Hastings Center Report

Bioethics, I argued nearly a decade ago, has been very slow to respond to the profound insights into population health and its distribution that have emerged from the social epidemiology literature of the last several decades.¹ Strikingly, that literature shows that universal coverage medical systems do not eliminate the general association found between socioeconomic status (SES) and health—that the richer you are, the longer and healthier your life will be. Since many people think access to health care is the key determinant of health inequalities between various social groups, the persistence of the SES gradient of health in the face of universal coverage is surprising. It is also troubling because universal coverage is much easier to establish than a redistribution of the many other important goods that are social determinants of health—income, wealth, education, political participation, control over one's life.

Gopal Sreenivasan's thoughtful "Health Care and Equality of Opportunity" pushes us to reexamine the relationship between opportunity, health, and health care by drawing attention to the importance of the social determinants of health and their contribution to health inequalities. Suppose, as I have argued elsewhere, that protecting health, viewed as normal functioning, makes a significant if limited contribution to protecting the range of opportunities effectively open to individuals. Although serious departures from normal functioning reduce those opportunities significantly, other things also affect the opportunities people have, including their talents and skills, education, wealth, and family resources. Because health is important to opportunity, and since various accounts of justice require us to protect opportunity, we have reasons of justice for improving population health.

Being in equally poor health, however, is not the goal of justice; rather, promoting normal functioning equitably is. Indeed, the ultimate goal of people concerned with health equity and people interested in maximally improving population health is the same—all people functioning normally over a normal lifespan—even if health maximization and health equity conflict short of the ultimate goal. (Sreenivasan downplays this point, since he claims a fair equality of opportunity account is concerned only with relative shares of opportunity and health.) If we have social obligations to assure people fair equality of opportunity, then we should, among other things, arrange institutions, including medical systems, so that they protect and promote normal functioning, thereby making whatever significant contribution to equality of opportunity is possible by protecting health.

How much should we emphasize universal coverage as opposed to redistributing the social determinants of health? Suppose, Sreenivasan argues, we can move people closer to having equal shares of opportunity by redistributing the social determinants than by spending so heavily on universal coverage systems. Then, if equal opportunity is our goal, we should not insist on universal coverage, and assuring equal opportunity cannot be the grounds for universal coverage.

Sreenivasan's argument implies that we should spend less on medicine and more on improving the social determinants, depending on the empirical evidence about their relative causal contribution to health. It does not imply abandoning all medical care or dropping universal coverge for what medical care is given. Indeed, we know from a six-volume Institute of Medicine report and many other studies that lack of insurance increases health inequality since the uninsured get "too little too late."

In any case, Sreenivasan admits, universal coverage significantly improves population health. Suppose we achieve a just distribution of the socially controllable factors affecting health other than health care but still lack a universal coverage. The prevalence of ill health, we might then imagine, is as equitable as it can be across social groups, health care aside. Some people, however, still get ill and others do not. If access to effective medical services is now dependent on ability to pay, then equality of opportunity will not be protected to the degree universal access can achieve. Just how robust the required universal coverage benefit package should be is a matter for deliberation. Still, unless there is universal access to an appropriate array of medical resources regardless of ability to pay, then we have not done what a principle protecting fair equality of opportunity requires.