Mercy Killers is a one-man show that details the consequences of a medical health-care catastrophe (breast cancer) in a family.1 This disturbing fictional account is actually a daily event in cancer centers: losing insurance for technicalities, losing a home because of an inability to pay the mortgage, bankruptcy, humiliation and loss of dignity, divorcing spouses or quitting jobs to become eligible for indigent care, compromising on morality to save one’s life, and often dying of lack of care when treatments exist but are not accessible or affordable. “Mercy killers” in the play refers to assisting the spouse in dying when cancer recurs. Its double meaning is the demise of mercy in the era of modern health care. Profit, the killer of mercy in the for-profit health-care industry, aims to maximize profits, even when this harms patients.
Because of the terrible consequences of the lack of health care for millions of Americans, an important question is whether health care in the United States should be considered a basic human right, or is it only a privilege or an entitlement?
Health Care in Europe vs United States
Most European nations have had some form of national insurance for more than a century. The primary reasons for these insurance programs were not payment of medical expenses, but income stabilization and protection of wage loss when sick.2 In some ways, this is analogous to the American Social Security program. European social insurance programs have evolved over time into vibrant universal health-care systems. Both the European Union and the United Nations recognize health care as a basic human right; 38% of the constitutions of the members of the United Nations guarantee medical care.3
The United States is a rare nation in the Organization for Economic Cooperation and Development (OECD): It does not recognize universal health care as a human right. South Africa established universal health care in 1996, 2 years after ending apartheid. In contrast, it took the United States 50 years after the Civil Rights Act of 1964 before it enacted the Patient Protection and Affordable Care Act (ACA)—our first attempt to establish universal health care in more than 200 years.4
Diverse Ideologies
The reluctance of America to embrace universal health care may have been influenced by earlier ideologic movements in the 19th century. William Graham Sumner brought Darwinian evolution and Malthusian economic theory into the American sociopolitical arena.5 His ideology, aligned with capitalism in many aspects, was readily accepted then by most Americans. Mr. Sumner’s view is that the world population was increasing geometrically and resources increasing arithmetically.
Therefore, “civilization has a simple choice”: “liberty, inequality, survival of the fittest” or “not-liberty, equality, and survival of the un-fittest. The former would carry society forward and favor its best members. The latter would carry society downwards and favor the worst members.” Mr. Sumner theorized that the pressure of a competitive system would strengthen a society over generations. An inference of this theory is that governmental intervention would interfere with natural selection and weaken societies.
Societal Darwinism may have cast its long shadow over health care in the United States in the form of medical Darwinism (survival of the fittest), hence the acceptance of unequal health care or health care as an entitlement rather than a human right. The 20th century nurtured the idea of fairness in reaching the American Dream, and the need for equal opportunities and social safety nets that protect Americans at times of vulnerability. This shift in attitude has varied with the ideologies of governments in power.
A Texas legislator asked in 2003: “Where did this idea come from that everybody deserves free education? Free medical care? Free whatever? It comes from Moscow. From Russia. It comes straight out of the pit of hell.”6 Today, politicians avoid making such public statements because most Americans believe health care should be guaranteed—83% believe health insurance is absolutely essential or very important, and 70% believe the United States should have universal health care (similar to Medicare for Americans 65 years or older).7
Americans believe in reward for hard work but also in equal opportunity, hence fair access to health care and education. Children with poor health care or poor education are doomed to failure in adulthood. Health-care inequality leads inevitably to poverty and to compromises on ethical principles to access basic necessities.
Excessive Resources Yet Suboptimal Outcomes
America is among the richest nations in the world and spends more on health care than any other country (18% of our gross domestic product—two to three times more than other advanced nations). Yet we rank poorly in objective measures of health-care outcomes.8
Why is there this dichotomy between excessive resources and suboptimal outcomes? In the European health-care systems, most financial resources are directed toward patient care. However, the for-profit nature of the health-care system in the United States results in less than one-third of the dollars being directed to patient care. The rest is diverted as profits for the health-care industry. Also, large sums of money are spent by insurance companies to deny (rather than provide) health care (“denial management”). Thus, universal health care (opposed by some for being prohibitively expensive) can in the long run become more efficient and more affordable if implemented properly.
Equal Access to Health Care
Physicians abide by two universal principles of the Hippocratic Oath: protection of patients from harm and injustice. Lack of needed health care is both harmful and unjust.9 Physicians should advocate for universal health care as a human right.
