating healthcare as a right—and recognize that achieving the highest possible standards of public health is a legitimate government function.

photo: Tony Gutierrez / AP Photo

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Is health care a human right?

• Published: 13 August 2016
• Volume 37 , pages 249–257, ( 2016 )

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Few things in human life seem as important as health. Without it, one’s projects are likely to flag and falter, one’s experiences may darken, one’s life be less than it could be. In an era that invokes human rights for many phenomena that are less crucial than health, it seems natural to assert a human right to health. In the last few decades this assertion has been made by activists, by politicians, by the United Nations. The rhetoric of a human right to health has become a rallying cry. And because the talk of such a human right is so widespread, it is important that philosophers now do what they are good at doing: analyzing and assessing this sort of claim.

It is easy to see what might concern a philosopher. Take Article 12 of the International Covenant on Economic, Social and Cultural Rights. It proclaims a “right of everyone to the enjoyment of the highest attainable standard of physical and mental health” [ 1 ]. Can this be correct? Can there be a right to health? Rights usually correspond to duties, and duties obtain only if some duty-bearer has the power to do some particular thing. But can there be a duty-bearer who has the power to make everyone healthy ? It seems possible at most to provide health care , with the hope that this will lead to health. And even if the right is not to health but to health care, can everyone be given “the highest attainable standard” of health care? Should we neglect all other good things in order to procure the maximum health for the maximum number of people? Surely, health care is only one important good among others (e.g., education, safety from violence), and in a world of scarce resources, everyone cannot have all good things. Should we then construe a human right to health as a right to health care and attempt to specify it in some reasonably clear way?

Doing so will generate plenty of questions. What are the grounds for thinking that there is in fact such a human right? If the right exists, what is its content and what are its limits? Can the right be justified by linking it to other things that are already widely accepted as human rights? Who are the duty-bearers of the right? Does the right depend on accepting some picture of human flourishing, even if only a broad and general one? How does the right fit with the common belief that governments have an obligation to provide many of the material conditions for a healthy life, many of the so-called social determinants of health, such as clean air and water?

The contributors to this special issue develop these topics from a variety of perspectives. There is, I think, no basic agreement among the contributors. That is all to the good. What emerges are reasons to support the claim that there is a human right to health care, but also reasons to be mindful of that right’s limits, and even reasons to be skeptical about the claim that there is such a right. As I say, such differences are welcome. They are what one gets when one applies seven first-class philosophical minds to a deep and difficult topic.

Matthew Liao argues for a human right to health care on the ground that health care is a fundamental condition for the pursuit of a good life. Here is his argument for the fundamental conditions approach :

(1) Human beings have human rights to the fundamental conditions for pursuing a good life. (2) Basic health is a fundamental condition for pursuing a good life. (3) Therefore, human beings have a human right to basic health. (4) A human right to basic health implies a human right to those essential resources for maintaining and promoting basic health. (5) Basic health care is an essential resource for maintaining and promoting basic health. (6) Therefore, there is a human right to basic health care.[ 2 ]

Liao’s central thought is that there are some activities such “that if a human life did not involve the pursuit of any of them, then that life could not be a good life.” A condition of the good life involves being able to pursue an adequate range of these activities (e.g., deep personal relationships; active pleasures such as creative work and play). What Liao calls “the fundamental capacities” are those capacities required to pursue the basic activities. These include, e.g., “the capacity to think, to be motivated by facts, to know, to choose an act freely … to develop interpersonal relationships, and to have control of the direction of one’s life.” The ground for a human right to health care is its relation to the fundamental capacities, and this relation goes through the fact that, in general, health care is crucial to sustaining these capacities.

Now, Liao accepts (1) that there can be no right to health but at most a right to some of the social determinants of health, among them being health care, and (2) that health care is unlikely to be the most important social determinant of health. Nevertheless, he argues, “if we have a right to X, and Y is an essential means to X, it seems that we should have a right to Y”; we do have a right to health; health care is an essential means to health (even if other things are as well); therefore, we have a right to health care.

Many issues remain. For instance, who has the duty to make good on that right? Here, Liao distinguishes between primary and associate duty-bearers of rights. Primary duty-bearers are those who are at the levers of power. With health care, primary duty-bearers have the duty to set up institutions such that basic health care is available to all. Secondary duty-bearers must merely do what is needed to enable the primary duty-bearers to do their job. Secondary duty-bearers might be merely obliged to pay the taxes that support the institutions that make health care available.

Liao finishes by asking whether, in practice, the duty to make health care available to all could be so demanding as to call the human right into question. This goes to the more general question of the limits to the demandingness of morality. In a world of scarce resources and vast human needs, we are likely to have to adjust what can be demanded of us in one sphere to what can be demanded in another. Liao’s thought is that any such adjustment ought to be framed in terms of the thesis that there is a human right to the fundamental conditions for pursuing a good life. Health care is not the only such condition; however, it is an important condition and any balancing of duties will have to find an important place for it.

Jennifer Prah Ruger [ 3 ] begins by noting four features of current American health care. First, in terms of the United States constitution, health care rights are purely negative rights, e.g., the state may not prevent a woman from having an early-term abortion. Second, a patchwork of statutes (among them EMTALA, Medicare, Medicaid, SCHIP, ACA) has created a patchwork of positive legal rights to health care. Third, this patchwork of legal rights is fundamentally inadequate and needs to be replaced. Finally, fourth, as part of replacing it, a morally proper standard for health care provision is needed.

The standard that Ruger proposes is the health capability paradigm (HCP). Based on the capabilities approach pioneered by Amartya Sen and Martha Nussbaum, the “HCP provides a standard for health and health care toward which we can strive in our social and political organization, and a yardstick against which to measure our progress…. [It] is rooted in the Aristotelian view of the good life as human flourishing.” (One can see an overlap with Matthew Liao’s view.)

A couple of things should be noted about the HCP. First, it is different from an equality of opportunity approach to access to health care. Footnote 1 The latter has no independent standard for health care’s contribution to a good human life; rather, it stresses that access to health care is a condition for having an equal opportunity to attain the things that a modern society makes available. Such equal opportunity is assumed to be a requirement of fairness, independent of any substantive view of human flourishing. By contrast, the HCP builds in an outline of human flourishing through its specification of what it takes to be the key human capacities. Second, for policy purposes that outline needs to be made more precise, but in a diverse society it is important that no detailed account of human flourishing be built into health care legislation. Here, as a way to find useable content for such legislation, Ruger appeals to the idea of an incompletely theorized agreement. The hope is that, although we might have reasonable disagreements about many details, we can accept some basic goals for health care legislation, for instance, “preventing premature death and preventable morbidity…. These central elements represent universally valued elements of health capability.”

This might seem anodyne. In fact, in Ruger’s hands it becomes radical because it is coupled with a commitment to equality. “The HCP employs ‘shortfall equality,’ used in welfare economics, to assess health policies and health inequalities…. Inequalities in health capabilities are unjust if they represent a shortfall from the optimal standard and can be prevented, avoided, or ameliorated.” It is easy to move from the standard of shortfall equality to the conclusion that, at least in terms of the distribution of health capabilities, many existing societies, almost certainly including the United States, are unjust.

Ultimately, Ruger argues, a just and stable distribution of health capabilities will depend upon the widespread internalization of an appropriate social norm with regard to such things. Citizens must come to regard health care as a positive right and so come to see inequality in health care as a basic injustice that must be remedied. In this regard, achieving just health care in the United States will require much transformation of our public norms.

In his contribution, James Nickel [ 5 ] takes on the topic of linkage arguments. Such arguments are popular in the human rights literature. They move from a right of some kind that is widely accepted—widely accepted as a right—to another right that is claimed to be, in some sense, a condition of realizing the widely accepted right. However, as Nickel shows, the structure of this sort of argument is not simple. Nickel’s claim, made in careful and subtle detail, is that there are many ways in which one right Alpha might have another right Beta as its condition, that most of these ways come in degrees, and that, in the end, whether a given Beta is a sufficiently crucial condition of a given Alpha so as itself to count as a right will depend on a variety of empirical facts.

Here are a few of the many complexities that Nickel details. Beta might reduce the cost of realizing Alpha, thus making Alpha’s realization more likely; Beta might promote “acceptance, knowledge, and use” of Alpha (suppose there is a right to political participation; a population of adequately educated citizens might avail themselves more often and easily of that right); or Beta might promote “the willingness and ability of dutybearers to meet their responsibilities” (suppose there is a right to political participation; adequately educated officials might be more adept at making sure that citizens can avail themselves of this right).

The complexities also include ways in which it might be a mistake to think that Beta is a needed support of Alpha. For instance, a given Beta might be needed for a complete realization of right Alpha but not for its sufficient realization, in which case there may not be a compelling defense of Beta as a right.

Focused more particularly on a right to health care (RHC), Nickel asks “whether or not the full realization of RHC is indispensable or very useful to the realization of other [important] rights.” Nickel’s conclusion is complex, specific, and remarkable for its carefulness. He argues that there are ways in which RHC contributes to other rights. For example, it is less costly to educate healthy children; moreover, good health care reduces the likelihood of epidemics with their associated threat to such rights as freedom of movement and association. There are other ways in which Nickel believes RHC supports other rights (although he also notes that there might be ways in which RHC undermines other rights). However, he finds, and perhaps this is not surprising, the strongest linkage argument to be between RHC and a right to life. “The availability to all of an adequate basket of health care services and products will save lives from injuries and diseases that are amenable to medical treatment. Full realization of RHC is arguably indispensable to blocking some important threats to the right to life of many residents of [a] country.” Thus, Nickel concludes, a linkage argument does in fact ground RHC in its support of other rights, and it strongly grounds RHC in support of a right to life. Such conclusions, Nickel notes, “are not spectacular, but neither are they insignificant.”

Sarah Conly [ 6 ] accepts the existence of a right to health care but stresses that, like any right, its scope is limited by facts about scarce resources and human psychological tendencies. Rights are constrained by context, and, Conly argues, context involves considering costs and benefits. “How important is the exercise of a particular practice or the provision of a particular good? And, how costly is it to others? … [W]hat one can claim as a right will be sensitive to social costs, individual benefits, and the ratio of the two.”

There are real world limits to the supply of health care. Without beggaring other needs—in effect, other human rights, e.g., the right to education or to be safe from crime—we cannot supply health care to the max. But if health care is a great benefit, and yet, sadly, we cannot supply it to the max, then we ought to reduce the demand for it. This consideration naturally leads Conly to preventive health care. An obvious tack is health education, and Conly supports it. However, health education alone is insufficient. Incentives are needed. “We need to make it much more difficult to engage in behaviors that are bad for us.” There are many possibilities: taxing fast food or soda, prohibiting ads for such things, imposing portion limits in restaurants. Conly calls for creative ways to get us to adhere to a healthier form of living. At the limit, harmful foods and other things could be banned.

Conly knows that talk of taxes and prohibitions will raise hackles. “The right to health care is typically taken to expand our options, not to reduce them.” But if rights are sensitive to costs, then we must think about reducing the cost of a right to health care. Moreover, rights come with obligations: “the recipients of health care, in claiming their right, also place themselves under some obligations.”

An opponent might urge that lifestyle changes, although desirable, ought to be voluntary. And those who fail to adopt healthy lifestyles have only themselves to blame, and so ought to have no claim to health care resources. Conly thinks this “ignores too many realities of human psychology.” People are weak of will. They will predictably often take the course of least resistance, i.e., poor self-care. Conly thinks that such realities are sufficiently pervasive that institutions must play a role in guiding our choices. Nevertheless, Conly acknowledges that there is a difference between a person who engages in an unhealthy lifestyle because of limited alternatives (e.g., living in a food desert), difficult-to-avoid flaws in rationality, or other excusing conditions and a person who does so with full knowledge and unimpaired rationality. She thinks that the first retains a right to health care while the second does not. However, she goes on to note both that few people will fit into the second category and that society might still have a duty not to let such people suffer. That someone has no rights claim to health care does not entail that society has no duty to provide it. (Of course, the duty must then be justified in a different way.)

Overall, Conly’s essay is a plea to approach the issue of a right to health care with realism as well as with a willingness to make hard choices. Health care is resource intensive. We cannot all have all of it that we want; perhaps all of us cannot even have all of it that we need. Therefore, we must recognize our duty to conserve the resource and to find rules (legal and otherwise) to ensure that we do so.

In his essay, David Reidy [ 7 ] argues for a “cautious and circumspect use of human rights language within deliberation over and advocacy for improved health and health care policies around the world.” Reidy reaches this conclusion in an unusual way: by focusing on the moral status of the international treaties that guarantee a right to health care (e.g., the International Covenant on Economic, Social and Cultural Rights (ICESCR)). These are often regarded as signal international achievements. They seem to be proper responses to the fact, as Reidy emphasizes, that our moral rights often need institutional embodiment for their effective exercise. To “provide persons … with specific, targeted high-priority normative direction,” he notes, “rights typically require some measure of conventional or institutional embodiment or social recognition.”

It is precisely for this reason that one might applaud treaties such as the ICESCR. Here at last, one might think, is the needed institutional embodiment. Yet Reidy points out that there is a normative gap between the existence of such treaties and their moral force to bind individuals. The problem is not that the treaty signatories might have signed unwillingly. Even if they were willing signers, the internal structure of a signing state might not provide it with the moral power to bind individuals in its territory. Reidy asks the reader to consider a treaty between Syria and North Korea. Even if the various leaders signed it with enthusiasm, its content would hardly be morally binding on individual Syrians and North Koreans. Reidy’s point is that the content of a treaty is not morally binding unless the entity that signs the treaty is morally entitled to impose obligations upon those under its jurisdiction—and in many actual cases, including with some states that signed the ICESCR, the signatory does not hold legitimate power and so does not have such an entitlement. A treaty could thus be legally binding under international law but fail morally to bind individuals to act in accordance with it.

Reidy argues that valid legal obligations are also valid moral obligations only if they “arise out of a law-making process that satisfies certain substantive conditions of legitimacy.” He presses that it is “the nature of domestic law-making processes [that] determines whether states have the standing or status necessary for the international legal obligations and legal reasons created by their voluntary or consensual undertakings to have prima facie moral force.” Reidy develops this point by urging that only a “constitutional, rule of law, republic,” one that already protects “the most basic of human rights,” can generate moral obligations that bind its citizens.

