Public Health Law + US uninsured

Ara’s Blog: for September 3, 2008 (week 2) Readings.

The question posed is: how can the US allow having a high number of uninsured within its population? My immediate response to this would be: its existence is embedded in the political as well as cultural infrastructure of American health development. This was briefly brought forth in Chapter 2’s reading, titled “political explanations of health policy”. I’d like to expand on my response by utilizing public health law concepts. It’s a field of personal interest and I believe these concepts would be a great foundation to build upon during the rest of the semester.

It’s the government’s responsibility to protect the health of the populations that have significant relationships established in need of provisional public health services, and that they [the government] must implement them in a manner which yields conformity (but must protect civil liberties). And this is where the difficulty arises. There are trade-offs: providing health services and protecting private/self-interests as well as civil liberties; namely, autonomy—which is the predominant cultural explanation in the demand of services.

Public health can only be achieved through communal effort. Yes, the individual can manage in attaining the basic goods in life, including medical services, but no individual can assure his or her health. Since there are many communal goods that the population has a stake in (i.e., environment, sanitation, clean air/water, safe roads/health products, and control of infectious disease), these are collective goods that can be secured when being provided and protected on behalf of populations (i.e., via government) and with the cooperative involvement of communities.

However, as much as public health is indispensable to the individual so as to provide the means to enjoy fulfilling lives and to the community so as to provide the foundation for social, political, economic growth through the subsequent social productivity, the government’s role in the provision of health services can’t be absolute. In other words, there can’t be complete guarantee of health care services. How is that so? Let’s ask ourselves:

a) How much [medical and health service provision] is enough?

b) How is it determined as to whether the resources were allocated effectively and implemented properly?

c) How do we determine whether the “Standard of health” has been reached?

d) How do we objectively define “Standard” of health, let alone, “health”?

e) Is it proper to say that a population has the “right to health”? This may be demanding an unattainable request; namely, perfect health and well-being. Instead, is it justifiable to say that society has a “right to services”?

For these reasons and more bioethical dimensions, there can’t be an absolute governmental role in health care provisions.

A challenge in assuring universal insurance is the perennial conflict of state and individual interests. While the state tries to sustain beneficence and non-maleficence, there is a conflict with the individual’s right to bodily integrity, liberty, and autonomy. So the question then becomes: What should a policy embody so as to balance such interests?

Theoretically, it should ensure the just distribution of burden, costs, and benefits. The ideal situation would be to provide the benefits to those in need, while giving the burden and costs to those that are endangering the public’s health. And even while the services are provided to those in need, that they are done justly and equitably. Unfortunately, there are two types of policies that we may encounter: under-inclusive and over-inclusive.

Under-inclusive health policies will place the benefits toward only a small subgroup of people and thereby not be able to reach everyone who may be in need of it (unjust distribution). Furthermore, it will regulate/penalize only a subgroup of people that are thought to be “Dangerous, high risk” (unjust regulation). Essentially, the cut off points for beneficial provision and regulation are too low.

Over-inclusive health policies on the other hand, will place the benefits of service to a large group of people that may not all necessarily need it (wasteful spending). Essentially, the cut-off point for distribution and regulation is too high.

With such an imbalance, what are other alternatives? Or, should there even be an alternative? Should government even bother intervening and providing health services? Is it there *duty*? Regarding health provision, the government stands on a “negative constitution”, with “no affirmative obligation” to act, or to protect; even if such aid may be necessary to secure life, liberty, or property interests.

Furthermore, judicial refusal to examine government’s failure to act, irrespective of circumstances, leaves the state free to abuse its power and cause harm to citizens. In other words, a constitutional rule that punishes government misfeasance (when the state intentionally or negligently causes harm) but not nonfeasance (when the state simply does not act) provides an incentive to withhold services and interventions.

Questions: how is inactive negligence of causing harm (direct or indirect) not the same as active negligence of causing harm (direct/indirect)? Why isn’t the former held just as accountable as the latter?

Lastly, I’d like to just make the argument of providing universal insurance on the grounds of human rights. Is health a human right? In what manner? How do we justify it as a public good? The fact of the matter is, they have mutual interactions. In that: if government doesn’t safeguard society from the violation of civil liberties, social and economic burdens will arise as well as the loss of social trust and adherence to health initiatives. Despite the fact that the protection of civil liberties entails the deprivation of such liberties from select groups of individuals, is the American society and culture willing to accept such a trade-off at the expense of others? Either answer to that question will yield the same outcome: universal insurance and protection of civil liberties can’t be attained.

And in an American culture where civil liberties are of highest priority, along with the demands of highest health services, the race for their simultaneous acquisition is never-ending....

**For further information on over-inclusive, under-inclusive policies, as well as the concept of negative constitution, please refer to:

Gostin, Larry o. Public health law: power, duty, restraint. Berkeley: University of California Press, 2000. (Chapter 1, 2, and 4).

THANK YOU for your time...