I Once heard from a physician specialized in public health that American healthcare should be named “sick care” because the system has a reactive focus. People fall ill and then seek for care that a healthcare facility will provide. This is opposite from a proactive focus, that is, actions and strategies that can stimulate health and well-being, promoting population health as much as possible. Such a change in focus would require the American health system to shift from focusing on tertiary care to emphasizing primary care, with measures of health prevention and promotion. This shift does not eliminate tertiary care, where medical care is more specialized and highly technological. People would still fall ill with need of tertiary care, but fewer should need expensive hospital care. Theoretically, a shift of perspective, that is, from a hospital-centralized care to a community-based care, would promote more population health and, at the same time, would be cheaper. Consequently, this shift would create more health equity in a system that is full of health inequities and disparities. Many other countries, such as Canada, Brazil and Cuba, have made this shift since the Declaration of Alma-Ata and the WHO recommendation to focus on primary care for creating health equity. For countries that made this transition, their health indicators have improved in the last 10 years.
In the USA, tertiary has been predominant throughout American healthcare systems, with few exceptions for initiatives of some groups. This focus is not surprising, considering the healthcare system is dominated by the private sector that needs to sell its product to profit. Technically, it is not precise to say the “American healthcare system.” This country does not have a uniform healthcare system; rather, it has several systems that vary according to state laws and health institutions. There are federal regulations through the ACA, such as policies regulating insurance companies. But these regulations function within a sector that is highly controlled by a capitalist market, in a constant fight against governmental interventions to regulate the healthcare market.
Health care in the USA is closer to a libertarian perspective based on a free-market approach than a communitarian view focused on the common good. Advocates of this perspective even argue that the free market can solve the problem of health care coverage in the USA, where there are approximately 28 million uninsured people. For them, the problem is that the health market is not economically free enough.
In a libertarian economy, the state is not responsible for creating opportunities for people to develop their life, but only for creating the freedom they need to pursue what they want, as long as this pursuit does not diminish the freedom of others. The state works only as a power to guarantee people’s freedom and to punish those who act against individual autonomy and integrity. As a result, all are free to play in the marketplace, in a fair and meritocratic competition. Therefore, a libertarian economy does not include you, but you work to include yourself in the marketplace. As a part of this market, you can negotiate with insurance companies and health providers for good deals. The problem begins when these players do not have conditions nor have opportunities to develop and/or to include themselves in the marketplace. Social vulnerability is their fate. Consequently, health injustice and disparities grow, marginalizing even more those who are socially vulnerable.
The current market-based health care in the USA is strongly influenced by a libertarian economy. This economic model of governance – especially related to goods central for people’s flourishing such as health and health care – leads companies and businesses to where the money is, and not to people’s substantial needs, especially those people socially vulnerable with no opportunity and condition to enter the marketplace. When we think about health care, this market-based perspective seems cruel for middle- and low-income families and the poor. Health and health care are basic conditions for them to be able to access opportunities to be included in the marketplace and participate in the common good. However, a libertarian market by itself cannot do it. On the contrary, it marginalizes those who are socio-economically vulnerable, and excludes those who are in the middle by leading them to bankruptcy because of their medical bills.
The free market perspective combined with the focus on tertiary care where economic gain is higher are behind a sentence that I often hear: “Americans cannot afford to get sick.” And I would add: “in a system that wants you sick, so it can make money.” On the contrary, health insurances create mechanisms, such as copayment and high deductibles, to make Americans think twice, three times, ten times before seeking for a doctor. All of this seems a contradiction in a system that moves around money and not around people. In other words, people become means for an end, that is money, more profit.