The implication of Reidy’s argument is startling. Rights need duty-bearers to make them effective. But who counts as a moral—not merely a legal—duty-bearer for a human right to health care turns out to be far from straightforward. The mere fact that, say, the ICESCR is valid international law is not enough. According to Reidy, there can be no proper international moral structure for the human right to health care until the states that are signatories to the relevant treaties are internally structured in a morally adequate way. Perhaps all individuals do have a human right to health care, and perhaps such rights require institutional embodiment to be effective. Still, for such international arrangements to be morally binding on the individuals subject to them, the states involved must have met an appropriate standard of political legitimacy.

Gopal Sreenivasan [ 8 ] notes the following common claims:

There can be no human right to health because achieving health is beyond what social institutions can accomplish.

If there is a human right in this neighborhood, it is a two-pronged right: a right to an adequate provision of the social determinants of health (e.g., clean water) and a right to health care, for such things are within the purview of social institutions.

Sreenivasan challenges both of these claims. Against the claim that there is a human right to the social determinants of health, he presses that a human right is an individual right, something due the individual, but that the social determinants of health often require large-scale state action that affects and might even place duties upon many people. He concludes that such state action cannot be due an individual as her human right. His example is herd immunity from a disease. Jack cannot have a human right to such immunity because achieving it would require vaccinating millions of people. This might be good to do, but Jack, merely as one human being among others, cannot have a human right that millions of people be vaccinated. The burden is too great. It is one thing to claim that one has a right that the state do X with respect to oneself; it is quite another to claim that one has a right that the state do X (or Y or Z) to millions of others.

This tosses the ball back to whether there is a human right to health care. That looks as if its focus is properly individual. Here, Sreenivasan makes a different point. The appeal to health care rather than to the general provision of what makes for health (health care plus the social determinants of health) seems arbitrary because, in the end, what we care about is that social institutions facilitate citizens’ health to the extent that existing technology and resources permit. But if what makes for health are two instruments for achieving what we care about, namely, health, and if there is no human right (no individual right) to one of them (the social determinants), then it is unclear that what we care about, namely, health, can ground a human right to the other instrument. Consider that both instruments are focused on attaining the same goal. Now, given that health resources are finite, any sensible health bureaucrat must trade off resources allotted to one instrument against those allotted to the other. If one instrument is a human right while the other is not, it would seem that individual health care (the alleged human right) ought generally to win out over the social determinants of health (a goal, not a right). But the social determinants of health are far and away the more important instrument for attaining citizens’ health—the thing we care about. It would be a pyrrhic victory to gain a human right at the cost of losing the point of the right. It seems conceptually more sensible, Sreenivasan argues, to concede that there is no human right to health care.

Sreenivasan has further ingenious arguments against the claim that there is a human right to health care. As with the argument above, they target the common thought that one can get a human right to health care by subtracting from the claim of a human right to health. One concedes the absence of a right to the latter but asserts the seemingly more straightforward right to the former. Sreenivasan shows that this move requires far more defense than it has been given.

John Tasioulas and Effy Vayena [ 9 ] stress the need to distinguish between a claim of individual right to health care and the general social duty (incumbent upon governments, multi-national companies, perhaps even individuals) to remedy health shortfalls. Even were all human rights met, there could still be such shortfalls. This could be due to many things, e.g., unhealthy choices by individuals, problematic social determinants of health. Unlike other contributors to this issue, Tasioulas and Vayena accept that there is a right to health but they insist that it has two components: “health policy … has to be responsive both to human rights, including prominently the right to health, and to global common goods that bear on health.”

Many issues now need resolution. For instance, there is the problem of distinguishing what falls under the right to health from what falls under other rights (or is not a right at all). Health is clearly connected to many things but Tasioulas and Vayena argue that mere connection does not entail inclusion in a human right to health. It is both misleading and a hindrance to useful policy to put “entitlements to food, housing, life, education, privacy” and many other things under a right to health. (Here, Tasioulas and Vayena seem to agree with James Nickel that we should be very careful about linkage arguments.) Tasioulas and Vayena urge that the right to health includes only such other rights as serve “one’s interest in health as [their] primary and direct objective, as in the case of clean air and water.”

A second issue concerns the determination of when a health interest becomes a health right. Tasioulas and Vayena press that duty-bearers who are supposed to act in such a way as to realize the purported right must actually be able to do so (e.g., at present it is not a practical possibility for all human beings to have “the highest attainable standard of physical and mental health”). Moreover, even if it is possible to realize an alleged health right, there is a threshold of burdensomeness on the duty-bearer that would remove the duty and thus forestall the claim of right. In practice, applying the standards of possibility and burden to determine what is and is not a health right will surely be difficult; still, these are the key standards to apply.

Finally, Tasioulas and Vayena address the issue of global common goods. These differ from rights but can be of profound importance. An individual might not have a right to a new kidney but it would be a great common good for there to be “a social ethos that … helps maintain an adequate supply of organs for transplant.” Both the state and individuals might have a duty to promote such an ethos.

Although they press the distinction between individual rights and common goods, Tasioulas and Vayena also stress that the distinction can be complicated. In some cases, they argue, individual rights do entail a common good. “[T]he relationship between human rights and common goods is not mutually exclusive.” Here, they disagree with Gopal Sreenivasan. In particular, they argue that herd immunity is a human right although each individual’s rights claim is not to make millions of others be vaccinated but to “a proportionate share” of what is involved “in a vaccination programme aimed at securing” herd immunity. Tasioulas and Vayena draw the inference that “some aspects of the common good are rights-based, in the sense that they include elements to which we have a right; and what these rights confer is a right to benefit from the common good in question.” This disputed issue—whether or how far a health care common good can be rooted in a claim of individual human right—is clearly among the most important to resolve.

In a vague and general way all the writers in this special issue and, indeed, most people believe that it would be a good thing if everyone were able to avail herself of adequate health care. Yet public policy requires that choices be made, and making policy choices usually involves setting up a moral hierarchy. The frequent claim that health care is a human right is a way to assert that it belongs near the top of any moral hierarchy. But of course not every claim is justified, so we need to know whether health care truly is a human right. It will be clear from reading the contributions to this special issue that there is ongoing disagreement about whether there is indeed a human right to health care; and if there is, what grounds such a right as well as how, in a morally defensible way, limits can be set to it. There is, then, plenty of work still to be done.

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Acknowledgments

These papers were initially given at a symposium, “Is Health Care a Human Right?” presented by the Neubauer Collegium for Culture and Society and the Pozen Family Center for Human Rights at the University of Chicago on October 10–11, 2014. I am very grateful to both the Neubauer Collegium and the Pozen Center for their help. I want also to thank the Franke Institute for the Humanities for its support of the symposium.

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Brudney, D. Is health care a human right?. Theor Med Bioeth 37 , 249–257 (2016). https://doi.org/10.1007/s11017-016-9376-6

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Published : 13 August 2016

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DOI : https://doi.org/10.1007/s11017-016-9376-6

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Health Care is a Right, not a Privilege

“If you have your health, you have everything,” the classic saying goes. This is obviously not perfectly accurate, as many healthy people certainly do not have everything. However, it does reflect the connection that the right to health has to other human rights, and the interdependency that all human rights have with each other. Poor health can keep us from going to school or to work, caring for our families, or fully participating in our communities. States are responsible for respecting, protecting and fulfilling their human rights obligations, with international, regional, national and local actors supporting states and holding them accountable. The right to health exists, distinct from traditional political and civil rights, and there is an entire global apparatus built around making the right meaningful and real. I will spend this year exploring and evaluating these systems and human rights frameworks, seeking to understand how to best implement the human right to health.

So what does the right to health mean? States are obligated to fulfill the right through the provision of access to health care and hospitals, safe drinking water and sanitation, and food and housing. It entitles people to a system of disease prevention, treatment and control with access to essential medicines. It extends beyond these entitlements to people’s freedoms, such as the freedom to say no to medical treatment. It relates to a range of health determinants , including gender equality, healthy working conditions, and health-related education. The right to health is not the right to be healthy, which is outside of states’ direct control. This is why it is referred to as the right to the “highest attainable standard” of health. UN bodies, specialized agencies, the private sector, and even health professionals have responsibilities related to the right to health. The nature of businesses’ specific obligations are a bit unclear, and states are ultimately accountable for human rights violations, but there is a growing effort to define human rights standards that are applicable to businesses.

The right to health is idealistic in many ways, but it can be monitored and enforced. Accountability and monitoring take place at national, regional and international levels with involvement from states, NGOs, national human rights institutions, international treaty bodies and UN Special Rapporteurs. At the national level, administrative and political mechanisms contribute to accountability, such as national health policies and budgets. National judicial mechanisms can provide legal remedies to individuals when their rights are violated. Incorporating the right to health into national or subnational laws allows courts to judge violations with direct reference to the ICESCR. For example, Argentinian courts have ruled that the state must guarantee an available supply of antiretroviral drugs to people who are HIV-positive. Additionally, the Treatment Action Campaign in South Africa illustrates the ability of NGOs to use advocacy and social mobilization to fight for the right to health in its work for equal access to HIV treatment. In 2001, the Pretoria High Court ruled in favor of the Treatment Action Campaign and held that government restrictions on the drug nevirapine were unconstitutional, since the drug was proven to be effective but the government decided that it could only be distributed at two research sites. The Constitutional Court upheld the Pretoria ruling, stating that the government’s policy did not meet South Africa’s constitutional obligations to provide access to health care that “takes account of pressing social needs.” The government then removed nevirapine restrictions at public hospitals and clinics and created a comprehensive program to progressively realize the rights of pregnant women to prevent mother-to-child HIV transmission.

Through this series of blog posts, I will write about the usefulness of the human rights framework to global health endeavors. I strongly believe that, as the UN High Commissioner on Human Rights and WHO have stated , “The right to health is a fundamental part of our human rights and of our understanding of a life in dignity.” Physical and mental health allow adults to work and children to learn. The right to health cannot be realized without the realization of other rights that exist at the root of poverty, such as the rights to food, housing and water. Through exploring victories and pitfalls, I want to improve our understanding of how to best implement the right to health in practice. Achieving health equity worldwide requires innovative and interdisciplinary work, which necessitates a comprehensive understanding of international human rights law and governance.

Julia Kaufman is a T’18 Alumna and a 17′-18′ Human Rights Scholar at the Institute.

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Is Health Care a Right?

By Atul Gawande

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right. The responses were always interesting.

A friend had put me in touch with a forty-seven-year-old woman I’ll call Maria Dutton. She lived with her husband, Joe, down a long gravel driveway that snaked into the woods off a rural road. “You may feel like you are in the movie ‘Deliverance,’ ” she said, but it wasn’t like that at all. They had a tidy, double-wide modular home with flowered wallpaper, family pictures on every surface, a vase of cut roses on a sideboard, and an absurdly friendly hound in the yard. Maria told me her story sitting at the kitchen table with Joe.

She had joined the Army out of high school and married her recruiter—Joe is eleven years older—but after a year she had to take a medical discharge. She had developed severe fatigue, double vision, joint and neck pains, and muscle weakness. At first, doctors thought that she had multiple sclerosis. When that was ruled out, they were at a loss. After Joe left the military, he found steady, secure work as an electrical technician at an industrial plant nearby. Maria did secretarial and office-manager jobs and had a daughter. But her condition worsened, and soon she became too ill to work.

“I didn’t even have enough energy to fry a pound of hamburger,” she said. “I’d have to fry half of it and then sit down, rest, and get up and fry the rest. I didn’t have enough energy to vacuum one room of the house.” Eventually, she was diagnosed with chronic-fatigue syndrome and depression. She became addicted to the opioids prescribed for her joint pains and was started on methadone. Her liver began to fail. In 2014, she was sent two hundred miles away to the Cleveland Clinic for a liver-transplant evaluation. There, after more than two decades of Maria’s deteriorating health, doctors figured out what the problem was: sarcoidosis, an inflammatory condition that produces hardened nodules in organs throughout the body. The doctors gave her immunosuppressive medication, and the nodules shrank away. Within a year, she had weaned herself off the methadone.

“It was miraculous,” she said. In middle age, with her daughter grown up and in the Army Reserves herself, Maria got her life back and returned to school. All along, she’d had coverage through her husband’s work. “They have amazing insurance,” she said. “I think one year the insurance paid out two hundred thousand dollars. But we paid out, too.”

This was an understatement. Between a six-thousand-dollar deductible and hefty co-pays and premiums, the Duttons’ annual costs reached fifteen thousand dollars. They were barely getting by. Then one day in 2001 Joe blacked out, for no apparent reason, at a Girl Scout meeting for their daughter and fell down two flights of stairs, resulting in a severe concussion. It put him out of work for six months. Given the health-care costs and his loss of income, the couple ran out of money.

“We had to file for bankruptcy,” Joe said. He told me this reluctantly. It took them more than five years to dig out of the hole. He considered the bankruptcy “pretty shameful,” he said, and had told almost no one about it, not even his family. (This was why they didn’t want me to use their names.) He saw it as a personal failure—not the government’s. In fact, the whole idea that government would get involved in the financing of health care bothered him. One person’s right to health care becomes another person’s burden to pay for it, he said. Taking other people’s money had to be justified, and he didn’t see how it could be in cases like this.

“Everybody has a right to access health care,” he allowed, “but they should be contributing to the cost.” He pointed out that anyone could walk into a hospital with an emergency condition, get treated, and be billed afterward. “Yes, they may have collectors coming after them,” he said. “But I believe everybody should contribute for the treatment they receive.”

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Like her husband, Maria leans conservative. In the 2016 election, Joe voted for Donald Trump. Maria voted for Gary Johnson, the Libertarian candidate. But on health care she was torn. Joe wanted Obamacare repealed. She didn’t.

“I am becoming more liberal,” she said. “I believe that people should be judged by how they treat the least of our society.” At her sickest, she had been one of them. But she was reluctant to say that health care is a right. “There’s where the conservative side comes in and says, ‘You know what? I work really hard. I deserve a little more than the guy who sits around.’ ”

A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe. They both told me about people they know who don’t work and yet get Medicaid coverage with no premiums, no deductibles, no co-pays, no costs at all—coverage that the Duttons couldn’t dream of.

