For the last fifty years, the United States healthcare system has done an extremely poor job of delivering healthcare in a just and fair manner. The United States holds the dubious distinction of being the only industrialized nation in the world lacking provisions to ensure universal coverage. We attempt to provide some of the reasons this dysfunctional system has persisted and show that healthcare should not be a commodity. We begin with a brief historical overview of healthcare delivery in the United States since WWII. This is followed by a critical analysis of the for-profit model including reasons to support the view that healthcare should not be a free market commodity. We also demonstrate how special interest groups have been able to win support for their practices based on propaganda rather than fact. A brief analysis of the Affordable Care Act is offered along with critical comments regarding its ineffectiveness. We conclude with a brief overview of international approaches that have resulted in universal coverage and suggest the United States ought to adopt an approach similar to those outlined so that it no longer stands as the only industrialized nation to ignore the glaring problems that exist.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Ezekiel Emanuel makes the point this way: “Prior to the passage of the ACA, [Affordable Care Act], Americans’ access to healthcare was inadequate. Nearly 50 million Americans were uninsured, and millions more were underinsured, with austere, unreliable policies that failed to protect them from grave financial loss or bankruptcy if they developed a serious illness” (Emanuel 2017, 20).
It was expensive for most Americans at this time as well. “The principal reason why people do not receive the care they need is that they cannot afford to pay for it on an individual basis at the time they need it. This is true not only for needy persons. It is also true for a large proportion of normally self-supporting persons” (Markel 2014).
This notion is further reinforced by the Emergency Medical Treatment and Labor Act (EMTALA) which requires that all patients entering an emergency room be treated and stabilized regardless of their ability to pay (CMS.Gov 2017). Ironically, hospitals are provided no financial assistance for complying with the law, and yet must act as for-profit industries. This highlights both the lack of appropriateness for using a market-based system to deliver healthcare and the moral requirement that patients should be treated without regard for their ability to pay.
It should be emphasized here that loss of employment could be due to layoffs and not employee conduct. In other words, we cannot always blame the unemployed people for losing their jobs. Furthermore, the types of COBRA coverages offered to employees who were laid off often creates financial hardship (Andrews 2013).
In the same speech and in line with our thinking, Bevan makes the following observation: “ … the best way to finance the scheme (the NHS), the fairest and most equitable way, would be to obtain the finance from the Exchequer funds by general taxation, and those who had the most would pay the most. It is a very good principle. What more pleasure can a millionaire have than to know that his taxes will help the sick?” (Bevan 1958, ¶26).
ACEP.org. 2019. EMTALA fact sheet. https://www.acep.org/life-as-a-physician/ethics%2D%2Dlegal/emtala/emtala-fact-sheet/. Accessed June 10, 2019.
AMA. 2019. Code of medical ethics overview. https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-overview. Accessed December 12, 2019.
Anderson, R. 2014. Pharmaceutical industry gets high on fat profits. BBC News, November 6. http://www.bbc.com/news/business-28212223. Accessed June 10, 2019.
Andrews, M. 2013. Laid off and looking for health insurance? Beware of COBRA. NPR, September 17. https://www.npr.org/sections/health-shots/2013/09/17/223341729/laid-off-and-looking-for-health-insurance-beware-of-cobra. Accessed June 10, 2019.
Askin, E. and N. Moore. 2014. The health care handbook, 2nd ed. St. Louis: Washington University.
Berchick, E.R., E. Hood, and J.C. Barnett. 2018. Health insurance coverage in the United States: 2017. United States Census Bureau. Report no. P60-264. https://www.census.gov/library/publications/2018/demo/p60-264.html. Accessed June 10, 2019.
Bevan, A. 1958. NHS Debate 1958 House of Commons, July 30. https://www.sochealth.co.uk/national-health-service/the-sma-and-the-foundation-of-the-national-health-service-dr-leslie-hilliard-1980/aneurin-bevan-and-the-foundation-of-the-nhs/nhs-debate-house-of-commons-30-july-1958/. Accessed June 10, 2019.
