H A S T I N G S C E N T E R R E P O R T 3March-April 2007

Bioethics, I argued nearly a decade ago, has been veryslow to respond to the profound insights into popula-tion health and its distribution that have emerged

from the social epidemiology literature of the last severaldecades.1 Strikingly, that literature shows that universal cover-age medical systems do not eliminate the general associationfound between socioeconomic status (SES) and health—thatthe richer you are, the longer and healthier your life will be.Since many people think access to health care is the key de-terminant of health inequalities between various socialgroups, the persistence of the SES gradient of health in theface of universal coverage is surprising. It is also troubling be-cause universal coverage is much easier to establish than a re-distribution of the many other important goods that are so-cial determinants of health—income, wealth, education, po-litical participation, control over one’s life.

Gopal Sreenivasan’s thoughtful “Health Care and Equalityof Opportunity” pushes us to reexamine the relationship be-tween opportunity, health, and health care by drawing atten-tion to the importance of the social determinants of healthand their contribution to health inequalities. Suppose, as Ihave argued elsewhere, that protecting health, viewed as nor-mal functioning, makes a significant if limited contributionto protecting the range of opportunities effectively open toindividuals. Although serious departures from normal func-tioning reduce those opportunities significantly, other thingsalso affect the opportunities people have, including their tal-ents and skills, education, wealth, and family resources. Be-cause health is important to opportunity, and since variousaccounts of justice require us to protect opportunity, we havereasons of justice for improving population health.

Being in equally poor health, however, is not the goal ofjustice; rather, promoting normal functioning equitably is.Indeed, the ultimate goal of people concerned with health eq-uity and people interested in maximally improving popula-tion health is the same—all people functioning normally overa normal lifespan—even if health maximization and healthequity conflict short of the ultimate goal. (Sreenivasan down-plays this point, since he claims a fair equality of opportunity

account is concerned only with relative shares of opportunityand health.) If we have social obligations to assure people fairequality of opportunity, then we should, among other things,arrange institutions, including medical systems, so that theyprotect and promote normal functioning, thereby makingwhatever significant contribution to equality of opportunityis possible by protecting health.

How much should we emphasize universal coverage as op-posed to redistributing the social determinants of health?Suppose, Sreenivasan argues, we can move people closer tohaving equal shares of opportunity by redistributing the so-cial determinants than by spending so heavily on universalcoverage systems. Then, if equal opportunity is our goal, weshould not insist on universal coverage, and assuring equalopportunity cannot be the grounds for universal coverage.

Sreenivasan’s argument implies that we should spend lesson medicine and more on improving the social determinants,depending on the empirical evidence about their relativecausal contribution to health. It does not imply abandoningall medical care or dropping universal coverge for what med-ical care is given. Indeed, we know from a six-volume Insti-tute of Medicine report and many other studies that lack ofinsurance increases health inequality since the uninsured get“too little too late.”

In any case, Sreenivasan admits, universal coverage signifi-cantly improves population health. Suppose we achieve a justdistribution of the socially controllable factors affectinghealth other than health care but still lack a universal cover-age. The prevalence of ill health, we might then imagine, is asequitable as it can be across social groups, health care aside.Some people, however, still get ill and others do not. If accessto effective medical services is now dependent on ability topay, then equality of opportunity will not be protected to thedegree universal access can achieve. Just how robust the re-quired universal coverage benefit package should be is a mat-ter for deliberation. Still, unless there is universal access to anappropriate array of medical resources regardless of ability topay, then we have not done what a principle protecting fairequality of opportunity requires.

1. N. Daniels, B. Kennedy, and I. Kawachi, “Why Justice Is Goodfor Our Health: The Social Determinants of Health Inequalities,”Daedalus 128, no. 4 (1999): 215-51; revised as Is Inequality Bad for OurHealth? (Boston, Mass.: Beacon Press, 2000).

Norman Daniels is Mary B. Saltonstall Professor in the School of Pub-lic Health at Harvard University. His forthcoming book is Just Health:Meeting Health Needs Fairly (Cambridge University Press).

Rescuing Universal Health Care

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