“I see people on the same road I live on who have never worked a lick in their life,” Joe said, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.” Maria described a relative who got disability payments and a Medicaid card for a supposedly bad back, while taking off-the-books roofing jobs.

“Frankly, it annoys the crap out of me—they’re nothing but grasshoppers in the system,” Joe said, recalling the fable about the thriftless grasshopper and the provident ant.

The Duttons were doing all they could to earn a living and pay their taxes—taxes that helped provide free health care for people who did nothing to earn it. Meanwhile, they faced thousands of dollars in medical bills themselves. That seemed wrong. And in their view government involvement had only made matters worse.

“My personal opinion is that anytime the government steps in and says, ‘You must do this,’ it’s overstepping its boundaries,” Joe said. “A father, mother, two kids working their asses off—they’re making minimum wage and are barely getting by—I have no problem helping them. If I have someone who’s spent his whole life a drunk and a wastrel, no, I have no desire to help. That’s just the basics.”

Such feelings are widely shared. They’re what brought the country within a single vote of repealing major parts of President Obama’s expansion of health-care coverage. Some people see rights as protections provided by government. But others, like the Duttons, see rights as protections from government.

Tim Williams, one of my closest childhood friends, disagreed with the Duttons. Tim is a quiet fifty-two-year-old with the physique of a bodybuilder—he once bench-pressed me when we were in high school—and tightly cropped gray hair that used to be flame red. He survived metastatic melanoma, in the nineties, and losing his job selling motorcycles, during the great recession. He went through a year of chemotherapy and, later, three years without a job. He can figure out how to fix and build almost anything, but, without a college degree, he had few employment options. Hundreds of job applications later, though, he was hired as an operator at our town’s water-treatment plant, where I visited him.

The plant was built in the nineteen-fifties. We walked among giant pipes and valves and consoles that controlled the flow of water from local ground wells through a series of huge pools for filtration, softening, and chlorination, and out to the water towers on the tallest ridges surrounding the town. The low hum of the pump motors churned in the background.

People don’t think about their water, Tim said, but we can’t live without it. It is not a luxury; it’s a necessity of human existence. An essential function of government, therefore, is to insure that people have clean water. And that’s the way he sees health care. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together.

Before I entered the field of public health, where it’s a given that health care is a right and not a privilege, I had grown up steeped in a set of core Midwestern beliefs: that you can’t get something for nothing, and that you should be reluctant to impose on others and, likewise, to be imposed upon. Here self-reliance is a totemic value. Athens, Ohio, is a place where people brew their own beer, shoot their own deer, fix their own cars (also grow their own weed, fight their own fights, get their own revenge). People here are survivors.

Monna French was one. She was fifty-three years old and the librarian at Athens Middle School. She’d been through a lot in life. She had started a local taxi company with her first husband, but they couldn’t afford health insurance. When she gave birth to her daughter Maggie and then to her son, Mac, the couple had to pay cash, pray that there’d be no unaffordable complications, and try to leave the hospital the next morning to avoid extra charges. When Monna and her husband divorced, litigation over the business left her with no income or assets.

“I had twenty-six dollars, two kids, and a cat,” she said.

She held down five part-time jobs, working as a teaching assistant for three different schools during the day, bartending at night, and selling furniture at Odd Lots department store on weekends, while her parents helped with the kids. Finally, she got the librarian job. It was classified as clerical work and didn’t pay well. But it meant that her family had health insurance, and a roof over their heads. She also met Larry, an iron worker and Vietnam veteran, who became her second husband. He had two children, but he was older and they were grown. Together, Monna and Larry had a child of their own, named Macie. Then, thirteen years ago, Maggie, at age sixteen, was killed in a car accident. Seven years ago, Larry’s son, Eric, who had spina bifida and multiple medical needs, died suddenly in his sleep, at the age of forty.

After twenty-two years as a librarian, Monna still makes only sixteen dollars and fifty cents an hour. Her take-home pay is less than a thousand dollars a month, after taxes and health-insurance contributions. Her annual deductible is three thousand dollars. Larry, now seventy-four, has retired, and his pension, military benefits, and Medicare helped keep them afloat.

For all her struggles, though, Monna is the kind of person who is always ready to offer a helping hand. When I visited her, there were stacks of posters on her porch, printed for a fund-raiser she was organizing for her daughter’s high-school marching band. She raised money for her township’s volunteer fire brigade. She was the vice-president of her local union, one of the largest in the county, which represents school-bus drivers, clerical staff, custodians, and other non-certified workers. She’d been deeply involved in contract negotiations to try to hold on to their wages and health benefits in the face of cutbacks.

“I don’t know anything about health care,” she protested when I asked her for her thoughts on the subject. In fact, she knew a lot. And, as she spoke, I thought I glimpsed a place where the health-care divide might just allow a bridge.

Monna considered herself a conservative. The notion of health care as a right struck her as another way of undermining work and responsibility: “Would I love to have health insurance provided to me and be able to stay home?” Of course, she said. “But I guess I’m going to be honest and tell you that I’m old school, and I’m not really good at accepting anything I don’t work for.”

She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. “They have a card that comes in the mail, and they get everything they need!” she said. “Where does it end? I mean, how much responsibility do tax-paying people like me have? How much is too much?” She went on, “I understand that there’s going to be a percentage of the population that we are going to have to provide for.” When she was a young mother with two children and no home, she’d had to fall back on welfare and Medicaid for three months. Her stepson, Eric, had been on Medicaid and Social Security Disability Insurance before he died. Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid. “If you’re disabled, if you’re mentally ill, fine, I get it,” Monna said. “But I know so many folks on Medicaid that just don’t work. They’re lazy.” Like the Duttons, she felt that those people didn’t deserve what they were getting.

But then we talked about Medicare, which provided much of her husband’s health care and would one day provide hers. That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it.

I asked her what made it different.

“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.

“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.

Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.

The Oxford political philosopher Henry Shue observed that our typical way of looking at rights is incomplete. People are used to thinking of rights as moral trump cards, near-absolute requirements that all of us can demand. But, Shue argued, rights are as much about our duties as about our freedoms. Even the basic right to physical security—to be free of threats or harm—has no meaning without a vast system of police departments, courts, and prisons, a system that requires extracting large amounts of money and effort from others. Once costs and mechanisms of implementation enter the picture, things get complicated. Trade-offs now have to be considered. And saying that something is a basic right starts to seem the equivalent of saying only, “It is very, very important.”

Shue held that what we really mean by “basic rights” are those which are necessary in order for us to enjoy any rights or privileges at all. In his analysis, basic rights include physical security, water, shelter, and health care. Meeting these basics is, he maintained, among government’s highest purposes and priorities. But how much aid and protection a society should provide, given the costs, is ultimately a complex choice for democracies. Debate often becomes focussed on the scale of the benefits conferred and the costs extracted. Yet the critical question may be how widely shared these benefits and costs are.

Arnold Jonas is another childhood friend of mine. Blond, ruddy-faced, and sporting a paunch at fifty-two, he has rarely had a nine-to-five job and isn’t looking for one. The work he loves is in art and design—he once designed a project for the Smithsonian—but what usually pays the bills is physical labor or mechanical work. He lives from paycheck to paycheck. (“Retirement savings? Ha! You’re funny, Atul.”) Still, he has always known how to take care of himself. “I own my house,” he told me. “I have no debts.”

This is a guy who’s so handy that the cars he drives are rehabbed wrecks rebuilt from spare parts—including the old Volvo that he drove to the strip-mall Mexican restaurant near my family’s house, where we were catching up. But when I asked him about health care he could only shake his head.

“I just try not to think about it,” he said. He hadn’t seen a doctor in at least a decade. He got a health-care plan through an insurance-agent friend, but could only afford one with minimal benefits. He wasn’t sure whether he’d got an Obamacare subsidy. “I don’t read the fine print, because it’s going to be completely confusing anyway.” All he knew was that the plan cost him a hundred and ten dollars a month, and the high deductible (however many thousands of dollars it was, it was well beyond his savings account) made doctors’ visits almost out of the question.

“I am lucky I can get my teeth looked at because I’m dating a dental hygienist. But”—here he showed me his white-toothed grin—“I can’t date a dental hygienist and a cardiologist.”

Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life. But here was one that was beyond his control. “The biggest worry I have would be some sort of health-care need,” he said. A serious medical issue would cost him his income. As an independent contractor, he isn’t eligible for unemployment benefits. And, having passed the age of fifty, he was just waiting for some health problem to happen.

So did he feel that he had a right to health care? No. “I never thought about it as a matter of rights,” he said. “A lot of these things we think are rights, we actually end up paying for.” He thinks that the left typically plays down the reality of the costs, which drives him crazy. But the right typically plays down the reality of the needs, which drives him crazy, too.

In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care.

“I think the goal should be security,” he said of health care. “Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here.’ ” He went on, “Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.”

He told me about a friend who’d undergone an emergency appendectomy. “She panicked when she woke up in the hospital realizing it would cost her a fortune,” he said. “Think about that. A lot of people will take a crappy job just to get the health benefits rather than start an entrepreneurial idea. If we’re talking about tax breaks for rich people to create jobs and entrepreneurialism, why not health care to allow regular people to do the same thing?”

As he saw it, government existed to provide basic services like trash pickup, a sewer system, roadways, police and fire protection, schools, and health care. Do people have a right to trash pickup? It seemed odd to say so, and largely irrelevant. The key point was that these necessities can be provided only through collective effort and shared costs. When people get very different deals on these things, the pact breaks down. And that’s what has happened with American health care.

The reason goes back to a seemingly innocuous decision made during the Second World War, when a huge part of the workforce was sent off to fight. To keep labor costs from skyrocketing, the Roosevelt Administration imposed a wage freeze. Employers and unions wanted some flexibility, in order to attract desired employees, so the Administration permitted increases in health-insurance benefits, and made them tax-exempt. It didn’t seem a big thing. But, ever since, we’ve been trying to figure out how to cover the vast portion of the country that doesn’t have employer-provided health insurance: low-wage workers, children, retirees, the unemployed, small-business owners, the self-employed, the disabled. We’ve had to stitch together different rules and systems for each of these categories, and the result is an unholy, expensive mess that leaves millions unprotected.

No other country in the world has built its health-care system this way , and, in the era of the gig economy, it’s becoming only more problematic. Between 2005 and 2015, according to analysis by the economists Alan Krueger and Lawrence Katz, ninety-four per cent of net job growth has been in “alternative work arrangements”—freelancing, independent contracting, temping, and the like—which typically offer no health benefits. And we’ve all found ourselves battling over who deserves less and who deserves more.

The Berkeley sociologist Arlie Russell Hochschild spent five years listening to Tea Party supporters in Louisiana, and in her masterly book “ Strangers in Their Own Land ” she identifies what she calls the deep story that they lived and felt. Visualize a long line of people snaking up a hill, she says. Just over the hill is the American Dream. You are somewhere in the middle of that line. But instead of moving forward you find that you are falling back. Ahead of you, people are cutting in line. You see immigrants and shirkers among them. It’s not hard to imagine how infuriating this could be to some, how it could fuel an America First ideal, aiming to give pride of place to “real” Americans and demoting those who would undermine that identity—foreigners, Muslims, Black Lives Matter supporters, feminists, “snowflakes.”

Our political debates seem to focus on what the rules should be for our place in line. Should the most highly educated get to move up to the front? The most talented? Does seniority matter? What about people whose ancestors were cheated and mistreated?

The mistake is accepting the line, and its dismal conception of life as a zero-sum proposition. It gives up on the more encompassing possibilities of shared belonging, mutual loyalty, and collective gains. America’s founders believed these possibilities to be fundamental. They held life, liberty, and the pursuit of happiness to be “unalienable rights” possessed equally by all members of their new nation. The terms of membership have had to be rewritten a few times since, sometimes in blood. But the aspiration has endured, even as what we need to fulfill it has changed.

When the new country embarked on its experiment in democracy, health care was too primitive to matter to life or liberty. The average citizen was a hardscrabble rural farmer who lived just forty years. People mainly needed government to insure physical security and the rule of law. Knowledge and technology, however, expanded the prospects of life and liberty, and, accordingly, the requirements of government. During the next two centuries, we relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

Health care has been the cavernous exception. Medical discoveries have enabled the average American to live eighty years or longer, and with a higher quality of life than ever before. Achieving this requires access not only to emergency care but also, crucially, to routine care and medicines, which is how we stave off and manage the series of chronic health issues that accumulate with long life. We get high blood pressure and hepatitis, diabetes and depression, cholesterol problems and colon cancer. Those who can’t afford the requisite care get sicker and die sooner. Yet, in a country where pretty much everyone has trash pickup and K-12 schooling for the kids, we’ve been reluctant to address our Second World War mistake and establish a basic system of health-care coverage that’s open to all. Some even argue that such a system is un-American, stepping beyond the powers the Founders envisioned for our government.

In fact, in a largely forgotten episode in American history, Thomas Jefferson found himself confronting this very matter, shortly after his Inauguration as our third President, in 1801. Edward Jenner, in England, had recently developed a smallpox vaccine—a momentous medical breakthrough. Investigating the lore that milkmaids never got smallpox, he discovered that material from scabs produced by cowpox, a similar condition that afflicts cattle, induced a mild illness in people that left them immune to smallpox. Smallpox epidemics came with a mortality rate of thirty per cent or higher, and wiped out upward of five per cent of the population of cities like Boston and New York. Jefferson read Jenner’s report and arranged for the vaccination of two hundred relatives, neighbors, and slaves at Monticello. The President soon became vaccination’s preëminent American champion.

But supplies were difficult to produce, and the market price was beyond the means of most families. Jefferson, along with his successor, James Madison, believed in a limited role for the federal government. They did not take expanding its power and its commitments lightly. By the time Jefferson finished his two terms as President, however, city and state governments had almost entirely failed to establish programs to provide vaccines for their citizens. Thousands of lives continued to be lost to smallpox outbreaks. Meanwhile, vaccination programs in England, France, and Denmark had dramatically curbed the disease and measurably raised the national life expectancy. So, at Jefferson’s prompting, and with Madison’s unhesitating support, Congress passed the Vaccine Act of 1813 with virtually no opposition. A National Vaccine Agent was appointed to maintain stocks of vaccine and supply it to any American who requested it. The government was soon providing free vaccine for tens of thousands of people each year. It was the country’s first health-care entitlement for the general population. And its passage wasn’t in the least controversial.

