An Ode to America: Universal Health Coverage through the Capabilities Approach

The United States Declaration of Independence states, “all men are created equal” and vows to protect their unalienable rights to “Life, Liberty, and the Pursuit of Happiness”. These rights and liberties underline the foundational basis for America and are still held sacred even today. However, it is difficult to see how these values hold up when a study by the American Journal of Public Heath calculates that an estimated 45,000 deaths are associated annually with a lack of heath insurance in the US[1]. With the privatization of healthcare, about 27 million Americans are uninsured[2] and are, therefore, at greater risk of suffering serious health concerns or piling up an enormous hospital bill.

In her book, “Women And Human Development: The Capabilities Approach”, Martha Nussbaum draws on the approach by establishing the basis for capabilities as “a foundation for basic political principles that should underwrite constitutional guarantees.”[3] I argue for Nussbaum’s capabilities approach as a more appropriate proposal towards American health care as it promotes the right to life, liberty, and the pursuit of happiness. Her approach satisfies these fundamental American values by providing universal health coverage for physical and mental well-being, promoting and respecting free choice, and securing individual ability to carry out one’s life plan.

Nussbaum’s Capability Approach and Health

Nussbaum’s capability approach ensures every citizen is provided with access to exercise the rights necessary to live a human life. She breaks down the ability to exercise these rights as functionings and capabilities. Functionings can be described as a desired end product, a being or doing, and “are what render a life fully human.”[4] Capabilities are the individual’s ability to exercise these functionings. Nussbaum lists out ten capabilities she declares as a social minimum for human flourishing: life, bodily health, bodily integrity, imagination, emotions, practical reasoning, affiliation, concern for other species, play, and control over environment[5]. Health itself is a functioning and should be granted to every individual up to a certain age. However, sustaining health should be a capability, as it is up to the individual to exercise this functioning. Therefore, universal health insurance is an essential factor in provision for the capability of health.

Right to life

How are Americans equally endowed by the government the right to life when those who are uninsured have a 40 percent chance increased risk of dying than their insured counterparts[6]? The provision of good health is a vital component to sustaining human life, as it not only necessary for the promotion of other capabilities, but also for our preservation. Physical health is detailed under two components in Nussbaum’s list of capabilities; life and bodily health. Nussbaum’s list articulates the capability of life as “being able to live to the end of a human life of normal length; not dying prematurely, or before one’s life is so reduced as to be not worth living.”[7]. Considering Nussbaum’s definition of life in an approach to universal healthcare would mean providing every American a baseline insurance to protect against any issues that might curtail their physical health. Similarly, the capability of bodily health permits citizens to the ability to be in good health[8]. The government must ensure these capabilities are met for everyone such that each citizen has equal opportunity to actualize their functions of life and bodily health.  Simply put, health care is simply too important a value to be completely withheld from some citizens. Providing adequate care for a normal lifespan and good health is essential right entitled to all Americans.

Nussbaum’s approach also considers the mental components of health, extending the provision of care beyond the physical standpoint. The consequences of mental illness are often disregarded due to its lack of visibility, but its effects are still widely felt. Despite 76 percent of Americans agreeing that mental health is equally as important as physical health, roughly one in four Americans— 25 percent— noted they have had to choose between paying for mental health treatment and daily necessities[9]. To ameliorate this mental health dilemma, Nussbaum’s list includes emotions to emphasize the responsibility of “supporting forms of human association that can be shown to be crucial in their development.”[10] Therefore, a suitable health care plan must also provide insurance for mental illnesses. Nussbaum also remediates the social stigmas which hinder mental recovery[11] through the capability of affiliation, which procures social interaction and treatment “as a dignified being whose worth is equal to that of others.”[12]  Nussbaum’s list would insure care for the mental state and external conditions of health, to promote the right to life.

Promotion of Liberty

Underpinning the framework for the capability approach in health care lies the freedom for adults to make their own choices. Nussbaum stresses the importance of allowing individuals to exercise their own values, emphasizing “capability, not functioning, is the appropriate political goal”[13]. Recall, she is not asking the government to place people in these desirable end states, but rather provide them with the option to achieve them. Moreover, the U.S. government physically cannot grant individuals the functioning of health as maintaining good health still requires personal responsibility. Therefore, a proficient health care plan which insures people to the capability of mental and physical health also naturally provides them with the liberty to choose whether to exercise this capability by sustaining their health.

It is imperative to follow Nussbaum’s appeal to capabilities in the health care approach as it respects the individual’s right to make their own choices, and “we do not respect people when we dragoon them into this functioning.”[14] Respect for each individual’s right to exercise the capability of maintaining health not only adds to the worth of them achieving this functioning, but also protects specific choices or values (religious, nutritional) in accordance with their plan for life[15]. Therein, respect for other people’s liberty is entrenched in the framework for Nussbaum’s capability approach applied to universal healthcare.

