PHA-Exch> Human rights principles for financing health care in the U.S.

[Claudio Schuftan]

From: Anja Rudiger anja at nesri.org



Ten Health Care Financing Principles to Ensure

Universality, Equity, and Accountability

The goal of a healthy society is at the core of human rights principles,
which place a duty on government to

protect everyone’s health. In the United States, this requires urgent health
care reform to end the needless

loss of life, health, and well-being of millions of people. Although current
reform plans are primarily driven

by a sense of economic necessity, based on cost concerns, they do implicitly
share a common

understanding of health as a social goal. Where those proposals fall short
is in assuming that these shared

social and financial goals can be realized as by-products of fragmented,
market-based services.

Whether it is the systematic denial of coverage and care in the private
insurance system, the price-inflated

private Medicare plans, the poor results of privatized Medicaid
administration, or the costly Massachusetts

health reform, in no instance has the market succeeded in providing
equitable access to quality care at a

cost affordable to individuals and society as a whole. Indeed, as a market
good, health care is by definition

exclusionary, sold only to those who can pay, and readily exhaustible,
depleted by private interests that

literally “take their cut” from available resources through profit, leaving
less for the public at large.

A society disposed to protect both bodily and financial health requires the
collective provision of health care

on a guaranteed and sustainable basis. In such a society, health care is
treated as a public good, rather

than as a commodity sold in a marketplace dominated by private interests.
The following ten principles for

financing health care emerge from human rights standards recognized in the
United States and around the

world. They are intended to guide the design of a sustainable,
cost-effective system that secures

comprehensive health care for all.



1 Focused on health: Health care financing must be completely aligned with
the central

purpose of a health system: protecting people’s health.

The goal of a healthy society must take precedence over factors such as
market imperatives, profit motives, and

the vagaries of policy and budget cycles. A health care system should be
financed in a way that guarantees and

secures comprehensive health care for everyone, consisting of all preventive
care, screening, information,

treatments, therapies, and drugs needed to protect people’s health,
including mental health, dental and vision

care, and reproductive services.



2 Universal and unified: Health care financing must secure automatic access
to care for everyone

and avoid separating people into different tiers.

How health care is financed must not lead to differences in how people
receive health care, either with regard to

access, quality, or outcomes. Everyone must be included and get automatic
access to equal high quality health

care, guaranteed throughout their lives and appropriate to their needs.
Financing mechanisms should produce a

unified health care system and not give rise to different tiers of access or
coverage. When everyone is part of the

same system, and can access and use it in the same way, the system itself is
stronger and more sustainable

since everyone benefits from supporting it.



3 Public: Health care is a public good that should be publicly financed and
administered.

Health care is a public good that belongs to all of us, and burdens and
benefits must be shared equitably by all.

The government has a duty to guarantee everyone equal and easy access to
public goods. It can best meet this

obligation through public financing and administration of health care, as
this minimizes the disincentives to

providing care that characterize the business model of private insurers.
Steps toward a public system may

include expanding public programs such as Medicaid and Medicare,
establishing a strong public insurance plan

option, and effectively regulating the private insurance sector.



4 Free: At the point of access, health care services must be provided
without charges or fees.

When visiting a doctor, clinic or hospital, patients should not have to pay.
Health care funds should be collected

independent of the actual use of care, to avoid creating a barrier to care.
Services must be provided based on

clinical need, not payment, regardless of the financing mechanism used.



5 Equitable: Health care financing must be equitable and non-discriminatory.

Finances for health care provision must be raised and spent in an equitable
way. General progressive taxation

constitutes the most equitable mechanism, followed by sliding scale social
insurance contributions. Whichever

model the government adopts, financial contributions from individuals must
be according to ability to pay, in order

to be affordable for all (e.g. on a sliding scale starting at zero). They
must be assessed in a non-discriminatory

way, i.e. they cannot differ on grounds of health status, gender, age,
employment or any other status except

income. In a similar fashion, corporations should be required to contribute
to the costs of the health care system.



6 Centered on care: Care should be financed as directly as possible, without
intermediaries.

Insurance coverage, if used as a vehicle for financing care, works only if

based on the principle of risk and income solidarity.

The key function of a health care system is to provide care, not coverage.
If insurance coverage is used as a

vehicle for financing care, this can only benefit all if those who happen to
enjoy better health or higher incomes

contribute at a level that helps support the whole system, including those
in poorer health or with low incomes.

This grounds the system in the principles of risk and income solidarity and
means that insurance must include

everyone (guaranteed issue), spread costs and risk across society as a whole
(community ratings, large pool),

guarantee comprehensive benefits to all, and collect contributions based on
ability to pay.



7 Responsive to needs: Resources must be allocated equitably, guided by
health needs.

Health care spending must be guided by health needs and rectify existing
disparities in resource allocation and

infrastructure development. Resources must be used equitably for the benefit
of all, while recognizing that some

communities and individuals may need more care and different services than
others. Communities should be

involved in determining how their needs are met, and their participation
should be fully funded.



8 Rewarding quality: Financing mechanisms must reward the provision of
quality, appropriate

care and the improvement of health outcomes.