Two centuries later, the Affordable Care Act was passed to serve a similar purpose: to provide all Americans with access to the life-preserving breakthroughs of our own generation. The law narrowed the yawning disparities in access to care, levied the taxes needed to pay for it, and measurably improved the health of tens of millions. But, to win passage, the A.C.A. postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth. The prospects and costs for health care in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)? Any of these can work. Each has been made to work universally somewhere in the world. They all have their supporters and their opponents. We disagree about which benefits should be covered, how generous the financial protection should be, and how we should pay for it. We disagree, as well, about the trade-offs we will accept: for instance, between increasing simplicity and increasing choice; or between advancing innovation and reducing costs.

What we agree on, broadly, is that the rules should apply to everyone. But we’ve yet to put this moral principle into practice. The challenge for any plan is to avoid the political perils of a big, overnight switch that could leave many people with higher costs and lower benefits. There are, however, many options for a gradual transition. Just this June, the Nevada legislature passed a bill that would have allowed residents to buy into the state’s Medicaid plan—if the governor hadn’t vetoed it. A similar bill to allow people to buy into Medicare was recently introduced in Congress. We need to push such options forward. Maintaining the link between health coverage and jobs is growing increasingly difficult, expensive, and self-defeating. But deciding to build on what’s currently working requires overcoming a well of mistrust about whether such investments will really serve a shared benefit.

My friend Betsy Anderson, who taught eighth-grade English at Athens Middle School for fifteen years, told me something that made me see how deep that well is. When she first started out as a teacher, she said, her most satisfying experiences came from working with eager, talented kids who were hungry for her help in preparing them for a path to college and success. But she soon realized that her class, like America as a whole, would see fewer than half of its students earn a bachelor’s degree. Her job was therefore to try to help all of her students reach their potential—to contribute in their own way and to pursue happiness on their own terms.

But, she said, by eighth grade profound divisions had already been cemented. The honors kids—the Hillary Clintons and Mitt Romneys of the school—sat at the top of the meritocratic heap, getting attention and encouragement. The kids with the greatest needs had special-education support. But, across America, the large mass of kids in the middle—the ones without money, book smarts, or athletic prowess—were outsiders in their own schools. Few others cared about what they felt or believed or experienced. They were the unspecial and unpromising, looked down upon by and almost completely separated from the college-bound crowd. Life was already understood to be a game of winners and losers; they were the designated losers, and they resented it. The most consistent message these students had received was that their lives were of less value than others’. Is it so surprising that some of them find satisfaction in a politics that says, essentially, Screw ’em all?

I met with Mark, a friend of Arnold’s, at the Union Street Diner, uptown near the campus of Ohio University, which makes Athens its home. The diner was a low-key place that stayed open twenty-four hours, with Formica tables and plastic cups, and a late-night clientele that was a mixture of townies and drunken students. I ordered a cheeseburger and onion rings. Mark ordered something healthier. (He asked me not to use his last name.) The son of a state highway patrolman, he had graduated from Athens High School five years ahead of me. Afterward, he worked as a cable installer, and got married at twenty-three. His wife worked at the Super Duper grocery store. Their pay was meagre and they were at the mercy of their bosses. So, the next year, they decided to buy a convenience store on the edge of town.

Mark’s father-in-law was a builder, and he helped them secure a bank loan. They manned the register day and night, and figured out how to make a decent living. It was never a lot of money, but over time they built up the business, opening gas pumps, and hiring college students to work the counter part time. They were able to make a life of it.

They adopted a child, a boy who was now a twenty-five-year-old graduate of the local university. Mark turned fifty-seven and remained a lifelong conservative. In general, he didn’t trust politicians. But he felt that Democrats in particular didn’t seem to recognize when they were pushing taxes and regulations too far. Health-care reform was a prime example. “It’s just the whole time they were coming up with this idea from copying some European model,” he said. “And I’m going, ‘Oh shit. This is not going to end up good for Mark.’ ” (Yes, he sometimes talks about himself in the third person.)

For his health coverage, Mark trusted his insurance agent, whom he’d known for decades, more than he trusted the government. He’d always chosen the minimum necessary, a bare-bones, high-deductible plan. He and his wife weren’t able to conceive, so they didn’t have to buy maternity or contraceptive coverage. With Obamacare, though, he felt forced to pay extra to help others get benefits that he’d never had or needed. “I thought, Well, here we go, I guess I’m now kicking in for Bill Gates’s daughter’s pregnancy, too.” He wanted to keep government small and taxes low. He was opposed to Obamacare.

Then, one morning a year ago, Mark’s back started to hurt. “It was a workday. I grabbed a Tylenol and I go, ‘No, this isn’t going to work, the pain’s too weird.’ ” It got worse, and when the pain began to affect his breathing he asked his wife to drive him to the emergency room.

“They put me in a bed, and eight minutes later I’m out,” he recalled. “I’m dying.” Someone started chest compressions. A defibrillator was wheeled in, and his heart was given a series of shocks. When he woke up, he learned that he’d suffered cardiac arrest. “They said, ‘Well, you’re going to Riverside’ ”—a larger hospital, in Columbus, eighty miles away. “And I went back out again.”

He’d had a second cardiac arrest, but doctors were able to shock him back to life once more. An electrocardiogram showed that he’d had a massive heart attack. If he was going to survive, he needed to get to Columbus immediately for emergency cardiac catheterization. The hospital got him a life-flight helicopter, but high winds made it unsafe to fly. So they took him by ground as fast as an ambulance could go. On the procedure table, a cardiologist found a blockage in the left main artery to his heart—a “widow-maker,” doctors call it—and stented it open.

“The medicine is just crazy good,” Mark said. “By twelve-thirty, I was fixed.”

After that, he needed five days in the hospital and several weeks at home to recover. Although he had to take a pile of drugs to reduce the chance of a recurrence, he got his strength back. He was able to resume work, hang out with his buddies, live his life.

It was only after this experience that Mark realized what the A.C.A. had given him. Like twenty-seven per cent of adults under sixty-five, he now had a preëxisting condition that would have made him uninsurable on the individual market before health-care reform went into effect. But the A.C.A. requires insurers to accept everyone, regardless of health history, and to charge the healthy and the less healthy the same community rate.

“This would have been a bad story for Mark,” he said. “Because the same time you’re being life-flighted is the same time you lose value to an employer. Your income is done.”

He no longer opposed the requirement that people get insurance coverage. Fire insurance wouldn’t work if people paid for it only when their house was on fire, and health insurance wouldn’t work if people bought it only when they needed it. He was no longer interested in repealing protections for people like him.

In this, he was like a lot of others. In 2013, before the implementation of the A.C.A., Americans were asked whether it was the government’s responsibility to make sure that everyone had health-care coverage, and fifty-six per cent said no. Four years after implementation, sixty per cent say yes.

“But that doesn’t mean I have to sign on for full-blown socialism—cradle-to-grave everything,” Mark said. “It’s a balance.” Our willingness to trust in efforts like health reform can be built on experience, as happened with Mark, though we must recognize how tenuous that trust remains. Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and the vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise.

Eight years after the passage of the Vaccine Act of 1813, a terrible mistake occurred. The Agent accidentally sent to North Carolina samples containing smallpox, instead of cowpox, causing an outbreak around the town of Tarboro that, in the next few months, claimed ten lives. The outrage over the “Tarboro Tragedy” spurred Congress to repeal the program, rather than to repair it, despite its considerable success. As a consequence, the United States probably lost hundreds of thousands of lives to a disease that several European programs had made vanishingly rare. It was eighty years before Congress again acted to insure safe, effective supplies of smallpox vaccine.

When I told this story to people in Athens, everyone took the repeal to be a clear mistake. But some could understand how such things happen. One conservative thought that the people in North Carolina might wonder whether the reports of lives saved by the vaccine were fake news. They saw the lives lost from the supposed accident. They knew the victims’ names. As for the lives supposedly saved because of outbreaks that didn’t occur—if you don’t trust the government’s vaccines, you don’t necessarily trust the government’s statistics, either.

These days, trust in our major professions—in politicians, journalists, business leaders—is at a low ebb. Members of the medical profession are an exception; they still command relatively high levels of trust. It does not seem a coincidence that medical centers are commonly the most culturally, politically, economically, and racially diverse institutions you will find in a community. These are places devoted to making sure that all lives have equal worth. But they also pride themselves on having some of the hardest-working, best-trained, and most innovative people in society. This isn’t to say that doctors, nurses, and others in health care fully live up to the values they profess. We can be condescending and heedless of the costs we impose on patients’ lives and bank accounts. We still often fail in our commitment to treating equally everyone who comes through our doors. But we’re embarrassed by this. We are expected to do better every day.

The repeal of the Vaccine Act of 1813 represented a basic failure of government to deliver on its duty to protect the life and liberty of all. But the fact that public vaccination programs eventually became ubiquitous (even if it took generations) might tell us something about the ultimate direction of our history—the direction in which we are still slowly, fitfully creeping.

On Mark’s last day in the hospital, the whole team came in to see him. He thanked them. “But I didn’t thank them for taking care of me,” he said. “I thanked them for when I was smoking, drinking, and eating chicken wings. They were all here working and studying, and I appreciated it.”

“That’s what you thanked them for?”

“Yeah,” he said. “Because if Mark wasn’t going to stop this, they were going to have to keep working hard. Something had to happen because Mark was clogging up.” And those people did keep working hard. They were there getting ready for Mark, regardless of who he would turn out to be—rich or poor, spendthrift or provident, wise or foolish. “I said, I am glad they do this every day, but I’m hoping to do it only once.” ♦

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By Malcolm Gladwell

By Rivka Galchen

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A Right to Health Care

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Research output : Contribution to journal › Article › peer-review

What does it mean to say that there is a right to health care? Health care is part of a cooperative project that organizes finite resources. How are these resources to be distributed? This essay discusses three rival theories. The first two, a utilitarian theory and an interst theory, are both instrumental, in that they collapse rights to good states of affairs. A third theory, offered by Thomas Pogge, locates the question within an institutional legal context and distinguishes between a right to health care that results in claimable duties and other dimensions of health policy that do not. Pogge's argument relies on a list of "basic needs," which itself, however, relies on some kind of instrumental reasoning. The essay offers a reconstruction of Pogge's argument to bring it in line with a political conception of a right to health care. Health is a matter of equal liberty and equal citizenship, given our common human vulnerability. If we are to live as equal members in a political community, then our institutions need to create processes by which we are protected from the kinds of suffering that would make it impossible for us to live as equal members.

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• Issues, ethics and legal aspects
• Health Policy

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• Right to health care Social Sciences 100%
• Right to Health Medicine & Life Sciences 94%
• Health Policy Medicine & Life Sciences 21%
• Psychological Stress Medicine & Life Sciences 21%
• health policy Social Sciences 15%
• reconstruction Social Sciences 14%
• resources Social Sciences 13%
• Delivery of Health Care Medicine & Life Sciences 13%

T1 - A Right to Health Care

AU - Eleftheriadis, Pavlos

PY - 2012/6

Y1 - 2012/6

N2 - What does it mean to say that there is a right to health care? Health care is part of a cooperative project that organizes finite resources. How are these resources to be distributed? This essay discusses three rival theories. The first two, a utilitarian theory and an interst theory, are both instrumental, in that they collapse rights to good states of affairs. A third theory, offered by Thomas Pogge, locates the question within an institutional legal context and distinguishes between a right to health care that results in claimable duties and other dimensions of health policy that do not. Pogge's argument relies on a list of "basic needs," which itself, however, relies on some kind of instrumental reasoning. The essay offers a reconstruction of Pogge's argument to bring it in line with a political conception of a right to health care. Health is a matter of equal liberty and equal citizenship, given our common human vulnerability. If we are to live as equal members in a political community, then our institutions need to create processes by which we are protected from the kinds of suffering that would make it impossible for us to live as equal members.

AB - What does it mean to say that there is a right to health care? Health care is part of a cooperative project that organizes finite resources. How are these resources to be distributed? This essay discusses three rival theories. The first two, a utilitarian theory and an interst theory, are both instrumental, in that they collapse rights to good states of affairs. A third theory, offered by Thomas Pogge, locates the question within an institutional legal context and distinguishes between a right to health care that results in claimable duties and other dimensions of health policy that do not. Pogge's argument relies on a list of "basic needs," which itself, however, relies on some kind of instrumental reasoning. The essay offers a reconstruction of Pogge's argument to bring it in line with a political conception of a right to health care. Health is a matter of equal liberty and equal citizenship, given our common human vulnerability. If we are to live as equal members in a political community, then our institutions need to create processes by which we are protected from the kinds of suffering that would make it impossible for us to live as equal members.

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UR - http://www.scopus.com/inward/citedby.url?scp=84864004518&partnerID=8YFLogxK

U2 - 10.1111/j.1748-720X.2012.00663.x

DO - 10.1111/j.1748-720X.2012.00663.x

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A right to health care

Affiliation.

• 1 Mansfield College, University of Oxford.
• PMID: 22789045
• DOI: 10.1111/j.1748-720X.2012.00663.x

What does it mean to say that there is a right to health care? Health care is part of a cooperative project that organizes finite resources. How are these resources to be distributed? This essay discusses three rival theories. The first two, a utilitarian theory and an interst theory, are both instrumental, in that they collapse rights to good states of affairs. A third theory, offered by Thomas Pogge, locates the question within an institutional legal context and distinguishes between a right to health care that results in claimable duties and other dimensions of health policy that do not. Pogge's argument relies on a list of "basic needs," which itself, however, relies on some kind of instrumental reasoning. The essay offers a reconstruction of Pogge's argument to bring it in line with a political conception of a right to health care. Health is a matter of equal liberty and equal citizenship, given our common human vulnerability. If we are to live as equal members in a political community, then our institutions need to create processes by which we are protected from the kinds of suffering that would make it impossible for us to live as equal members.

© 2012 American Society of Law, Medicine & Ethics, Inc.

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• Global Health
• Health Services Accessibility / ethics*
• Health Services Accessibility / legislation & jurisprudence
• Human Rights* / legislation & jurisprudence
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OCR Health Equity Factsheet

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) implements statutes that are critical to health equity, including federal civil rights laws, conscience and religious freedom laws, the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules, and the Patient Safety Act and Rule, which together protect fundamental rights of non-discrimination, conscience, religious freedom, and health information privacy. OCR’s Strategic Plan provides a framework for how compliance work, partnerships, and operations can implement the Biden-Harris Administration’s commitment to advancing health equity, as described in President Biden’s Executive Orders 14076 , 13985 , 14091 and 14110 .

