Liberty, Choice, and Foundations for Health Justice

One of the most common arguments motivating the defense of the healthcare system in the United States is the ideal of choice. Healthcare libertarians claim that there is validity in the freedom that underscores the importance of choice — referencing how patients receive care from their preferred doctor, or their favorite medical center, or are afforded coverage under the plan they deem to be best. To defeat these claims about the central importance of choice and how they factor in to decision making when it comes to healthcare policy, it is not simply enough to cite the efficiency and expedience of socialized healthcare systems in other nations. Repetition of statistics showing how socialized healthcare and universal coverage raises quality of life indicators does little to convince those who stand by their own values of liberty and choice. Rather, the debate demands a value analysis weighing the overwhelming and comprehensive benefits of a single-payer system, and why it is that these arguments defeat the case for retaining “choice” in the healthcare market. Doing so requires understanding of the intricate ways in which single-payer healthcare models are set-up, and also draws upon the reflections of scholars that note the importance of healthcare in securing health justice.
The insurance market in the United States is notoriously complex, not least because of the numerous attempts at reform that have taken place in past years. The Patient Protection and Affordable Care Act (PPACA), passed by Congress in 2010, was successful in both establishing a mandate that all individuals must have health coverage, and in eliminating the practice of insurers refusing to provide coverage for pre-existing conditions at great cost to patients. However, the PPACA left much to be desired, with particular emphasis on the lack of public options, which would dramatically lower costs of care and allow states to negotiate with pharmaceutical costs to similarly lower drug prices.

Nearly eight years and numerous re-litigations of the healthcare bill later, the state of American healthcare represents above all else “the abject failure of market liberalism” (Faust, “The Case for Single Payer). Numerous leftist organizing groups and politicians — including Senator Bernie Sanders in his 2016 Presidential campaign — are finally collaborating on a platform demanding a unified single payer system, concisely described as “the proposition that the government covers health care for all citizens, with payment covered by taxes” (Martin, “Uniquely Golden”).

The benefits of single payer are sourced in its simplicity. Allowing the federal government to provide large scale insurance models makes room for truly universal coverage, not unlike proposed Medicare-for-all plans. Moreover, the huge amount of administrative costs that will be reduced by cutting out private-sector insurance firms results in lower aggregate prices for the federal government. Negotiating lower drug prices with pharmaceutical companies will be made easier through a now- streamlined process, in which the federal government can leverage itself as the single player in the market to dis-incentivize price hikes. Finally, and perhaps most importantly, the single payer model solves the central conundrum to the “market liberalism” model depicted by Faust — the issue “lies in the structure of private markets for health insurance — which creates powerful incentives to avoid sick people and attract healthy ones” (Reich, “Why a Single-Payer Healthcare System is Inevitable”). While the increased protections enacted with bills like the PPACA do make progress in the face of providing protections for individuals for pre-existing conditions, the central problem of private insurers becoming less competitive as they attract more sick individuals remains. The profit-seeking motivations of these insurance companies forces them to reconcile their competition within the market with their ability to actually provide coverage for a significant number of sick or disabled individuals.

There are a number of arguments conventionally pitched against the single-payer proposal, including the ability of the federal government to fund such initiatives. There are multiple analyses that suggest otherwise, including a recent model developed by the University of Massachusetts-Amherst that suggests a single-payer model in California (notably one state, instead of the entire nation), would cost a total of $331 billion, considerably less than the budget for the state’s “$368 billion in healthcare spending overall” (Shure, “Why Single-Payer Would Work in California). But the larger question of choice and liberty when it comes to matters as personal as medical coverage still looms over the debate, and poses a significantly more prominent challenge to issues at the core of the disagreement about who, or what is responsible for the livelihood of individuals.

Rooted in the practices of libertarianism under scholars like Nozick, there are certainly those that purport that single-payer models deny freedom to choose which healthcare plans are best fitting for individuals and their families. These critics are correct. Individuals that want to see specific doctors, retain exorbitant health-care plans (or, in some cases, want no coverage at all), or to visit certain private medical centers will have their freedom to do so suppressed under the enactment single-payer proposals. Such suppression of freedoms violates the minimal state proposed by Robert Nozick, who contends that redistribution in the form of benefits like health-care would violate the liberty of individuals who do not wish to be included in such systems. Yet other scholars, including Elizabeth Anderson, are adamant in declaring health-care as part of a system of “democratic equality” in which states “aim for equality across a wide range of capabilities” (Anderson, “What is the Point of Equality?” pp. 317). More broadly, the capabilities thinkers, including Amartya Sen and Martha Nussbaum, feel that the allocation of resources including healthcare should depend on degree of access to those resources. The single-payer model gives universal access to healthcare, with coverage that takes the insurance pool to be the entire population regardless of current medical condition.

Though a consensus agreement with the capabilities thinkers requires an agreement on the idea that healthcare is a human need rather than a standard commodity, this line of thought offers powerful conclusions that the choice of some individuals to choose their own doctors or healthcare plans comes largely at the misery expense of others. In a practical realization of the single-payer model, there will certainly be instances in which individual liberties and freedoms will have to be compromised in order to make room for efficiency — that is, individuals may not demand more resources from the system than they need. This is precisely what is at stake within the larger framing of the healthcare debate; capabilities thinkers and supporters of states premised on democratic equality recognize not only that healthcare is a primary human need, but that the redistribution of resources to secure that human need is justifiable. Those without the financial means to afford coverage under the neoliberal market model of the present are not given any leeway with respect to choice or liberty — those values require a certain level of income before they can be considered.

Thankfully, most advanced economies have already reached this conclusion, with some having done so long ago. Yet even within already established universal health care systems, inequity and lack of access to resources remains a perpetual concern. However, activists like Faust are correct when writing of the vision to obtain “health justice” — that housing access, food options, and personal safety can all be conceptualized as health justice in that providing for them can have the added effect of lowering healthcare costs (Faust, “The Case for Single Payer). Faust collaborates with and adds to the long standing view of the capabilities thinkers that single-payer is not the final goal of left-wing organizing work, but rather that it is a vehicle by which we can actualize a more just and egalitarian society. To bring the vision of these thinkers to life, then, an unequivocal endorsement of single-payer as part of future political platforms is only the first step.


Works Cited

Anderson, Elizabeth. 1999. ‘What is the Point of Equality?’ Ethics, 109 (2): 287-337.

Faust, Timothy. “The Case for Single-Payer.” Jacobin, medicare-for-all-bernie-sanders.

Martin, Glen. “Uniquely Golden: Single-Payer May Work in California.” Cal Alumni Association, 11 Apr. 2017, may-work-california.

Nozick, Robert. 1974. Anarchy, State, and Utopia. New York: Basic Books.

Reich, Robert. “Why a Single-Payer Healthcare System is Inevitable.” Robert Reich, 22 Aug. 2016,

Shure, Natalie. “Why Single-Payer Health Care Could Work in California.” Pacific Standard, 23 June 2017,

No Comments Yet

Leave a Reply

Your email address will not be published.

At Yale-NUS College, we are thinking about ideals of equality and democracy, and how they relate to practice, in Singapore and in the wider world.

This website showcases our reflections.

Articles were originally submitted as course papers for Professor Sandra Field’s classes Contemporary Egalitarianism and Democratic Theory.

The Equality&Democracy project has been made possible through the support of a Teaching Innovation Grant from the Yale-NUS Centre for Teaching and Learning: ‘Applying Political Philosophy to Real World Cases’.

Copyright © 2018 Equality & Democracy.
All rights Reserved.