The Government’s Role in Protecting Health Equity: Lessons from the Education Sector

Modern debate over government control of institutions is the buzz-phrase-heavy, less verbose distant relative of the political-philosophy discussions that ruled the land during the Cold War.   These early debates were mostly about the fundamental question of whether a government should guarantee equality of outcome (communism) or equality of opportunity (capitalism), and often called on the sophisticated works of long-deceased sociologists and economists.  Modern political discourse takes place on a different playing field: Protests, editorials, facebook groups and tweets are the modern weapon of choice, as opposed to the verbose arsenal of academics (neither for better nor for worse).

In today’s debates, the absolute rightness of government involvement in an institution, idea, or strategy serves as a red herring, and receives all of the argumentative firepower from all involved.  This false-polarization has played out most recently in the health care debates, which have regressed into pie fights about the wrongness of government intervention, rather than growing into a productive dialectic about the systematic and moral nuances associated with securing health equity.

Where might we look for examples to help move this debate forward? Are there other paradigms that harbor similar issues, but have, for whatever reason, been able to escape the same kind of immature inertia that typifies health equity debates?

Public education remains a gigantic elephant in the room of the debates about whether or not health access and equity should be government-controlled. Modern debates about public education are plentiful, most recently (and notably) the charter school controversy.

Unlike debates about health care and social security, however, advocates for expunging government involvement in education altogether are almost entirely absent.  Politicians suggesting that education should be entirely privatized would have few political friends and might even find themselves alone on the far right.

For example, No Child Left Behind has been the object of intense debate because of its content, not because anyone felt like its signature and endorsement by George W. Bush was an “infringement on individual liberty (the sine qua non of the far right).” It was contentious because experts debated its appropriateness and effectiveness [1].

The question then: Why does education get the proverbial “pass” on government involvement, and can we engineer the health equity debates with a similar get-out-of-jail-free card?

In doing so, health equity advocates can side-step petty discussions that weigh them down and spend more time and effort imagining novel studies, programs, bills, and strategies.  In arguing for the government’s responsibility in alleviating health disparities and securing health equity, we can utilize analogies in the educational context in several ways.

Firstly, government protection of health care as a right need not abolish the private health care sector, the same way that public education doesn’t undermine private education. A popular and characterless argument against publicly protected health care is that such a system would automatically and necessarily subvert market-driven competition and the provision of choice.   This is simply not true.

Like education, advocates for government protected health equity could argue that control should be relegated to basic services: child health, primary care, prenatal care, childbirth, management of a selection of chronic illnesses, etc.  In the education sector, parents have the right to send their children to boutique private primary and secondary schools.  Similarly, individuals should have the right to utilize private health care providers, should they choose.  The problem with the status quo is that there is no structure in place to guarantee the most basic of health services to anyone.  It is this malady that many health justice advocates are calling attention to.

In addition, many of the same moral justifications for education’s status as a right can be easily transfigured in the health equity context, without a loss in argumentative nutritional value. At its most basic, human rights activism is fueled by the repulsive images of a society without that right guaranteed. Denying women or people color the right to vote, for example, is a lamentable political stance because there is something naturally unsettling about the image of groups being denied a basic right based race or gender.

Education occupies a similar space: images of an America without a primary or secondary public school structure are troubling: children walking the streets all hours of the day, nothing to occupy their mind and their time.  It’s so radical and repulsive an idea that it’s almost beyond our public imagination.

Strangely, the reality of a society without structures in place to address health inequities might be equally unsettling, and yet somehow, this has been allowed to persist.   American society today allows the mentally ill to go untreated and likely to end up homeless or incarcerated [2].  This society permits mothers without guaranteed access to prenatal care, poor children to grow up near environmental hazards [3] and without access to foods that facilitate proper development [4]. This society sees hard-working Americans lose their property to repossession because of medical debt [5].  Our reality is a very savage one.

When debating the appropriateness of public protection of health equity, we should adopt the aforementioned analogies to the education sector, not because health and education are exactly the same, but because the moral and economic underpinnings that justify education-for-all are similar enough to justify the protection of health equity-for-all.   The education sector is rife with problems of its own, but not because we question whether education should be protected as a right (almost everyone agrees that it should), but because we disagree on what should be taught and how this education should be delivered.

The goal should be to get health care and health equity discussions to a similar state, where we can discuss the specifics of how government can provide and protect it in a fiscally responsible and sustainable way.

References:

1)      http://www.time.com/time/magazine/article/0,9171,1625192,00.html

2)      Greenberg, G.A., and Rosenheck, R.A. Jail incarceration, homelessness, and mental health: a national study. Psychiatry Serv. 2008. Feb; 59(2): 170-7

3)      Gilbert C. Gee and Devon C. Payne-Sturges, “Environmental Health Disparities: A Framework Integrating Psychosocial and Environmental Concepts,” Environmental Health Perspectives 112, no. 17 (2004)

4)      http://www.cdc.gov/healthyyouth/nutrition/facts.htm

5)      http://articles.cnn.com/2009-06-05/health/bankruptcy.medical.bills_1_medical-bills-bankruptcies-health-insurance?_s=PM:HEALTH