Editorial

The Right to Healthcare

International law is clear on the meaning of the right to health, and it is time that right be made real.

The International Covenant on Economic, Social, and Cultural Rights, one of the two core covenants adopted under the Universal Declaration of Human Rights, recognizes "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."

Although the United States is not a party to the covenant, just about every other country is.

The United States is not a party to the economic and social rights treaty in part because the agreement contains what are considered affirmative rights -- the right not only to be free of government interference (such as the right not to have the government interfere with speech rights, or the right not to be tortured), but a positive obligation by government to provide certain conditions so they people may live free of fear or want.

One criticism of affirmative rights is that they are ephemeral. Governments face real resource constraints, and a right that demands a government spend money it does not have serves no purpose, the argument runs.

But human rights advocates are not just dreamers.

International legal bodies have worked out a sensible framework for balancing a government's duty to guarantee people with an adequate standard of living, including adequate food, clothing and housing, healthcare and education, with their real resource constraints.

The basic rule is that governments first must not impose obstacles to realization of this right, and that they must also take all appropriate measures -- what they can reasonably do, given realistic constraints -- to fulfill their affirmative rights obligations.

When it comes to healthcare, what all this means in practice is that governments cannot rely on the market to deliver healthcare. Experience in rich and poor countries alike shows that market mechanisms will work to deny people care -- and, indeed, the best profit opportunity for private insurers comes from maneuvering to avoid providing insurance to those most likely to become sick.

The sick should not be penalized for needing healthcare. It is penalty enough being sick in the first place.

Providing healthcare costs money. In poor countries, it actually does not cost that much. In rich countries, it does. Whatever the cost, all people of a country should pay those costs -- they should not be apportioned to the ill -- and all people should be able to get access to care.

For developing countries, perhaps the most the most pressing policy implication of that principle is the abolition of user fees -- charges for using healthcare. There is an abundance of evidence that such charges -- even when they are as low as a dollar or two -- deter people from getting care that they need.

It certainly means expanding the role of the public sector in health provision. The Venezuelan approach that Peter Maybarduk recounts in this issue is resource-intensive and probably replicable only in middle-income countries. But the real lesson from Venezuela is transferable to poorer developing countries: with political commitment, major improvements in providing access to appropriate healthcare can be achieved, and quickly.

Unfortunately, under pressure from the International Monetary Fund and World Bank, as well as government donors, industry lobbies and market fundamentalist economists and policy advisors, too many developing countries are moving in the opposite direction. Celia Iriart, Howard Waitzkin and Emerson Merhy document the disturbing trend of multinational insurers gaining an ever-expanding foothold in Latin America, and the deleterious consequences.

At least in developing countries, resource constraints are a plausible explanation of failure to deliver healthcare to all. What possible excuse does the the richest country in the world, the United States, have?

Forty-five million people in the United States do not have health insurance. Another 50 million have inadequate insurance. And even those with decent insurance coverage frequently have to confront bureaucratic hassles and decisions that can interfere with the provision of care -- and at the very least induce a migraine headache.

The market-based health insurance system in the United States has failed totally.

As Rose Ann DeMoro and Claudia Fegan argue in interviews in this issue, it must be replaced entirely. The solution is simple: a single-payer system, where the federal government takes over the role of providing health insurance.

The economics are quite simple, as Fegan explains: "We could take the amount of money that we're spending on healthcare today, and provide coverage for everyone. We could do that if we eliminated the 25 to 30 percent of every healthcare dollar that goes to overhead for the insurance industry. Publicly administered plans take less than 5 percent in administrative overhead."

In the process, the level of care could actually be improved, with healthcare funding decisions based on public health needs, not distorted as they now are by the profit-based priorities of health insurers and other profit-maximizing actors in the healthcare field.

Making the right to health real through such policy reforms, of course, is not primarily a matter of making good arguments. It is a matter of overcoming the vested and ideological interests that stand in the way.