Appeal to Pursuit of Happiness

Nussbaum’s approach elaborates on the pursuit of happiness, implementing it into her list of capabilities. She lists practical reason as “being able to form a conception of the good and to engage in critical reflection about the planning of one’s life”[16]. Thus, building on the Aristotelian idea that individuals should be able to be able to plan their own life in accordance with their idea of what they want and pursue that plan. Considering the right to the pursuit of happiness ranks among the ten capabilities, it is necessary to provide a healthcare plan to allow the individual to exercise this capability.

To figure out how and why, we must evaluate how we provide each citizen with adequate healthcare. On one hand, gauging health by social factors would provide a more concrete metric for ensuring mutual care among citizens. However, each person is unique to their own condition and lifestyle. Basing the value of health on determinants focuses on health inequalities among social groups (race, gender), and not at an individual level. As Nussbaum states, “the capabilities sought are sought for each and every person, not… for groups or families or states or other corporate bodies.”[17] Therefore, the preferred method for determining an individual’s provision of healthcare should be their current or potential lifestyle. Afterall, shouldn’t people be insured against conditions they believe are more likely to happen? Constructing an insurance scheme that matches an individual’s plan of life secures the right to their pursuit of happiness by safeguarding them against possible accidents. Additionally, individuals would be more comfortable pursuing their plan knowing they don’t have to worry about the fiscal consequences of any potential health complications in pursuing their life plan. Nussbaum’s approach would provide a health care package geared towards an individual’s life, insuring them against any issues they may face in their pursuit of happiness.

Discussion

Nussbaum’s approach incorporates traditional American values, calling for a social minimum to ensure feasibility of these values. How long are U.S. legislators going to ignore the irony in a country that boasts itself as the posterchild of democracy while remaining the only developed nation without universal health coverage? Although Nussbaum’s approach offers a succinct and patriotic argument in favor of universal healthcare in the United States, these instrumental benefits come at a very high cost. The U.S. spent nearly $1.2 trillion on domestic health coverage in 2019; more than any other country in the world and still ranks amongst the worst in health care. But do these exorbitant costs justify withholding resources from people that need them?  The U.S. government has had the option to negotiate lower medical and administrative costs, but instead keeps them high for profitability and political purposes[18]. However, many Americans who suffer from a lack of health insurance do not occupy positions of power to improve the overall health care situation. Health care should be treated as a fundamental human right, rather than just a talking point for politicians.

Citations

  1. Hopper, K. (2007). Rethinking social recovery in schizophrenia: What a capabilities approach might offer. Social Science and Medicine, 65, 868–879.
  1. Nussbaum, Martha. 2000. Women and Human Development: The Capabilities Approach, Cambridge: Cambridge University Press, pp34-110.
  1. Rowan K, McAlpine DD, Blewett LA. (2013). Access and cost barriers to mental health care, by insurance status, 1999-2010. Health Aff (Millwood).;32(10):1723-1730. doi:10.1377/hlthaff.2013.0133
  1. Wilper, Andrew P et al. 2009 “Health insurance and mortality in US adults.” American journal of public health vol. 99,12, 2289-95. doi:10.2105/AJPH.2008.157685

[1] Wilper, Andrew P et al. 2009 “Health insurance and mortality in US adults.” American journal of public health vol. 99,12, 2289-95. doi:10.2105/AJPH.2008.157685

[2] Ibid

[3] Nussbaum, Martha. 2000. Women and Human Development: The Capabilities Approach, Cambridge: Cambridge University Press, pp70-71

[4] Ibid, 86

[5] Ibid, 79-80

[6] Wilper, Andrew P et al. 2009 “Health insurance and mortality in US adults.” American journal of public health vol. 99,12, 2289-95. doi:10.2105/AJPH.2008.157685

[7] Nussbaum, Martha. 2000. Women and Human Development: The Capabilities Approach, Cambridge: Cambridge University Press, 79

[8] Ibid

[9] Rowan K, McAlpine DD, Blewett LA. (2013). Access and cost barriers to mental health care, by insurance status, 1999-2010. Health Aff (Millwood).;32(10):1723-1730. doi:10.1377/hlthaff.2013.0133

[10] Nussbaum, Martha. 2000. Women and Human Development: The Capabilities Approach, Cambridge: Cambridge University Press, 79

[11] Hopper, K. (2007). Rethinking social recovery in schizophrenia: What a capabilities approach might offer. Social Science and Medicine, 65, 868–879.

[12] Nussbaum, Martha. 2000. Women and Human Development: The Capabilities Approach, Cambridge: Cambridge University Press, 79

[13] Ibid, pp. 87

[14] Ibid, pp. 88

[15] Ibid pp.87

[16] Ibid, 79

[17] Ibid, 74

[18] Rowan K, McAlpine DD, Blewett LA. (2013). Access and cost barriers to mental health care, by insurance status, 1999-2010. Health Aff (Millwood).;32(10):1723-1730. doi:10.1377/hlthaff.2013.0133

“Hospital” by irihiyahn-percussion is licensed under CC BY-NC-ND 2.0

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.