Bischoff, L. 2016. Ohio hospitals want to overturn price disclosure law. Dayton Daily News, December 27. http://www.daytondailynews.com/news/ohio-hospitals-want-overturn-price-disclosure-law/PqWQ4QLlCh1E8aojbPHgmO/. Accessed June 10, 2019.
Blank, R.H., and V. Burau. 2014. Comparative health policy, 4th ed. New York: Palgrave Macmillan.
Bluth, R. 2017. Health-care price transparency faces opposition. The Enquirer, July 23. https://www.cincinnati.com/story/news/2017/07/23/health-care-price-transparency-opposed-ohio-hospitals-and-doctors/503442001/. Accessed June 10, 2019.
Bort, R. 2017. How bad is U.S. health care? Among high income nations, it’s the worst, study says. Newsweek, December 10. http://www.newsweek.com/united-states-health-care-rated-worst-637114. Accessed June 10, 2019.
Braybrooke, D. 1987. Meeting needs, Princeton, NJ: Princeton University Press.
Brock, D.W., and S.A. Wartman. 1990. When competent patients make irrational choices. New England Journal of Medicine 322: 1595.
Brody, D.S. 1980. The patient’s role in clinical decision making. Annals of Internal Medicine 93(5): 718-722.
Carroll, A. 2017. The real reason the U.S. has employer-sponsored health insurance. New York Times, September 5. https://www.nytimes.com/2017/09/05/upshot/the-real-reason-the-us-has-employer-sponsored-health-insurance.html. Accessed June 10, 2019.
CMS.gov. 2017. Emergency Medical Treatment & Labor Act (EMTLA). https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index. Accessed June 10, 2019.
Daniels, N. 1988. Equal opportunity and health care. New York, NY: Oxford University Press.
Davis, K., K. Stremikis, D. Squires, and C. Schoen. 2014. Mirror mirror on the wall: How the performance of the U.S. health care system compares internationally. The Commonwealth Fund. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2014_jun_1755_davis_mirror_mirror_2014.pdf. Accessed June 10 2019.
Deber, R.B. 1994. Physicians in health care management: 7. The patient-physician partnership: Changing roles and the desire for information. Canadian Medical Association Journal 151(2): 171-176.
DeMichele, T. 2019. The U.S. is the only very highly developed country without universal health care—Fact. Fact/ Myth.com, June 28. http://factmyth.com/factoids/the-us-is-the-only-very-highly-developed-country-without-universal-healthcare/. Accessed June 10, 2019.
Emanuel, E. 2017. Prescription for the future. New York, NY: Public Affairs
Emanuel, E.J., and L.L. Emanuel. 1992. Four models of the physician-patient relationship. Journal of the American Medical Association 267 2221.
Encyclopedia.com. 2008. Wage and price controls. http://www.encyclopedia.com/social-sciences-and-law/economics-business-and-labor/economics-terms-and-concepts/wage-and-price. Accessed June 10, 2019.
Engelhardt, H.T. 1996. Rights to health care, social justice, and fairness, in health care allocations. New York, NY: Oxford University Press.
Fischer, C. 2014. Why Americans resist universal healthcare. LA Progressive, April 3. https://www.laprogressive.com/why-americans-resist-universal-healthcare/. Accessed June 10, 2019.
Fisher, M. 2012. Here’s a map of the countries that provide universal health care (America’s still not on it). The Atlantic, June 28. https://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/. Accessed June 10, 2019.
Frakt, A. 2018. The astonishingly high administrative costs of U.S. health care. The New York Times, July 16. https://www.nytimes.com/2018/07/16/upshot/costs-health-care-us.html. Accessed June 10, 2019
Gamlin, R. 2016. Medical economics: Administrative costs are killing U.S. healthcare. Medical Economics, May 21. https://www.medicaleconomics.com/medical-economics-blog/administrative-costs-are-killing-us-healthcare. Accessed June 10, 2019.
Gawande, A. 2015. Overkill. The New Yorker, May 11.