OCR adopts the definition of health equity articulated in Executive Order 14091 of consistent and systematic treatment of all individuals in a fair, just, and impartial manner, including individuals who belong to communities that often have been denied such treatment, such as Black, Latino, Indigenous and Native American, Asian American, Native Hawaiian, and Pacific Islander persons and other persons of color; members of religious minorities; women and girls; LGBTQI+ persons; persons with disabilities; persons who live in rural areas; persons who live in United States Territories; persons otherwise adversely affected by persistent poverty or inequality; and individuals who belong to multiple such communities.

OCR is working to advance health equity through its rulemaking and enforcement activities, both of which allow OCR to effectuate and enforce standards of the law to prevent non-discrimination and advance fair, just and equal treatment in Federally funded health care programs and activities.

Disability and Aging

Health Equity Goal: Ensure non-discrimination and increase access to services in the community for persons with disabilities who want to return to their communities from institutional settings or are at risk of institutionalization.

• Improve opportunity for people living with disabilities by resolving individual and systemic complaints alleging Olmstead violations and by increasing educational activities for the public that raise awareness of OCR’s enforcement authorities, including press releases on Olmstead resolutions, internal and external presentations, and website updates. Olmstead enforcement strategies include early complaint resolutions, systemic relief, technical assistance, guidance, and outreach. Impact: Ensures individuals who have been wrongfully institutionalized or are at risk of institutionalization are aware of their rights and receive the services to which they are legally entitled in their own homes and communities.

Health Equity Goal: Combat and prevent discrimination and advance opportunities for individuals with disabilities through rulemaking.

• Update and clarify critical regulatory provisions that help persons with disabilities accesshealth and human services and prohibit discrimination on the basis of disability under Section 504 of the Rehabilitation Act . The rule updates Section 504 to align with other disability non-discrimination laws and adds specifics to prevent and respond to discrimination on the basis of disability in health and human services. Impact: Will help protect the general health and wellbeing of individuals with disabilities by clarifying what counts as discriminatory medical treatment and improving patients’ ability to have meaningful access to necessary medical equipment and health and human service programs.
• Issued guidance on civil rights protections for people with disabilities that makes clear that civil rights protections remain in full force and effect during disasters or emergencies, including during the COVID-19 pandemic. Impact: Improves protections for people with disabilities during public health disasters and emergencies.
• Issued guidance on how disability non-discrimination laws apply to certain people - affected by COVID-19. The guidance provides clarity on “Long COVID” and disability rights under the ADA, section 504, and Section 1557. The guidance also provides resources for additional information and best practices. Impact: Helps educate the public on how disability rights laws apply to conditions related to the COVID-19 pandemic.

Non-discrimination in Health Care

Health Equity Goal: Ensure non-discriminatory access to health care services and supporting persons with disabilities seeking access to medication.

• Resolved complaints with national pharmacy chains to ensure timely access to medications for women and persons with disabilities, including access to prescriptions for individuals with disabilities. As a result, the pharmacies implemented new processes to promote access to medication by preventing potential delays. Impact: Improves access to medication so individuals with disabilities are able to get timely access to vital prescriptions.

Health Equity Goal: Advance non-discrimination in health and human services programs through rulemaking.

• Released proposed revisions to regulations implementing Section 1557 of the Affordable Care Act (ACA) that restores and strengthens non-discrimination civil rights protections for LGBTQI+ people, women, and individuals seeking care in Federally funded health programs and activities. The proposed rule affirms protections against discrimination on the basis of sex, including sexual orientation, gender identity, and pregnancy, in the provision of health services. Impact: Improves non-discrimination protections for marginalized communities, including gender diverse individuals, LGBTQI+ individuals, pregnant people, individuals with limited English proficiency, and individuals with disabilities. The proposed Section 1557 Rule would expand the applicability of non-discrimination standards in health care to health coverage, including limited-duration health plans, and to the Department’s activities related to health programs such as the Medicare and Medicaid programs and the Indian Health Service.  
• Released a proposed update to the HHS Grants Rule that prohibits sex discrimination in specific HHS grant programs by clarifying that the prohibition on discrimination on the basis of sex includes discrimination on the basis of sexual orientation and gender identity. Impact: Clarifies non-discrimination protections in specific HHS grant programs including services and grants that provide aid to refugees, assistance to people experiencing homelessness, substance use treatment and prevention, community mental health services, maternal and child health services, and community services. 

Operations and Outreach

Health Equity Goal: Provide outreach and technical assistance to the public to advance our health equity activities in civil rights and HIPAA.

• Ensured communications are available to the public by widely publicizing OCR’s dedicated email for inquiries and monitoring and responding to inquiries on a daily basis, with over 55,000 responses to public inquiries per year. Impact: OCR connects with the public by regularly responding to inquiries on subjects such as civil rights, religious conscience, and health information privacy through providing technical assistance, information on rulemaking, and, at times, speaking directly with staff.
• Translated the OCR Complaint Portal into 15 languages and updated the complaint   form to include gender inclusive language. Impact: Increase the accessibility of OCR services for people with different language access needs and gender identities.
• Updated OCR’s toll-free support line to provide the consumer with self-service options and provide OCR the ability to collect data on calls received to serve callers better. Impact: Improves ability to provide individuals information more efficiently, re-route their calls to other agencies, and start to identify trends from data received from callers. 

Language Access

Health Equity Goal: Advance meaningful access for individuals with limited English proficiency and effective communication for individuals with disabilities by issuing guidance to states and health care providers and by ensuring the Department delivers linguistically appropriate and accessible programs and services

• Relaunched the Language Access Steering Committee and released an HHS Language Action Plan setting forth practical guidance, best practices, and action steps Operating and Staff Divisions can use to develop their own, agency-specific language access plans. The plan also calls for agencies to collect data regarding their language access services. Impact: The Language Access Plan helps Departmental agencies ensure access to timely, quality language assistance services including translation and effective communication services that will have a disproportionately greater impact on individuals with disabilities and individuals with limited English proficiency. The data collection component of the Language Access Plan also helps agencies identify and address communication barriers to equal opportunity that underserved communities face.  
• Issued a letter reminding states of their obligations under federal civil rights laws to ensure that individuals and families continue to have access to effective communication in Medicaid and Children’s Health Insurance Program coverage as states return to normal processes to redetermine enrollees’ eligibility, (i.e., post COVID-19 public health emergency Medicaid and CHIP “unwinding”). Impact: Improves compliance with civil rights requirements by requiring states to meet individuals’ communication needs. This letter helped to improve states’ understanding of their responsibility to provide effective communication in the Medicaid Unwinding process and addresses communication needs for individuals identified in EO 14091, Further Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. OCR’s letter reminded states of their obligations to ensure non-discrimination on the basis of race, color, national origin, and disability, and anticipates that this work will bolster state efforts to retain children and families on Medicaid programs, reducing the medical and financial risks caused by coverage gaps.  
• Issued guidance on federal non-discrimination laws that require accessibility for people with disabilities and limited English proficiency in health care provided via telehealth. Impact: Helps health care providers better understand their non-discrimination obligations and helps patients better understand their rights under federal law.

Environmental Justice

Health Equity Goal: Address health disparities and reduce environmental risks for underserved communities by ensuring compliance with federal civil rights laws.

• Initiated the first-ever federal government environmental justice enforcement action over a lack of wastewater disposal systems in Lowndes County, Alabama, where the majority of residents are Black and low income. Entered a Settlement Agreement that requires the State of Alabama to take several actions to address the problem, including assessing need for wastewater disposal, developing a public health and infrastructure plan, seeking funding and technical assistance, and adopting a moratorium on enforcing criminal statutes and liens on properties that lack approved wastewater disposal systems. Impact: Helps residents of Lowndes County access clean water and public health resources. The Settlement Agreement requires the Alabama Department of Public Health to take a number of measures, including launching a public health campaign, providing educational materials on the impacts of sewage to health care providers, and creating a sustainable and equitable public health infrastructure improvement plan. This action also creates a model for future actions under Title VI and Section 1557.

Substance Use Disorder and Related Conditions

Health Equity Goal: Increase awareness of non-discrimination laws that protect individuals involved in child welfare who are in recovery from substance use disorder.

• Resolved a complaint that a county child welfare agency denied an individual the opportunity to apply to be a foster parent because she receives medication for the treatment of substance use disorder. The investigation and subsequent settlement identified systemic concerns regarding the state child welfare agency’s oversight of county child welfare agencies’ compliance with federal disability rights laws. Impact: Protects the civil rights of individuals with substance use disorders. OCR enforced its authorities through a voluntary resolution agreement that required the state welfare agency to take a number of corrective actions that adopt OCR non-discrimination standards for individuals living with a substance use disorder.

Health Equity Goal: Increase Health Care Coordination and Confidentiality for Patients with Substance Use Challenges

• Published a Final Rule on Confidentiality of Substance Use Disorder Patient Records to bring its requirements into closer alignment with HIPAA Rules. Impact: Increases coordination among providers in any setting, including those who treat individuals with substance use disorder and clarifies protections surrounding records disclosure to help address concerns that discrimination and fear of prosecution may deter individuals with substance use disorder from seeking health care. Such protections include civil enforcement and requiring reporting of breaches of substance use disorder treatment records.  
• Introduced a video series on federal disability rights protections that apply to some individuals in recovery from an opioid use disorder. The five-part series discusses   protections that apply to some individuals in recovery from an opioid use disorder and       provides an overview of medications for opioid use disorder (MOUD). Impact: Provides clear and accessible guidance on disability protections for individuals in recovery for opioid use disorder.

Health Information Privacy

Health Equity Goal:  Advance health equity and the attainment of the highest level of health for all people by supporting the privacy and security of individuals’ health information.

• Protected patient privacy and access to health care by issuing Guidance on the HIPAA Privacy Rule and Disclosures of Information Relating to Reproductive Health Care , which addresses when the HIPAA Privacy Rule permits disclosure of protected health information without an individual’s authorization and the limitations on these disclosures. Impact: Helps improve privacy protections for patients seeking reproductive health care. Infringements on reproductive health privacy are likely to have a disproportionate impact on women and communities that have been historically underserved.  
• Released guidance on Protecting the Privacy and Security of Your Health Information When Using Your Personal Cell Phone or Tablet , which explains that the HIPAA Rules do not apply to individuals’ health information when it is stored or accessed using a personal mobile device. This guidance also explains how to turn off location services on Apple and Android devices and identifies best practices for selecting apps, browsers, and search engines that are recognized as supporting increased privacy and security. Impact: Supports patients’ privacy rights and expectations and advances confidence in the confidentiality of patient communications with their health care provider and the privacy of their health records. The guidance will help provide accessible information on health information privacy, including to individuals who may be reliant on telehealth services and those who may have not been previously exposed to information on data privacy.  
• Support Patient Privacy in Reproductive Health Care Privacy by publishing a notice of proposed rulemaking on the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule , which would prohibit the use or disclosure of protected health information to investigate or prosecute patients, providers, and others involved in the provision of lawful reproductive health care. Impact: Advances trust in the patient-provider relationship and ensures that patients’ private medical records will not be disclosed and used against people for merely seeking, obtaining, providing, or facilitating lawful reproductive health care. Infringements on health information privacy related to reproductive health care are likely to have a disproportionately greater effect on women, individuals of reproductive age, and individuals from communities that have been historically underserved.

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Right to health: Challenges and Opportunities

Rajesh kumar.

Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, Union Territory Chandigarh, India

Humans have been struggling for better quality of life for hundreds and thousands of years. The journey from the jungle -where ‘survival of the fittest’ was the rule- to modern human societies has progressed to a stage where ‘survival of the weakest’ is the main human value today. The absolute dominance of few individuals, who treated people as ‘subjects’ without any rights, could not continue for long. Last few centuries have witnessed several social revolutions such as French, American, and Russian revolution which changed the social, economic and political structure of the societies around the world, and the rights of every human have been recognized.

The Article 25 of the Universal Declaration of Human Rights (1948) by the United Nations grants the right to a standard of living adequate for the health and well-being to humans including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond human control. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, enjoy the same social protection.( 1 )

International Covenant on Economic, Social and Cultural Rights (1966) further state in Article 12 that the States recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, and the steps to be taken to achieve the full realization of this right include those necessary for:

• (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child,
• (b) The improvement of all aspects of environmental and industrial hygiene,
• (c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; and
• (d) The creation of conditions which assure to all medical service and medical attention in the event of sickness.( 2 )

In 1946, detail plans for health development had been presented in the ‘Report of the Health Survey and Development Committee’ to the Government of India under the chairmanship of Sir Joseph Bhore.( 3 ) And in 1950 Indian constitution proclaimed it as a ‘sovereign socialist secular democratic republic’, which guarantees “the right to life and liberty” (Article 21) and includes among the duties of the State “to raise the level of nutrition and the standard of living and to improve public health” (Article 47).( 4 , 5 )

World Health Organization had also advocated Primary Health Care strategy in 1978 for achieving the Health-for-All by year 2000.( 6 ) Consequently Government of India also formulated its first National Health Policy in 1983.( 7 ) United Nations had also presented comprehensive millennium development goals (MDGs) in year 2000 to be achieved by year 2015 which includes health goals also, and now a post-2015 agenda for sustainable development is being discussed.( 8 )

Despite these efforts, large inequalities still exist between and within countries. Life expectancy at birth varies from nearly 51 years in Chad to 84 years in Japan.( 9 ) In Indian states also it varies from about 62 years in Assam to 74 years in Kerala.( 10 ) What are the causes of these inequalities? Why some societies are healthier than others? Why disease occurs? These questions have been intensely debated around the world during the 19 th century.

Max von Pettenkofer (1818–1901), a German physician, had advocated that environment and host factors play an important role in disease causation besides the agent.( 11 ) This line of thinking was later denoted as the ‘Epidemiological Triad’. This idea of the Triad found reflection in the first text book of epidemiology by Stallybrass in 1931 in Liverpool, UK.( 12 ) The occurrence of disease due to the loss of equilibrium between Agent, Host, and Environment has now been accepted unequivocally as the theory of disease causation.