America is aberrant among advanced nations in not guaranteeing basic health care. Our country promulgates fairness, equal opportunity, and the potential to achieve the American Dream. However, American exceptionalism, the for-profit health-care industry, and physician concerns over income may be the triad that hindered progress toward universal health care.10 The reasons, stated and implied over time, have varied: opposition to “socialized medicine,” anticommunism, fears of hospital desegregation, antiwelfare sentiment, and more recently the unaffordable costs of universal health care.
Signed into law by President Johnson in 1965, Medicare and Medicaid were the first steps toward universal health care. Fifty years later, the ACA was the first endeavor to provide better and more expanded health care at affordable costs.11 One year into the implementation of the ACA, the rate of uninsured Americans fell from 18% to 10%, even lower in states that accepted the ACA Medicaid expansion (7% vs 14%).12 More people approve of the ACA, and 81% of people enrolled in ACA plans are satisfied.13 Most important, it is saving lives.14,15
Freedom should not translate into denial of other human rights, including affordable health care to all. The American Dream implies fairness for equal opportunity. Medical Darwinism is not consistent with fairness in a country that spends so much on health care but fails to distribute it effectively. To live up to the ideals of America, equal access to health care is critical, and health care should be a basic human right. ■
Note: An expanded version of this editorial was published in the October 2015 issue of Annals of Oncology (26:2193-2195, 2015).
Disclosure: Mr. Jones and Dr. Kantarjian reported no potential conflicts of interest.
References
1. Mercy Killers, The One-Man Show. Performed by Michael Milligan Available at http://mercykillerstheplay.com/. Accessed October 20, 2015.
2. Palmer K: A brief history: Universal health care efforts in the US: Physicians for a national health program. 1999. Available at http://www.pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-the-us. Accessed October 20, 2015.
3. Heymann J, Cassola A, Raub A, Mishra L: Constitutional rights to health, public health and medical care: The status of health protections in 191 countries. Global Public Health 8:639-653, 2013.
4. Price CC, Eibner C: For states that opt out of Medicaid expansion: 3.6 Million fewer insured and $8.4 billion less in federal payments. Health Aff (Millwood) 32:1030-1036, 2013.
5. Wikipedia. William Graham Sumner. Available at http://en.wikipedia.org/wiki/William_Graham_Sumner. Accessed October 20, 2015.
6. Ivins M: Bucking the Texas lockstep. The Washington Post. May 15, 2003.
7. Deam J: Health care survey yields surprises for the medical community. Houston Chronicle. Available at http://www.houstonchronicle.com/business/medical/article/Health-care-survey-yields-surprises-for-the-6227381.php. Accessed October 20, 2015.
8. Kantarjian H: Does the United States have the best health-care system in the world? The ASCO Post 5(Aug):172-174, 2014.
9. Kantarjian H, Steensma DP: Relevance of the Hippocratic Oath in the 21st century. The ASCO Post 5(Oct):1, 101, 104, 2014.
10. Krugman P: The politics of the welfare state, in The Conscience of a Liberal, pp 57-78. New York, W.W. Norton & Company, 2007.
11. Zwelling L, Kantarjian HM: Obamacare: Why should we care? J Oncol Pract 10:12-14, 2014.
12. Ho V, Marks E: Health Reform Monitoring Survey—Texas. Episcopal Health Foundation, Rice University’s Baker Institute, 2015. Available at http://www.episcopalhealth.org/files/7814/3040/3719/Issue_Brief_11_FINAL.pdf. Accessed October 20, 2015.
13. Collins SR, Rasmussen PW, Doty MM, Beutel S: Americans’ experiences with marketplace and Medicaid coverage. Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015. June 2015. Available at http://www.commonwealthfund.org/publications/issue-briefs/2015/jun/experiences-marketplace-and-medicaid. Accessed October 20, 2015.
14. Polite BN, Griggs JJ, Moy B, et al: American Society of Clinical Oncology policy statement on Medicaid reform. J Clin Oncol 32:4162-4166, 2014.
15. Sommers BD, Baicker K, Epstein AM: Mortality and access to care among adults after state Medicaid expansions. N Engl J Med 367:1025-1034, 2012.
Mr. Jones is a first-year medical student at The University of Texas Health Sciences Center, and Dr. Kantarjian is Chairman of the Leukemia Department at The University of Texas MD Anderson Cancer Center, Houston.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO.