Goldstein, A. 2018. Trump administration takes another major swipe at the Affordable Care Act. The Washington Post, July 8. https://www.washingtonpost.com/national/health-science/trump-administration-takes-another-major-swipe-at-the-affordable-care-act/2018/07/07/0f1ff4c4-821f-11e8-b851-5319c08f7cee_story.html?noredirect=on&utm_term=.5022c917535c. Accessed June 10, 2019.
Govtrack.us. 2017. H.R. 1628: American Health Care Act of 2017. https://www.govtrack.us/congress/bills/115/hr1628/summary. Accessed June 10, 2019.
Gray. R.E., B.D. Doan, and K. Church. 1990 Empowerment and persons with cancer: Politics in cancer medicine. Journal of Palliative Care 6(2): 33-45.
Huffingtonpost.com. 2015. Top 10 reasons people go bankrupt. http://www.huffingtonpost.com/simple-thrifty-living/top-10-reasons-people-go-_b_6887642.html. Accessed June 10, 2019.
Khazan, O. 2018. The 3 reasons the U.S. health care system is the worst. The Atlantic, June 22. https://www.theatlantic.com/health/archive/2018/06/the-3-reasons-the-us-healthcare-system-is-the-worst/563519/. Accessed June 10, 2019.
Kulesher, R., and E. Forrestal. 2014. International models of health system financing. Journal of Hospital Administration (3)4: 127-139.
Levine, M.N., A. Gafni, B. Markham, and D. MacFarlane. 1992 A bedside decision instrument to elicit a patient's preference concerning adjuvant chemotherapy for breast cancer. Annals of Internal Medicine 117(1): 53-58.
Long, M., M. Rae, and G. Claxton. 2016. Trends in employer-sponsored insurance offer and coverage rates, 1999-2014. Kaiser Family Foundation. https://www.kff.org/private-insurance/issue-brief/trends-in-employer-sponsored-insurance-offer-and-coverage-rates-1999-2014/. Accessed June 10, 2019.
Mangan, D. 2013. Medical bills are the biggest cause of US bankruptcies: Study. CNBC, June 25. http://www.cnbc.com/id/100840148. Accessed June 10, 2019.
Markel, H. 2014. 69 years ago, a president pitches his idea for national health care. PBS News Hour, November 19. http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/. Accessed June 10, 2019.
Martyn, A. 2016. Health insurance industry rakes in billions while blaming Obamacare for losses. Consumer Affairs, January 11. https://www.consumeraffairs.com/news/health-insurance-industry-rakes-in-billions-while-blaming-obamacare-for-losses-110116.html. Accessed June 10, 2019.
Marx, K. 1977. A contribution to the critique of political economy. Moscow: Progressive Publishers. https://www.marxists.org/archive/marx/works/1859/critique-pol-economy/preface.htm. Accessed June 10, 2019.
Monegain, B. 2012. Technology helps drive cost of US health care. HealthCareITNews, May 3. http://www.healthcareitnews.com/news/technology-helps-drive-high-cost-us-healthcare. Accessed June 10, 2019.
Neighmond, P. and R. Knox. 2012. Your Stories of Being Sick Inside the U.S. Health Care System. NPR, May 21. http://www.npr.org/sections/health-shots/2012/05/21/153028362/your-stories-of-being-sick-inside-the-u-s-health-care-system. Accessed June 10, 2019.
Nguyen, K.H., and B.D. Sommers. 2016. Access and quality of care by insurance type for low-income adults before the Affordable Care Act. American Journal of Public Health 106(8): 1409–1415.
Pear, R. 2018. A ‘sick joke’: Democrats attack health secretary on pre-existing conditions. The New York Times, June 12. https://www.nytimes.com/2018/06/12/us/politics/alex-azar-pre-existing-conditions-drug-prices.html. Accessed June 10, 2019.
President’s commission for the study of ethical problems in medicine and biomedical and behavioral research. 1983. An ethical framework for access to health care. Securing Access to Health Care, Vol. 1. Library of Congress Card No. 83-600501.
