Health Care & Public Goods

To base social benefits or other spoils of public goods on contribution, effort or tradition is not alien to some domains of the welfare state, as for example pensions that are tied to past contributions or unemployment benefits that are contingent on past contributions and present efforts to find a new job or to participate in further education.

Thus, we may ask ourselves: Why should one treat health and consequently also health care any differently from other domains of welfare, of (re)distribution, of the market economy and of society altogether? If we arrive at handling health and health care just like any other aspect of state welfare, we permit the enhancement of correlative justice principles in health policy making and in the public-private mix in health care. I argue this is so because correlative justice principles go hand in hand with policy models that rely on strong conditionality and on balanced or obligating reciprocity norms as social modes of exchange (cf. Mau 2004). Put differently, the allocation of all health-related resources would be assigned to private markets, while the distribution of all health-related risks and burdens would be transferred to the individual citizen. In this context all public health care would be tied to individual contributions or individual efforts. 

Making health an “ordinary” commodity would potentially amplify the consequences of socio-economic determinants of health and would possibly render vulnerable and marginalised groups more exposed to the dynamics of private markets and to crises shocks. Contrariwise, I propose that health and health care are “special” goods and categories due to the following rationales:

1) Health is not an “ordinary” commodity because it is inseparable from moralities and ethics (e.g. Fuchs and Zeckhauser 1987; Jennings and Hanson 1995; Emanuel 1997).

2) In relation to 1), health is not only not ordinary, but is a normatively special category because it levels the playing field and enables equal opportunities for further endeavours in all people’s lives, including their pursuit of wealth and well-being (cf. Daniels 2008).

3) Health care markets, and particularly the coverage of health care and medical interventions through health insurance providers, are prone to problems that result in inefficiency and inequity in shape of various market failures (Arrow 1963; Roemer 1982; Powers and Faden 2006; Zweifel 2011; Thomson et al. 2020). The most prominent disruptions are caused by ex-ante and ex-post moral hazard, monopolisation and collusion, adverse selection and risk selection. In addition, health insurance markets are plagued by free-riding and the assurance problem. Free-riding refers to behaviour, wherein people opportunistically avoid contributing to a public good, while consuming its benefits. The assurance problem describes a situation, wherein agents are sceptical of communal commitment and thus also of reaching necessary thresholds of sufficient aggregate contribution. 

4) Deriving from 3), real world markets, i.e. markets without complete property rights, full information and perfect competition, will fail to attain Pareto-optimality. Especially perfect competition will be violated by the existence of ‘natural monopolies’ in the provision of many public goods. Moreover, negative market externalities can call for public correction of market failures, even when very high costs for the public arise. Then it is the responsibility of public (health) policies and regulations to correct public health-related market failures and to provide health-related pure public goods (Horne 2019).

5) “The concept of solidarity as a guiding principle for health care has its diametrical opposite in the view that health care can most effectively and efficiently be provided as a commodity traded for profit” (Hart 2010, p. 154). This pertains to the view that the most efficient and cost-minimised health care provision can only be delivered by private providers through free markets. Recalling points 3) and 4), it might actually be the case that public health care is more economical and efficient than private provision in many circumstances. Some evidence suggests that increasing private provision of health care cannot be associated with efficiency-gains (Kruse et al. 2018).

6) Health care can be seen as a (public) solidarity good: Sound health is generally seen as a desirable outcome and benefit. To achieve sound health we relate to others’ behaviours and consumption choices. Sound public health produces many positive externalities and satisfaction in a society with good collective health will exceed satisfaction in societies with poor population health (cf. Sunstein and Ullmann-Margalit 2001; Kallhoff 2014).

7) Following from these previous corollaries, health care should additionally be treated as a normative public good (cf. Karsten 1995; Dees 2018; Abdalla et al. 2020) because (public) health ethics as well as deliberations from health equity and from distributive justice must enter any thoughtful discussion on health, health care and health policy. These domains inevitably evoke normative principles and values.