To make this situation even more complicated and showing the limitations of a libertarian approach to health care, I invite to consider the lack of power and governance that states and federal agencies have when there is a public health care crisis as the one we are facing now because of the coronavirus. The US Department of Health and Human Services (HHS) and the Centers for Disease Control & Prevention (CDC) have very limited power to address a national public health emergency. However, federal and state administration could use the policy power, that is, a “power to protect the public health, safety, and morals,” to coordinate and implement actions. Considering the current political atmosphere, political leaders are unlikely to use this power, and apart from this power, national public health actions are limited, which the coronavirus outbreak has shown. One of the main reasons for that is simple: American health care depends on the private health sector described above. HHS and CDC make recommendations, but they cannot make private health institutions do anything. They can provide funds for private institutions, especially non-profit ones, to provide some services and develop medical research, but this has a limited impact in a public health crisis that needs a broad, comprehensive and organized strategy. The USA does not have a public universal healthcare system which allows an organized national effort to address an issue that crosses all social classes, races, and particularities of each state. Even with the Congress approving $8.3 billion to address the coronavirus outbreak, it is questionable how this money will be used and allocated in a more efficient and effective way to help all those who need all over the country, as we see from how difficult it is to be tested for coronavirus.
At the beginning of the outbreak in the USA, the CDC recommended very strict criteria for testing. Then it expanded these criteria, but they still narrow, preventing many people from been tested. The limited availability of testing kits is also a problem. The CDC has not distributed them around the country because there are not enough for every county public health department. The number of infections is, thus, spreading faster than testing kits available to identify new cases. There are contradictions between what the federal administration says and what is actually happening. The CDC is primarily sending these kits to public laboratories, and also to private ones. In the American health system, the state does not have the public capacity to respond to a public health crisis. It depends on the help of the private health institutions, but state policies are limited to force this collaboration, unless the public health policy power is invoked. This means that the government does not have an interest in using this power to create a national coordinated public effort, which opens space for misinformation, wasting resources, and lack of efficiency: a recipe for national panic. Clearly more preoccupated with the economic impact than people’s life, Trump’s address to the nation created more confusion than solution.
On the top of that, we have to consider that many people – who may think they should be tested because what they feel and where they have been – may decide not to be tested for coronavirus because of the cost. Vice-president Mike Pence guaranteed that Medicare and Medicaid will cover this test. But there is no changing in federal policy to obligate private insurance to cover the coronavirus test and the expenses related to it, such as the medical staff and the facility used for the test. We can have a scenario where the testing itself is free, but one must pay for the related expenses (collecting the specimen, noting in the chart, getting follow up care). People are scared of high unexpected medical bills. Newspapers and social media already are showing stories of people who received a very expensive bill or decided not to get test because of expenses. Moreover, high deductible insurance plans are popular, but they cover next to nothing. People under these plans may not be willing to pay five thousand dollars up front to have a test. All this creates problems for identifying those who are infected and control the spread of the virus.
When there is no universal public health coverage, the power of a government to address a national public health care crisis is extremely limited. It can provide and allocate resources for free testing, it can make recommendations through national agencies (e.g. CDC), but it cannot provide the healthcare structure needed to address the crisis because this structure is almost totally controlled by the private sector grounded on a libertarian, market-based perspective of health care. Government interference in that system will be accused of being authoritarian and nondemocratic, especially by those who make tons of money in the healthcare market. This creates an ethical dilemma between the need of a broad, comprehensive, and coordinated action to combat the epidemic and the current market-based structure, commodified health system, while the coronavirus is spreading.
We cannot change the foundation of a system in the middle of this crisis, but we can work to join efforts to address this ethical dilemma. We need comprehensive approaches involving substantial collaboration between public and private sectors. Federal, state, and local authorities must coordinate their actions and allocation of resources without worrying about their political capital, putting the common good at the first place. Private hospitals, clinics, labs, and providers must join this effort as partners also responsible for the common good because this crisis cannot be addressed without their collaboration. Perhaps the economic loss will be significant, a disaster for those who control a market-based system, but that system cannot be protected at the cost of the human life. Considering the human rights principle of the inalienable and inherent human dignity, economic loss is justified to protect the human life. Moreover, I also hope that this crisis must become an opportunity for us to rethink our current model of commodified health care in this country.
Alexandre A. Martins is assistant professor in the Theology Department and the College of Nursing at Marquette University.