Quill, T.E. 1983. Partnership in patient care: A contractual Approach. Annals of lnternal Medicine 98(2): 228-234.
Rampell, C. 2017. Sorry, Republicans, but most people support single-payer health care. The Washington Post, April 17. https://www.washingtonpost.com/opinions/sorry-republicans-but-most-people-support-single-payer-health-care/2017/04/17/f0919bb6-23a6-11e7-bb9d-8cd6118e1409_story.html?utm_term=.1c35307ca259. Accessed June 10, 2019.
Rawls, J. 1999. A theory of justice, 2nd ed. Cambridge MA: Belknap Press/Harvard University Press
Sartre, J.P. 1989 (1946). No exit and three other plays. Translated by S. Gilbert. New York: Vintage Books.
Schneider, E.C., D.O. Sarnak, D. Squires, A. Shah, M. and M. Doty. 2017. Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. http://www.healthcareforalltexas.org/Mirror_Mirror_2017_International_Comparison.pdf. Accessed June 10, 2019.
Shepard, S. 2017. Poll: Plurality supports single-payer health care. Politico, September 20. http://www.politico.com/story/2017/09/20/single-payer-health-care-poll-242907. Accessed June 10, 2019.
St John, A. 2017. How the Affordable Care Act drove down personal bankruptcies. Consumer Reports, May 2. https://www.consumerreports.org/personal-bankruptcy/how-the-aca-drove-down-personal-bankruptcy/. Accessed June 10 2019.
Tau, B. 2012. Scalia wonders about a broccoli mandate. Politico, March 27. https://www.politico.com/blogs/politico44/2012/03/scalia-wonders-about-a-broccoli-mandate-118823. Accessed June 10, 2019.
The Editorial Board. 2013. The shame of American health care. The New York Times, November 17. http://www.nytimes.com/2013/11/18/opinion/the-shame-of-american-health-care.html?mtrref=undefined&gwh=0483693685D0A186E333E970150D99E4&gwt=pay&assetType=opinion. Accessed June 10, 2019.
The Editorial Board. 2019. How much will Americans sacrifice for good health care. The New York Times, February 16. https://www.nytimes.com/2019/02/16/opinion/sunday/medicare-for-all-universal-health-care.html. Accessed June 10, 2019.
Tozzi, J., and E. Ockerman. 2018. What it’s like living without health insurance in America. Bloomberg, April 3. https://www.bloomberg.com/news/features/2018-04-03/what-it-s-like-living-without-health-insurance-in-america. Accessed June 10 2019.
Tudor Hart, J. 1971. The inverse care law. The Lancet 1: 415-412
Veatch, R.M. 1972. Models for ethical medicine in a revolutionary age. Hastings Center Report (2)3: 5-7.
Waitzkin, H. 1978. A Marxist view of medical care. Annals of Internal Medicine 89: 264-278.
Watt, G. 2002. The inverse care law today. The Lancet 360: 252–254.
WorldBank.org. 2014. Health expenditure, total (% of GDP). https://data.worldbank.org/indicator/SH.XPD.TOTL.ZS. Accessed June 10, 2019.
Young, A. 2016. Making a killing under Obamacare. Salon, October 28. http://www.salon.com/2016/10/28/making-a-killing-under-obamacare-the-aca-gets-the-blame-for-rising-premiums-while-insurance-companies-are-reaping-massive-profits/. Accessed June 10, 2019.
We would like to thank Peter Jennings, Librarians/Associate Professor, Cuyahoga Community College, for his assistance in researching this topic. We would also like to thank two anonymous reviewers for their thoughtful and helpful comments on an earlier draft of this manuscript.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
LiPuma, S.H., Robichaud, A.L. Deliver Us From Injustice: Reforming the U.S. Healthcare System. Bioethical Inquiry 17, 257–270 (2020). https://doi.org/10.1007/s11673-020-09961-2
- Healthcare justice
- Healthcare and social policy
- Access to healthcare