It is not enough to have the knowledge about disease causation; political actions are needed to redress the problem. Rudolf Virchow (1821–1902), who is regarded as the father of social medicine, outlined the power of social policies in disease prevention; he said “Medicine is a Social Science and Politics is nothing but Medicine at a larger scale.”( 13 ) He practiced social medicine; would be seen at the barricades. As member of Municipal Council of Berlin, he worked towards modern water and sewerage system for the city. Later on, Thomas McKeon (1912–1988), a Professor of Social Medicine in Edinburgh, empirically showed that rise in overall standard of living, especially nutrition status, resulting from better economic conditions was responsible for the decline in mortality.( 14 ) He also highlighted the role of social policies in health development in his book ‘Introduction to Social Medicine’.( 15 )

Hugh R Leavell and Edwin G Clark from Harvard and Columbia Universities respectively elaborated in their book ‘Preventive Medicine’ in 1965 that prevention does not only mean prevention of disease and promotion of health but it also includes the prevention of disability and death by early diagnosis and treatment, thus laying the foundations of preventive medicine.( 16 ) Application of these ideas has played a key role in increasing the life expectancies at a lower income level in developing countries due to the large scale implementation of appropriate technology under the primary health care strategy such as immunization, oral rehydration therapy etc. Samuel H Preston, a Professor of Demography and Sociology in University of Pennsylvania, presented analysis of the mortality trends all over the world in 2007 to find out why mortality declines have occurred especially in the later half of the 20 th century. He concluded that no doubt the rise in incomes have led to rise in life expectancies but technological changes in medicine have played an important role.( 17 ) These ideas of social medicine and preventive medicine played a significant role in the life and work of Sidney L. Kark (1911–1998) who successfully practiced community medicine in South Africa for a number of years before moving on to Israel and USA.( 18 )

The importance of population based approaches was once again highlighted by Professor Geoffrey Rose (1926–1993) from London School of Hygiene and Tropical Medicine. According to him “the primary determinants of disease are mainly economic and social and therefore its remedies must also be economic and social ……….medicine and politics cannot and should not be kept apart.”( 19 ) The Public Health approach, which had led to the enactment of Public Health Act of 1948 in England, once again came to the fore.

The role of public health was re-emphasized by the Expert Committee on Public Health Systems (1996) formed by the Ministry of Health and Family Welfare, Government of India.( 20 ) Voluntary Health Association of India's (VHAI) Independent Commission on Health (1997) also stressed the need to open new schools of public health.( 21 ) Calcutta Declaration on Public Health (1999) emphasized the leadership role for public health and identified the need for creating career structures at the national, state, provincial and district levels.( 22 ) Sir Michael Marmot also once again brought the focus on social determinants of health in ‘closing the gap in a generation’. He stated “Why treat people………. without changing what makes them sick”.( 23 )

However, the focus of right to ‘health’ continued to be only on the right to ‘healthcare’ because in the current era of falling mortality and rising morbidity, the healthcare needs have become the ‘felt need’ of the people. India is also experiencing epidemiological transition. Non-communicable diseases are on the rise whereas communicable diseases (NCDs) also continue to be a public health problem and the agenda of high maternal and child mortality has not yet been tackled. According to the Office of Registrar General of India, NCDs are the cause of death in 42%, communicable diseases, maternal, perinatal and nutritional conditions in 38%, and 10% deaths are due to injuries and ill-defined causes.( 24 ) The dilemma is how to balance the investment on health promotion and medical treatment.

With technological advancements, the cost of healthcare is rising but investments in health are not rising. India invests only 1.1% of its gross domestic product (GDP) on health which is much lower than even other developing countries.( 25 ) Per capita health expenditure in India, Sri Lanka and Thailand is US$ 23, 31, and 71 respectively and the share of public expenditure in this was only 25% in India compared to 50% in Sri Lanka and Thailand.( 26 ) As a result most people have to pay heavy fee for medical care from out-of-pocket not only when they avail medical services from private sector but also for services available in the public sector medical institutions. According to National Sample Survey Organisation 71 st survey round the average cost of hospitalization per case was Rs. 16,956 and Rs. 26,455 respectively in rural and urban area.( 27 ) People have to pay out-of-pocket in public institutions as in these institutions the shortage of drugs and diagnostics is endemic and human resources are also in short supply, more so in rural areas. The health workforce per 10,000 was 11.8 in rural area and 42 in urban areas.( 28 )

Public health services have been neglected for a long time in India, and the resultant vacuum has been increasingly filled by the ‘quacks’ in the villages and corporate medical care hospitals in the urban areas. National Health Policy (2002) expressed the intention of the government to correct these deviations and some efforts have been made by government of India to reverse this trend.( 29 )

In the last decade, under the National Health Mission (NHM), larger investments have been made with some flexibility.( 30 ) Fund allocation increased from Rs. 4,633 crore in 2005–06 to Rs. 16,948 in 2013–14. Health infrastructure has also improved somewhat. Staffing has also gone up - more so at the grass root level. The number of Auxiliary Nurse Midwives (ANMs) increased from 1,33194 to 1,93,593. About nine lakh Accredited Social Health Activists (ASHAs) are in place- at least one in every village. About 75% of the babies are now born in health institutions. Infant Mortality Rate has declined from 68 in year 2000 to 40/1000 live births in year 2013, and Maternal Mortality Ratio has also registered a decline from 254 in 2004–2006 to 167/100,000 live births in 2011–2013. It is likely that the 4 th MDG will be achieved in India.

However, uncertainty about the continuation of NHM prevails. Which way the wind will blow? NHM will continue or it will be replaced by National Health Assurance Mission (NHAM)? Whether commitment for universal health care will be on the statute book? Right to health will be guaranteed or it will remain rhetoric? National Health Policy Draft (2015) is merely a statement of intentions rather than actions, i.e., ‘should be done’ needs to be replaced by ‘will be done’ at every place where ever it appears in the policy.( 31 ) At this juncture India is at cross roads.

Two issues are the cause of worry - whether there will be ‘rise in allocation of finances for health’ and ‘whether administrative structures will change for better governance of health’. Whether the current system of health financing through Out-Of-Pocket (OOP) expenditures, which is a very regressive method of health financing, will give way to another regressive policy of market oriented health insurance-based financing or more progressive tax-based financing? Universal healthcare delivery mechanism will be through strengthened and better administered public health system or through purchase of services from private sector corporate hospitals?

Experience from around the world indicates that the ‘free market’ principles do not work in the medical field due to asymmetry of information.( 32 ) USA spends about 19% of its GDP in a largely insurance-based and privately delivered health care model but the rise in life expectancy in USA is less than in other developed countries where tax-based financing through national health service-based public system prevails.( 33 ) Some developing countries such as Thailand and Sri Lanka are now providing universal health care (UHC) at a much lower investment through a tax financed public system.( 34 )

The out-of-pocket payments, rampant in India, push people to below poverty line. In Punjab a recent survey indicated that median hospitalization costs per case are Rs 17,000 and Rs 19,500 in public and private facilities respectively.( 35 ) About 50% of the people had to borrow money or had donations from relatives to meet out this cost. It has been seen in Haryana also that user charges push people out of the public services. Hospital admissions declined from 1721 to 1321 per lakh population in Yamuna Nagar district of Haryana after introduction of user fee.( 36 )

It is now clear that poor people are main utilizers of the public services especially in states where public financing is better which has sustained pubic services. It was observed that higher public spending encourages equity in utilization of services.( 37 ) The public system which is perceived to be of ‘poor quality’ is largely utilized by poor people; it is still serving large number of people. Public subsidies in public health institutions go to poorer section of society.( 38 )

A study in Punjab observed recently that though public facilities are not very well staffed but the staff client ratio is quite good.( 39 ) On an average each doctors attends to 40 patients per day. A rapid survey in Haryana indicates that 53% targets of UHC are already met.( 40 ) Hence, we need to identify the gaps in public services, and these gaps need to be plugged rather than experimenting with costly tertiary care medical insurance purchased by the govt. and services mainly bought from the private corporate hospitals. In this approach, under the constraint of limited financial resources, diversion of funds from preventive and primary care to tertiary care is a real risk as has been seen in some of the southern Indian states where such insurance schemes were launched in last decade.( 41 )

In current scenario where Indian economy is growing, it should not be very difficult to increase the investments in health from current level of 1.1% to about 3% of GDP. New governance structures such as autonomous heath centre/hospital boards with the active involvement of local self-government systems needs to be created. Govt. should provide universal coverage of essential health package through tax-based funding; increase budgetary outlays for health progressively; correctly set priorities of health interventions; strengthen public health infrastructure; improve governance of health services- human resource, procurement and distribution; strengthen medical education with quality to generate adequate workforce; ensure regulation of private providers through legislation and enforcement; and strengthen independent monitoring system to build accountability using information technology.

Hard political choices need to be made now. A concerted effort by academia and civil society should be launched to engage with union and state governments. A comprehensive public health law incorporating the right to health should be passed by the Parliament. The right to health cannot be guaranteed in isolation; already right to education, right to livelihood, food security, and right to information exist on the statute. Addition of right to health will make the entitlements of Indian citizen more complete as was envisaged by our forefathers while preparing Indian constitution.

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The physical sensations of watching a total solar eclipse

Regina G. Barber

Science writer David Baron witnesses his first total solar eclipse in Aruba, 1998. He says seeing one is "like you've left the solar system and are looking back from some other world." Paul Myers hide caption

Science writer David Baron witnesses his first total solar eclipse in Aruba, 1998. He says seeing one is "like you've left the solar system and are looking back from some other world."

David Baron can pinpoint the first time he got addicted to chasing total solar eclipses, when the moon completely covers up the sun. It was 1998 and he was on the Caribbean island of Aruba. "It changed my life. It was the most spectacular thing I'd ever seen," he says.

Baron, author of the 2017 book American Eclipse: A Nation's Epic Race to Catch the Shadow of the Moon and Win the Glory of the World , wants others to witness its majesty too. On April 8, millions of people across North America will get that chance — a total solar eclipse will appear in the sky. Baron promises it will be a surreal, otherworldly experience. "It's like you've left the solar system and are looking back from some other world."

Baron, who is a former NPR science reporter, talks to Life Kit about what to expect when viewing a total solar eclipse, including the sensations you may feel and the strange lighting effects in the sky. This interview has been edited for length and clarity.

Baron views the beginning of a solar eclipse with friends in Western Australia in 2023. Baron says getting to see the solar corona during a total eclipse is "the most dazzling sight in the heavens." Photographs by David Baron; Bronson Arcuri, Kara Frame, CJ Riculan/NPR; Collage by Becky Harlan/NPR hide caption

Baron views the beginning of a solar eclipse with friends in Western Australia in 2023. Baron says getting to see the solar corona during a total eclipse is "the most dazzling sight in the heavens."

What does it feel like to experience a total solar eclipse — those few precious minutes when the moon completely covers up the sun?

It is beautiful and absolutely magnificent. It comes on all of a sudden. As soon as the moon blocks the last rays of the sun, you're plunged into this weird twilight in the middle of the day. You look up and the blue sky has been torn away. On any given day, the blue sky overhead acts as a screen that keeps us from seeing what's in space. And suddenly that's gone. So you can look into the middle of the solar system and see the sun and the planets together.

Can you tell me about the sounds and the emotions you're feeling?

A total solar eclipse is so much more than something you just see with your eyes. It's something you experience with your whole body. [With the drop in sunlight], birds will be going crazy. Crickets may be chirping. If you're around other people, they're going to be screaming and crying [with all their emotions from seeing the eclipse]. The air temperature drops because the sunlight suddenly turns off. And you're immersed in the moon's shadow. It doesn't feel real.

Everything you need to know about solar eclipse glasses before April 8

In your 2017 Ted Talk , you said you felt like your eyesight was failing in the moments before totality. Can you go into that a little more?

The lighting effects are very weird. Before you get to the total eclipse, you have a progressive partial eclipse as the moon slowly covers the sun. So over the course of an hour [or so], the sunlight will be very slowly dimming. It's as if you're in a room in a house and someone is very slowly turning down the dimmer switch. For most of that time your eyes are adjusting and you don't notice it. But then there's a point at which the light's getting so dim that your eyes can't adjust, and weird things happen. Your eyes are less able to see color. It's as if the landscape is losing its color. Also there's an effect where the shadows get very strange.

Crescent-shaped shadows cast by the solar eclipse before it reaches totality appear on a board at an eclipse-viewing event in Antelope, Ore., 2017. Kara Frame and CJ Riculan/NPR hide caption

You see these crescents on the ground.

There are two things that happen. One is if you look under a tree, the spaces between leaves or branches will act as pinhole projectors. So you'll see tiny little crescents everywhere. But there's another effect. As the sun goes from this big orb in the sky to something much smaller, shadows grow sharper. As you're nearing the total eclipse, if you have the sun behind you and you look at your shadow on the ground, you might see individual hairs on your head. It's just very odd.

Some people might say that seeing the partial eclipse is just as good. They don't need to go to the path of totality.

A partial solar eclipse is a very interesting experience. If you're in an area where you see a deep partial eclipse, the sun will become a crescent like the moon. You can only look at it with eye protection. Don't look at it with the naked eye . The light can get eerie. It's fun, but it is not a thousandth as good as a total eclipse.

A total eclipse is a fundamentally different experience, because it's only when the moon completely blocks the sun that you can actually take off the eclipse glasses and look with the naked eye at the sun.

And you will see a sun you've never seen before. That bright surface is gone. What you're actually looking at is the sun's outer atmosphere, the solar corona. It's the most dazzling sight in the heavens. It's this beautiful textured thing. It looks sort of like a wreath or a crown made out of tinsel or strands of silk. It shimmers in space. The shape is constantly changing. And you will only see that if you're in the path of the total eclipse.

Shots - Health News

Watching a solar eclipse without the right filters can cause eye damage. here's why.

So looking at a partial eclipse is not the same?

It is not at all the same. Drive those few miles. Get into the path of totality.

This is really your chance to see a total eclipse. The next one isn't happening across the U.S. for another 20 years.

The next significant total solar eclipse in the United States won't be until 2045. That one will go from California to Florida and will cross my home state of Colorado. I've got it on my calendar.

