The Healthcare Debate – Back to Basics
Rethinking the Role of Government in Ensuring Health in Society
Jul 22, 2009
The US debate on President Obama’s Health-care proposals continues unabated. Although it is a US debate, it focuses on an issue that is fundamental to all societies, but especially in developing countries. Yet the issue of the limits of a Society’s responsibility for the health of the citizenry is not vigorously debated.
One often gains the impression that many people regard ‘Government’ as something foreign, something foisted on society by some outside agency, to be tolerated only insofar as it cannot be avoided. Yet democracy has ‘government’ as a central element of its philosophy.
Government in a democracy is supposed to be all the citizens acting as a collective; doing what we should be doing for each other to ensure the best possible living environment within which we can be free, prosperous and happy. If, in any democratic country, a government does not live up to this promise, the voting citizens have only themselves to blame.
The Limits of the State
A CBS report of July 20 filed from Washington, quotes Michael Steele, the chairman of the Republican Party, calling President Barack Obama's plan to overhaul health-care "socialism," and accused the president of “conducting a risky experiment that will hurt the economy and force millions to drop their current coverage.”
It is an unfortunate feature of politics that debates degenerate into labeling, name calling and general mendacity. Calling a plan ‘socialist’ says nothing about its merits or demerits. It merely appeals to people’s prejudices about socialism, aiming by subjective association to incorporate ideas into the plan that aren’t there; condemnation or approbation by association is equally reprehensible stratagems.
The specifics of the President’s plan concern only Americans, but the underlying issues are universal; issues relevant especially to developing countries with millions of poor who are unable to pay for private health-care. The question arises to what extent and on what basis citizens are collectively responsible to care for their fellows.
Clearly, in a moral society people cannot just be left to fend for themselves whatever their circumstances. Such an attitude tends to undermine the very reason d’etre of society itself. On the other hand, there is no reason why the citizen’s collective, i.e. the state, should fend for citizens who are well capable of fending for themselves.
Private vs. Public Health-Care
Should health care be in the private or the public domain?
The health of the citizen is of fundamental importance to society. There can be no question that the state, acting as the citizen’s collective, must be keenly involved in ensuring that the optimal level of health-care is available to all. This surely does not mean that all health care must be seen as a public good, i.e. deliverable by the state.
The state has an interest and an obligation to regulate private health-care to eliminate systemic risk. That means, inter alia, that all practitioners are properly qualified, ethically overseen and employ best practice; that medicines are as safe and effective as possible for their stated purposes; that their distribution is properly regulated and their availability is widespread.
It also means that the state has to put measures in place that ensure medical services remain affordable and available to the citizens at large. It must ensure that there are no corners in the market, no manipulative or abusive practices.
The state has a responsibility to see that the correct institutions are in place for effective and optimal health-care. None of this is problematic. The problem with private health-care only arises with those who cannot afford to pay.
Who Cares For the Poor?
The fundamental weakness of the market system is that by definition, prices are regulated by supply and demand, the one calling forth the other. ‘Demand’ is defined as demand by those who are both willing and able to pay. The willing who aren’t able to pay are excluded from ‘demand’. Consequently markets never supply those unable to pay. The poor are permanently marginalized.
Since the private sector will not provide health-care for the poor, the state has the responsibility, the duty to do so. How it achieves that depends on individual circumstances.
In South Africa, a developing country, an extensive matrix of private hospitals, clinics and highly competent practitioners exist. Simultaneously there is a vast array of under-resourced, badly administered state hospitals that theoretically serve the whole population. The situation creates a severe dichotomy with first class medical care available for the wealthy and deeply flawed, inadequate care available to the poor.
The state would do a lot better by abandoning its attempt to provide health-care for all citizens. It could better utilize its resources by supplying services only where the private sector does not do so, such as the deep rural areas, and otherwise to act as medical insurance for the poor. This would allow them to make use of the extensive and well-provided private health-care facilities.
In principle thus, the role of the state should be to effect a fair and equitable health-care system wherein it primarily acts as regulator, and overseer of the facilities in general, but also as residual guarantor of health-care for the poor. This is a fairness gauge for health-care in any country, developed or developing.
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