Health care spending must reward quality, appropriate care, and improved
health outcomes, rather than profitseeking,

marketing, unnecessary medical procedures, poor coordination, or other
interests or effects not linked to

protecting health. If care is financed through private insurance, regulation
must ensure (through measures such

as medical loss ratios) that resources are not diverted away from quality
care. Similarly, we should reward

providers who focus on quality and outcomes rather than volume, deliver
primary care, provide medical homes,

and serve communities and areas in need.



9 Cost-effective: Resources must be used effectively and sustainably to
protect the health of all.

Financial resources in the health care system must be used for the benefit
of the whole society, leaving no one

behind and investing in communities whose health has not kept up with that
of the rest of the population.

Wasteful or uncontrolled spending in some areas restricts opportunities for
protecting health in others, so the

cost-effectiveness of interventions should be taken into account (e.g.
through needs assessments, global

budgets for hospitals, control of capital expansion and technology projects,
etc.).



10 Accountable: Financing mechanisms and procedures must be accountable to
the people.

Whether public or private, all financing mechanisms and procedures must be
transparent and accountable to the

people for whose benefit they exist. The people have a right to participate
in the oversight of financing structures,

and the government has a duty to ensure that financing decisions are based
on the human rights principle of

universal, equitable health protection. Monitoring and evaluation systems,
as well as appropriate public and

private remedies, must be put in place to enable the public to measure and
oversee progress toward meeting

human rights standards.





How Reform Can Realize Our Human Right to Health Care

Human rights principles illuminate the social, economic, and moral aspects
of our health care crisis and

offer guidance for developing a holistic solution.

If we agree on the common goal of a healthy society, we need to create a
robust and sustainable system of

collective health care provision that guarantees that everyone can get the
health care they need, regardless

of their ability to pay.

If we agree on the need to contain the health care costs faced by families,
businesses, and government, we

need to use our limited resources as effectively as possible, accountable to
all of us. We cannot afford to

waste them on insurance middlemen and other corporate interests that inflate
prices and deplete resources

through bureaucracy, marketing, and profit-making.

If we agree on the moral obligation conferred by human rights, which entails
treating every person as our

equal, endowed with dignity and an equal opportunity to pursue a healthy
life, then we cannot exclude

anyone from health care, or give them inferior care, or force them to pay
private gatekeepers to access

care.

Our social goal of universal health protection requires that we pursue cost
containment by turning a volatile

market good into a sustainable public good. And only a public good can be
distributed equitably and thereby

help us meet our moral obligation for equal treatment.

Health care reformers who take into account these basic principles will be
able to develop a sustainable

system that is universal, equitable, and accountable to the people.



 Footnotes

1 International Covenant on Economic, Social and Cultural Rights, entered
into force in 1976 (hereinafter ICESCR), Art. 12; The

Committee on Economic, Social and Cultural Rights, The Right to the Highest
Attainable Standard of Health: 11/08/200 E/

C.12/2000/4 (General Comment 14) (hereinafter GC 14) at pars. 8, 9, 17, 34,
51 & 53.

2 ICESCR, Art. 12; GC 14 at pars. 12 (b) & 34. States must afford “equal
access” to care for all persons (GC 14, pars. 34 & 35),

which is threatened in a system with different access tiers — where, for
example, poorer patients, in part due to different

insurance options, see different doctors than wealthier patients — but
strengthened significantly in a unified system that affords

the same access route to all.

3 The international framework allows a public, private or mixed system (GC
14 at par. 36), provided that governments fulfill their

obligation to protect against private actors, such as insurers, undermining
the right to health care (GC 14 at par. 33). Given the

breadth of evidence that private or privately administered financing has led
to inequities and disincentives to providing

appropriate coverage and care, a mixed system seems more suited to reaching
human rights goals in the United States, with

full and equal access to private doctors and hospitals that are publicly
administered and financed. See generally GC 14 at pars.

33, 35, 36, 50 & 51.

4 The right to health requires the removal of all barriers interfering with
access to health services (GC 14 at par. 21), and payment

at the point of access, however small, has been proven to deter the uptake
of health care especially by poor people (see RAND

Corporation, “The Health Insurance Experiment,” RAND Research Highlights
2006 ). See generally GC 14 at pars. 21 & 50.

5 See GC 14 at pars. at 12, 18, 19, 21, 30, 34, 43(a), 43(e) & 51;
International Convention on the Elimination of All Forms of

Racial Discrimination, ratified by the United States in 1994, Article 5 (e)
(iv).

6 See GC 14 at pars. 12, 35 & 51.

7 See GC 14 at pars. 12, 17, 37 & 43.

8 See GC 14 at pars. 12, 35, 51 & 55.

9 See GC 14 at pars.18, 19, 47 & 51.

10 See GC 14 at pars. 17, 54, 55, 56, 57, 58 & 59.



 National Economic and Social Rights Initiative/ National Health Law Program

www.nesri.org

The Human Right to Health Program, run jointly by NESRI and NHeLP, is
developing human rights tools to support community organizations and
coalitions across the U.S. in their efforts to achieve rights-based health
care reform at the local, state, and federal level.

Subscribe to the Human Right to Health listserv:
https://lists.mayfirst.org/cgi-bin/mailman/listinfo/human_right_to_health
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