The digital story was written by Malaka Gharib and edited by Sylvie Douglis and Meghan Keane. The visual editor is Beck Harlan. We'd love to hear from you. Leave us a voicemail at 202-216-9823, or email us at [email protected].

Listen to Life Kit on Apple Podcasts and Spotify , and sign up for our newsletter .

NPR will be sharing highlights here from across the NPR Network throughout the day Monday if you're unable to get out and see it in real time.

Correction April 3, 2024

In a previous audio version of this story, we made reference to an upcoming 2025 total solar eclipse. The solar eclipse in question will take place in 2045.

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A newsletter briefing on the health-care policy debate in Washington.

Abortion and New York’s electoral state of play

Good morning! The solar eclipse is finally here. Still in the dark about the proper etiquette for the astrological phenomenon? My colleague Joel Achenbach has you covered . Not a subscriber? Sign up here .

Today’s edition: Former president Donald Trump said the abortion issue should be left to states after months of mixed signals. A Democratic-aligned advocacy group is launching an advertising blitz highlighting the Inflation Reduction Act’s drug-pricing provisions. But first …

Abortion rights politics take shape in New York

The battle over abortion rights is expected to play an outsize role in New York’s 2024 congressional races, particularly in House districts now represented by Republicans.

As the 2024 election cycle ramps up, the leading super PAC aligned with congressional Democrats plans to inject $45 million into Empire State races hoping to defend existing House seats and capture four more to regain the majority. Democrats are also banking on added voter enthusiasm in November because of a state ballot measure that would enshrine abortion rights in the New York Constitution.

Across the aisle, Republican strategists say New York will be central to efforts to protecting the GOP’s razor-thin edge in the House. Although state-level referendums protecting abortion have uniformly succeeded since the Supreme Court overturned Roe v. Wade , GOP officials contend the jury is still out on whether that success translates into an advantage for Democrats overall. 

THE ABORTION FOCUS

Even in reliably blue territory such as New York, the House Majority PAC — a super PAC focused on electing Democrats — intends to spotlight abortion and the proposed constitutional amendment in its advertising and outreach. You can expect some of that messaging to highlight the voting records of freshman Republicans on proposed federal abortion restrictions. 

In July, 10 of the 11 House Republicans representing New York congressional districts voted for the annual defense policy bill that included a measure to bar the Defense Department from paying for or reimbursing expenses related to most abortion services. 

That policy, along with a slate of other conservative demands, was later stripped from the legislation — but Democrats want voters to know where their representative stood . 

PLAYING DEFENSE

GOP strategists are advising their candidates to explain their views on abortion clearly and with empathy. That includes voicing support for state-level control and exceptions for rape, incest or to save the life of the mother. 

“In blue states where it is legal, they can also note that it’s a state issue and settled law,” said Courtney Parella , communications director for the Congressional Leadership Fund , the main GOP super PAC involved in the House races. 

The group recently launched a project targeting swing voters in Democratic-led states, including New York. The initiative will include efforts around early and absentee voting, grass-roots voter contact and persuasion advertising that capitalizes on voter concern over things such as immigration and crime. 

“Swing voters in blue states are fed up,” Parella said. “We’ve been able to do so well in New York over the last couple of cycles because these voters are seeing the damaging effects of one-party Democratic rule.”

The House Majority PAC thinks just the opposite . The group’s communications director, C.J. Warnke , expressed confidence in the political potency of abortion rights as an election issue, citing New York Democrat Tom Suozzi’ s recent victory in the special election for the seat of indicted and expelled former GOP congressman George Santos . The super PAC mentioned abortion in 39 percent of its paid media in the race between Suozzi and Republican Mazi Pilip , he added. 

“The abortion messaging in blue states in the last election cycle wasn’t as effective because a lot of them didn’t have votes yet,” Warnke said. “But now, as House Republicans continue to say crazier and crazier stuff … it hits home a little bit harder.” 

Reproductive wars

Trump outlines abortion policy after months of waffling.

New this A.M.: Former president Donald Trump said that abortion rights should be left to the states , after months of mixed signals about his position on the politically volatile issue, The Washington Post’s Hannah Knowles and Marianne LeVine report. 

“My view is now that we have abortion where everybody wanted it from a legal standpoint, the states will determine by vote or legislation or perhaps both, and whatever they decide must be the law of the land. In this case, the law of the state,” Trump said in a video released this morning . The presumptive GOP nominee also emphasized his support for exceptions to abortion bans for rape, incest and the life of the mother. 

The bigger picture: Trump campaigned in 2016 on appointing Supreme Court justices who would overturn Roe v. Wade and became a champion of the antiabortion movement. But he has waffled on the issue since the landmark ruling was overturned in 2022, as Republicans up and down the ballot have paid a political price for unpopular bans. Democrats have made abortion central to their case against Trump, relentlessly reminding voters of his Supreme Court picks who helped end a nationwide right to the procedure.

Meanwhile, in Wisconsin …

Republican Senate candidate Eric Hovde is softening his stance on abortion as he looks to unseat Wisconsin’s Democratic senator, Tammy Baldwin , The Post’s Mariana Alfaro reports. 

“As it pertains to abortion, look, I’m very clear on that issue: I believe in exceptions. I believe in the beauty of life. I think women early on in a pregnancy should have a right to make a choice,” Hovde told reporters Thursday, without defining “early.” 

Flashback: During a prior Senate campaign in August 2012, Hovde told the Wisconsin State Journal that he was “totally opposed to abortion,” a position he reiterated in a radio interview later. That same year, Hovde said he considered himself “pro-life” and advocated for overturning Roe v. Wade. 

The bigger picture: Hovde’s shift comes during an election cycle when many Republicans are struggling with the issue of abortion, prompting some to moderate their positions. Meanwhile, Democrats, particularly those in swing states such as Wisconsin, are highlighting Republican actions that curtailed nationwide access to abortions, a messaging strategy that proved successful for the party in the 2022 midterms.

Industry Rx

First in the health 202: ad blitz seeks to boost house democrats by highlighting ira drug-pricing provisions.

Protect Our Care is launching a fresh round of advertisements in a $5 million campaign tying House Democrats to provisions in the Inflation Reduction Act aimed at curbing health-care costs. 

The latest videos from the Democratic-aligned advocacy group commend nine incumbent Democrats for championing measures in the lower chamber that empowered Medicare to negotiate prescription drug prices and capped insulin costs at $35 per month for beneficiaries. The ads also urge lawmakers to pass a bill introduced last year that would extend these reforms to the broader health insurance market. 

In addition to television, streaming and digital ads, the campaign includes on-the-ground events and organizing initiatives to raise voter awareness about the law’s health-care reforms, the group told The Health 202. The nine Democrats highlighted in the messaging blitz include Reps. Frank Pallone Jr. (N.J.), Hillary J. Scholten (Mich.) and Yadira Caraveo (Colo.). 

White House prescriptions

Trump relies on a doctor who is a member of his golf club to vouch for his health.

My colleague Michael Kranish was out with a deep dive this weekend on Bruce A. Aronwald , shedding light on the 64-year-old physician from New Jersey responsible for Trump’s latest medical assessment. 

A review of Aronwald by The Post found him to be a well-respected local doctor who had found notable success with a “concierge” medical service catering to affluent clients such as Trump; some patients say he has never been openly political. He’s also a familiar face at Trump’s Bedminster golf club, where members have observed him spending time with the former president and his family.

Why it matters: Trump has declined to release details about his health beyond a short letter from Aronwald proclaiming that he was in “excellent health” and had “exceptional” cognitive ability without providing specifics. The assessment also lacks details about the extent to which Trump has continued to battle obesity and high cholesterol, as he did in office. While candidates aren’t required to disclose extensive health records, some experts say the lack of detail in Aronwald’s letter makes it difficult for voters to understand whether the 77-year-old is truly in better health than his 81-year-old opponent, as he regularly proclaims on the trail. 

• In contrast: Biden has released a six-page letter that details his blood tests, conditions and medications, which the White House contends gives voters a clearer picture of his health.

In other health news

• Two women who say abortion laws in their states put them in medical peril will stump for Biden in North Carolina and Wisconsin over the next two weeks . The president’s reelection team views their stories as powerful examples of how Republican-driven restrictions complicate health care, Colleen Long reports for the Associated Press . 
• The Food and Drug Administration approved Johnson & Johnson and Bristol Myers Squibb ’s CAR-T cell therapies for earlier treatment of multiple myeloma, a type of blood cancer. 
• As the United States eased into spring , only two states had increases or likely increases in coronavirus infections as of March 30, Linda Searing reports for The Post, citing an update from the Centers for Disease Control and Prevention . 

📅 Welcome back, Congress! The Senate is in session starting today, and the House is reconvening tomorrow. Here’s what we’re watching: 

On tap this week: Dentists and dental students will lobby on Capitol Hill as part of the American Dental Association ’s annual fly-in. More than 1,100 attendees from across the country are slated to meet with members of Congress in the coming days to push for oral health priorities, including reforming student loans and rectifying coverage gaps in dental plans. 

On Tuesday: The Senate Caucus on International Narcotics Control will examine the ways in which shell companies have been used to finance, traffic and launder the proceeds from illicit narcotics and synthetic opioids, such as fentanyl.

On Wednesday: A House Energy and Commerce subcommittee will consider several legislative proposals aimed at bolstering patient access to telehealth services. 

On Thursday: FDA Commissioner Robert M. Califf will testify before the House Committee on Oversight and Accountability , where he is expected to be grilled on the agency’s response to issues such as the infant formula crisis, drug shortages and tobacco regulation. The Senate Finance Committee will discuss Medicare physician payment reform. 

On Friday: Independent advisers to the FDA will weigh in on the potential use of minimal residual disease as an endpoint in multiple myeloma clinical trials. 

Health reads

After abortion attempts, two women now bound by child (By Amber Ferguson | The Washington Post)

As Florida restricts treatment for trans adults, one clinic presses on (By Casey Parks | The Washington Post)

Insurers reap hidden fees by slashing payments. You may get the bill. (By Chris Hamby | The New York Times)

Cloudy with a chance of totality 🌤️ https://t.co/rxVtLs1Lf3 pic.twitter.com/r2U8E8RRoI — Dave Jorgenson 【I】【N】 【B】【I】【O】 (@davejorgenson) April 5, 2024

Thanks for reading! See you tomorrow.

How to Choose a New Primary Care Doctor

Finding a primary care physician is the first step you can take towards your good health. Here are some tips to look for in order to choose the best care provider doctor for you.

This article is based on reporting that features expert sources.

How to Find a Primary Care Doctor

Getty Images)

When it comes to navigating the health care system, it can be confusing and overwhelming with the various types of doctors.

While there are many types of specialists , like a cardiologist or oncologist, that provide care for specific cases and instances, the one type of doctor everyone should have is a primary care doctor.

Primary care doctors serve as your first point of contact for your general health needs and concerns.

Key Takeaways:

• A primary care provider, or PCP, is a doctor who handles your routine health care. They can monitor different aspects of your health and refer you to specialists for more specific problems. 
• There are a variety of ways to find a primary care doctor for you. You can start by talking to family and friends, using an online search tool and checking online reviews. 
• After finding a doctor you’d like to try, consider things like wait time, office environment, and the provider’s communication to decide whether they’re a good fit for you.

Why You Need a Primary Care Physician

Although some people use urgent care or the emergency room for their primary care needs, that doesn't allow you to build a trusted, long-term relationship with one provider, says internal medicine physician Dr. James Wantuck, chief medical officer and cofounder of the telehealth platform PlushCare.

By building a relationship over time, the provider becomes a detective to find out what's wrong when something isn't right with your health. They can monitor changes or trends in your health over time to diagnose, treat and prevent any new health problems that may arise.

General and preventive care and services primary care providers offer include:

• Annual physicals and checkups.
• Blood tests.
• Health screenings .
• Routine vaccinations.
• Common and/or minor health issues, such as colds, flu , ear infections, rashes and insect bites.
• Chronic conditions, including allergies , asthma, diabetes, heart disease, high blood pressure and skin conditions.
• Women's health care, such as birth control, pelvic exams and Pap smears.

If you have a complex or specific medical condition that requires particular expertise, your primary care physician can refer you to see a medical specialist.

Types of Primary Care Physicians and Providers

There are several types of doctors who work as primary care physicians. Here's a breakdown of the types of doctors who are PCPs.

Family medicine physician

A family medicine physician cares for the whole person through all stages of life, from infant to older age. They will focus on seeing you as a whole person rather than just one specific health problem, says Dr. Ada Stewart, board chair of the American Academy of Family Physicians and a practicing family physician in Columbia, South Carolina.

A family medicine doctor will earn their four-year undergraduate degree, a medical degree and then take part in a three-year residency program.

Internal medicine physician

Also called internists, an internal medicine physician specializes in care for adults age 18 and over. This includes diagnosing, treating and helping to prevent health problems.

An internal medicine doctor will earn their four-year undergraduate degree, a medical degree and then take part in a three-year residency program.

Pediatrician

A pediatrician cares for children and young adults. Many pediatricians offer care through age 21, but some may advocate that you try to find a new provider around the age of 18.

After getting their medical degree, a pediatrician takes part in a three-year residency program for specialized training related to caring for children.

An OB-GYN can be a primary care provider for some women, particularly young, healthy women. However, OB-GYNs specialize in reproductive health and aren't equipped to handle problems like strep throat, COVID-19 or other health issues beyond women's health. Also, many family medicine and internal medicine physicians will handle routine gynecological care, such as Pap smears.

Nurse practitioner or physician assistant

A nurse practitioner or a physician assistant can be a primary care provider. Although they are not medical doctors, they work closely with physicians and will refer to their supervising doctor, says Dr. Susan Besser, a primary care provider specializing in family medicine at Mercy Personal Physicians at Overlea in Baltimore. In many states, nurse practitioners have the same prescriptive authority as doctors and can prescribe medications, but there are certain states that only allow medical doctors to issue certain prescriptions.

MD vs. DO Degrees

When you see a primary care physician, you may notice that some have an MD (doctor of medicine) degree, while others have a DO (doctor of osteopathic medicine) degree. Both receive similar training, but DOs study 300 to 500 hours of osteopathic manipulation, which is a hands-on approach used to treat the musculoskeletal system.

