Health, Health Care, and Equality of Opportunity: The Rationale for Universal Health Care

Introduction

Universal health care (UHC)—the provision of (basic) health care to everyone, free or at low cost at the point of access—is by many considered an essential component of a just society. While this practice is common in many parts of the world, there is as of yet no consensus on the best principled ethical rationale for provision in this manner.

A principle of equality of opportunity has been proposed as a compelling candidate. This justification for UHC hinges on the assumption that health care makes a very significant contribution to protect and promote health. However, in light of empirical research that suggests that health outcomes are shaped to a large extent by factors other than health care, such as income, education, housing, and working conditions, the question arises to what extent health care is really necessary to protect and promote health, and thereby opportunity.

Critics have used this empirical research as a basis to argue that Norman Daniels’ equality of opportunity rationale fails to justify UHC. In this article, I argue that this line of criticism relies on a set of health measures that are inadequate for an evaluation of the equality of opportunity rationale. It is assumed that the measures of health inequality in question accurately track inequalities in opportunity, but I show that this assumption does not hold. I propose some alternative metrics by which we can better assess the contribution of health to protecting equality of opportunity. Finally, in the last section of the article, I consider an alternative strategy for justifying UHC.

UHC and the Equality of Opportunity Rationale

UHC can be defined as everyone having access to “quality health services that meet their needs without being exposed to financial hardship in paying for them.” ¹ This is a broad definition that leaves it open whether we as a society ought to provide sufficient health care, where everyone has access to a basic minimum, however that is defined, or equal health care, where everyone has access to the same level of coverage and the wealthy are prevented from buying more. Furthermore, it leaves it open what kind of health system—for example, social insurance or public system—might be best suited to achieve this objective.

Nevertheless, a key feature of UHC thus...