General Practice vs. Internal Medicine

A general practice and an internal medicine practice will both provide primary care near you. Both general practitioners and internal medicine doctors have an undergraduate degree, go to medical school and complete a residency.

However, a general practitioner provides general primary care for all ages. An internal medicine doctor will focus on primary care for adults age 18 and older. If you begin to see an internal medicine doctor as an adult, your children wouldn't be able to see the same doctor.

Choosing a New Primary Care Doctor

If you have to choose a new primary care doctor because of a change in health insurance , a move or changing medical needs, consider these following tips.

1. Ask friends or family.

Many referrals to a primary care provider come from friends or family members. Their recommendation can be helpful because that person knows you well.

However, a stamp of approval from a friend or family member doesn't always mean the doctor is a good match for you. You'll have different health issues than your friend or family member.

Plus, the personality mix of the doctor and patient together is the real key to a successful relationship, says Dr. Ruth Brocato, a primary care provider specializing in family medicine at Mercy Personal Physicians at Lutherville, Maryland. If a friend or family member likes a doctor, ask what they like about that provider. This will help you determine if there's a potential match for you.

2. Check online reviews.

Online reviews are popular, but they should only be a starting point when choosing a new primary care provider. It's always helpful if you see mostly positive reviews, as that likely indicates the doctor cares about his or her public image. However, negative reviews may not always be accurate, and all reviews are anecdotal.

3. Check the doctor's background credentials.

This is usually easy to find on the practice's website. You can use their online information to check the following:

• Is the doctor licensed in your state? You can find out where a doctor is licensed to practice and their education background at the Federation of State Medical Boards website .
• What is the doctor's specialty: family medicine or internal medicine?
• Is the doctor board certified? Board certification refers to a special exam that doctors can study for and pass after completing medical school. Doctors aren't required to complete board certification, but it adds an extra layer of knowledge. Board certification also requires courses that refresh the doctor's knowledge every few years.

If it's important to you, you'll also want to take into account if the doctor is male or female.

4. Ask about health insurance coverage.

You can whittle down costs when you see a primary care provider who's covered by your private health insurance plan or Medicare or Medicaid. Many health insurance plans will require you a copay for each appointment, and the plan will cover the remaining cost. Insurance plans have online tools to help you verify which local primary care providers accept your insurance.

You can also call your insurance company to find providers in your area. If you find a primary care provider you like, but their office doesn't accept your insurance, talk to the provider's staff. They may be able to arrange an affordable self-pay option. The same is true if you don't have any health care coverage. If you have health insurance, your plan still may pay for a portion of the appointment as an out-of-network visit.

5. Consider the office location.

How close is the office to your home? Beyond that, find out if there's parking or if the office is close to a bus or subway line. If you or a family member has special needs, ask in advance if the office has an elevator and ramps for wheelchairs and walkers, Stewart advises.

6. Ask how long it takes to get an appointment.

You can do this by calling the office and simply asking them how quickly a patient can usually get an appointment. You'll also want to ask if they have same-day appointments in case you get sick and need to be seen urgently.

It also can be helpful to know how the doctor handles after-hours emergencies and non-emergencies, Stewart says. For example, is there another on-call physician, or does the office use an answering service to field nighttime calls? Another consideration nowadays: Does the office have telehealth appointments?

7. When visiting, consider how long your wait time is.

You usually can expect some waiting at any doctor's office, but you'll want to make sure you're comfortable with the average wait time. That comes with a caveat.

"Obviously, wait time is important, and I aim to be on time, but realize that I may have been delayed because I was comforting a new widow, talking to a parent whose child is struggling in school or even giving a patient a new cancer diagnosis," Brocato explains.

8. Evaluate how well the primary care provider listens.

Does the doctor take the time to listen to your concerns? Do you feel comfortable opening up to him or her?

As part of this, find out about their philosophy of medical care to see if you agree with it, Besser advises.

For instance, do they prefer to prescribe medications, or are they more interested in starting with lifestyle changes? Which do you prefer? The doctor's focus on prevention of chronic diseases, rather than only treating something once a condition develops, also can be important.

If you have a preexisting condition such as diabetes or high blood pressure , ask if the doctor regularly treats patients with your condition.

Some patients may also wish to ask if the doctor regularly treats LGBTQ patients.

9. Take cues from the office environment.

Staff friendliness and office cleanliness can help indicate the type of care you'll receive.

When choosing a new primary care physician, you can set up a meet-and-greet visit to get a better feel for that person and the office. You'll find out more information during that visit to help with your decision. You also can ask the doctor's office if they offer a trial period, so you can see over a few appointments if you feel comfortable going there. Even if they don't formally offer this, you should still be able to look for a new primary care provider when you want to switch to someone new.

Bottom Line

As you try to pinpoint the right primary care provider, keep in mind that it's an ongoing, collaborative relationship. You don't want to contact the provider only when you're sick.

Stay in touch for preventive care appointments, immunizations and when you need emotional or mental health support. By staying in touch, the provider gets to know you better, which helps to build a stronger relationship.

The U.S. News Health team delivers accurate information about health, nutrition and fitness, as well as in-depth medical condition guides. All of our stories rely on multiple, independent sources and experts in the field, such as medical doctors and licensed nutritionists. To learn more about how we keep our content accurate and trustworthy, read our  editorial guidelines .

Besser is a primary care provider specializing in family medicine at Mercy Personal Physicians at Overlea in Baltimore.

Brocato is a primary care provider specializing in family medicine at Mercy Personal Physicians at Lutherville, Maryland.

Stewart is president of the American Academy of Family Physicians and a practicing family physician in Columbia, South Carolina.

Wantuck is chief medical officer and cofounder of the telehealth platform PlushCare.

Tags: doctors , patient advice , patients , health care

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In Battle Over Health Care Costs, Private Equity Plays Both Sides

As medical practices owned by private equity firms fuel overbilling, a payment tool also backed by such investors helps insurers boost their profits.

By Chris Hamby

Insurance companies have long blamed private-equity-owned hospitals and physician groups for exorbitant billing that drives up health care costs. But a tool backed by private equity is helping insurers make billions of dollars and shift costs to patients.

The tool, Data iSight, is the premier offering of a cost-containment firm called MultiPlan that has attracted round after round of private equity investment since positioning itself as a central player in the lucrative medical payments field. Today Hellman & Friedman, the California-based private equity giant, and the Saudi Arabian government’s sovereign wealth fund are among the firm’s largest investors.

The evolution of Data iSight, which recommends how much of each medical bill should be paid, is an untold chapter in the story of private equity’s influence on American health care.

A New York Times investigation of insurers’ relationship with MultiPlan found that countering predatory billing is just one aspect of the collaboration. Low payments have burdened patients with unexpectedly large bills, slashed pay for doctors and other medical professionals and left employers that fund health plans with high, often unanticipated fees — all while making the country’s biggest health insurance companies a lot of money.

Often, when someone gets insurance through an employer and sees a doctor outside the plan’s network, the insurer routes the bill to MultiPlan to recommend an amount to pay. Both MultiPlan and the insurer receive processing fees from the employer, usually based on the size of the final payment: the smaller the payout, the bigger the fees.

This business model has made Data iSight a cash cow. Of the handful of tools MultiPlan offers insurers, Data iSight consistently makes the most frugal recommendations, typically resulting in the highest fees.

MultiPlan, which has been publicly traded since 2020, did not respond to detailed questions about Data iSight. A statement issued by an outside public relations firm said MultiPlan’s payment recommendations were fair and “widely accepted.” It said the company was “committed to lowering out-of-network costs,” including by using “data-driven tools to determine fair reimbursements.”

In recent years, concern over private equity’s investments in medical practices has grown, as studies have documented rising bills. Insurers and MultiPlan say that Data iSight is a necessary counterweight.

Caught between these moneyed interests are patients, who are mostly in the dark. If they encounter Data iSight’s name, it is typically in the fine print of dense paperwork. Those who have complained said they got little more than assurances that the calculations were rigorous and fair.

For Mary Lavigne, who has chronic pain, chiropractor appointments near Irvine, Calif., almost doubled in cost. Nadia Salim’s Boston-area therapy appointments also became almost twice as expensive. And Andrew Faehnle was on the hook for more than two-thirds of an ambulance bill after his 14-year-old was rushed to an emergency room in Anaheim, Calif. In each case, insurance statements cited Data iSight.

“I thought, ‘Who the heck are these people?’” Mr. Faehnle said. “I started Googling, ‘What’s Data iSight?’”

‘The Time Seemed Right’

MultiPlan’s business model is based on simple math: Take the amount a doctor charges, subtract MultiPlan’s recommended payout, and you have what the firm identifies as a savings or discount. Usually, MultiPlan and the insurer each collect a percentage of that declared savings as a processing fee.

This arrangement helps insurers profit from the most common way Americans get health coverage: through an employer that pays medical claims with its own money, using an insurer only as an administrator. Using MultiPlan, insurers cut medical bills, then charge employers for doing so.

For decades, MultiPlan determined payments primarily through negotiations. The discounts were modest but came with an agreement not to collect more from patients.

After MultiPlan’s founder, Donald Rubin, sold it in 2006, the company’s new private equity owners began a move toward automated pricing that executives would later call “MultiPlan 2.0.”

In 2010, it bought Viant, an Illinois-based firm that used algorithms to recommend reimbursements . But for some types of care, Viant’s calculations used a database of billed amounts. So if medical providers charged more over time, the recommended payments were also likely to rise.

A small firm in Grapevine, Texas, had developed an alternative strategy. Rather than start with a bill and negotiate it down, Tom Galas, a former insurance executive, wanted to calculate the cost of care and negotiate it up.

Mr. Galas bought an analytics firm called Data Advantage in 2005 and assigned a team at his company, National Care Network, to execute his vision. The result was Data iSight.

It drew on data that medical facilities submitted to the federal government and techniques developed by Medicare to estimate treatment costs. It then threw in some extra money, meant to allow a fair profit. The goal was to save insurers and employers money without paying so little that providers would sue them or go after patients for the balance.

In 2011, Mr. Galas sold to MultiPlan.

“The industry was condensing,” he said. “The time seemed right.”

Though he considered Data iSight revolutionary, he said, even he didn’t anticipate what it would become.

‘MultiPlan Is Magic’

Executives from the country’s major insurers gathered in Laguna Beach, Calif., in 2019 and heard from Dale White, a MultiPlan executive vice president.

He presented a slide showing the cover of a self-help book, “Life Is Magic,” that had been digitally altered to show Mr. White’s face and to read “MultiPlan Is Magic.” The slide added: “We have a few things up our sleeve, too.”

The firm’s annual revenues had reached about $1 billion, and three sets of private equity investors had cashed in. After buying MultiPlan for just over $3 billion in 2010 from the Carlyle Group, the firms BC Partners and Silver Lake sold it for a reported $4.4 billion in 2014 to Starr Investment Holdings and Partners Group, which sold it two years later to Hellman & Friedman for a reported $7.5 billion.

Hellman & Friedman, which owned the company when it went public in 2020, declined to comment.

Fueling the growth was Data iSight. The annual revenue it brought MultiPlan grew from $23 million in 2012 to more than $323 million in 2019, according to an investor presentation in 2020. The next year, the chief executive, Mark Tabak, told investors that Data iSight was MultiPlan’s top moneymaker among its biggest insurance customers.

While the company continued to offer other tools, it pitched Data iSight as an “industry-leading” and “state-of-the-art” way to “maximize savings.”

For insurers, the tool came with trade-offs: lower payments but potentially more patient complaints. They rolled it out gradually. The nation’s largest insurer by revenue, UnitedHealthcare, began using it in 2016 for certain plans and treatments, documents show.

As Data iSight spread, patients, doctors and medical facilities began receiving unwelcome surprises. Some practices that had negotiated contracts with MultiPlan found that they no longer received their agreed-upon rate, and patients were no longer protected from big bills.

Brett Lockhart had spine surgery at a facility near Cocoa, Fla., that had a negotiated rate with MultiPlan. When his insurer used Data iSight, he found himself on the hook for nearly $300,000. The bill is the subject of litigation and remains unpaid.

‘Crazy Low’ Payments

There was more to MultiPlan’s rising fortunes than just an increase in the number of claims. The average fee from each claim also grew, executives told investors.

In a presentation shortly before it became a publicly traded company in 2020, MultiPlan stressed that its tools were “scalable”: Reducing payments by just half a percent could yield an additional $10 million in profits, the company said.

After MultiPlan fell short of a revenue target in 2022, Mr. White, who had become chief executive, assured investors that the company had an “action plan” that included “aggressively implementing new initiatives with our customers to help them cope with accelerating health care costs.”

A change to Data iSight’s methodology, he said, should produce an additional $6 million in revenue.

MultiPlan has told investors it plans further “enhancements” to the tools, including use of artificial intelligence.

As patients and providers have demanded an explanation for declining payments, MultiPlan has fought to keep details about Data iSight confidential, contending in lawsuits that the information is proprietary.

Interviews and documents, some obtained after The Times petitioned federal courts, offer some insights .

Data iSight starts by using Medicare’s methods for setting rates. But subsequent calculations are less transparent. MultiPlan says it applies multipliers that allow for a fair profit for hospitals and something approximating a fair market rate for physicians. The documents show that MultiPlan allows insurers to cap prices and set what they consider fair profit margins for medical facilities.

MultiPlan has pitched Data iSight as an alternative to simply paying marked-up Medicare rates, an option some insurers offer. Paying around 120 percent of the government-set rate “sounds fair, maybe even generous,” one MultiPlan document said, but this is “inherently misleading” because “the average consumer does not understand just how low Medicare rates are.”

Interviews and documents, however, indicate that Data iSight’s recommended prices are sometimes about 160 to 260 percent of Medicare rates — amounts former MultiPlan employees described as “ridiculously low” and “crazy low.”

Even rates that may sound reasonable can strain medical practices. For example, UnitedHealthcare, citing Data iSight, offered Dr. Darius Kohan roughly 350 percent of the Medicare rate for a surgery to repair a patient’s eardrum. It amounted to $3,855.36.

Dr. Kohan, who has a small practice in Manhattan, said skimpy payments were forcing him to consider joining a large hospital system or private-equity-backed group.

“I am a dinosaur, but my patients like that,” he said. “I may not be able to sustain it.”

Chris Hamby is an investigative reporter for The Times, based in Washington. More about Chris Hamby