Solves health justice, and is politically popular.

B. Health Justice as a Legislative and Policy Priority Healthcare reform in the United States should seek primarily to promote health and health justice,24 and a national single-payer program is a stepping stone toward health justice.25 But what is health justice? At its root, health justice is a state of equity in which the health system works alongside community members to envision an environment that promotes health rather than destroying it or subordinating it to non-health concerns, such as profit or social control. It is about ensuring that all people, regardless of their socioeconomic background or standing, have quality healthcare.26

Equity is not a corollary or optional consideration in healthcare. “Health protection,” the ultimate goal of any healthcare system, encapsulates “equity—timely access not linked to employment status or ability to pay” and “financial protection against catastrophic health expenditure” among other key parameters that should drive political decisions about which type of healthcare system to construct to best promote the health of a population.27

A primary feature of programs that promote health justice is the elimination of means-testing in healthcare financing. Means-testing creates healthcare programs that only cover specific populations and have income or other qualification requirements and is itself is an obstacle to health justice. It not only eliminates certain groups of people for consideration for public benefits altogether, but also it creates barriers for people who are putatively eligible for programs, resulting in under-utilization of benefits28 and churn (the process “beneficiaries moving in and out of . . . coverage,” resulting in “delayed care and less preventative care.”29). These barriers are outputs of a system that uses insurance rather than need as a gatekeeper to care.

Because health outcomes—and the U.S. healthcare and healthcare finance system as a whole—are inextricably intertwined with other social issues, researchers often point to “social determinants of health” as causes of health disparities in the U.S. The U.S. Centers for Disease Control and Prevention (CDC) define “health disparities” as: preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. Populations can be defined by factors such as race or ethnicity, gender, education or income, disability, geographic location (e.g., rural or urban), or sexual orientation. Health disparities are inequitable and are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources.30

Health justice describes an absence of disparities,31 and a national single-payer program, which signals universal deservedness across the population and makes care free at the point of service, is a step toward addressing health disparities. Health justice requires far more, of course, but removing a primary barrier to healthcare— costs—moves the needle, as does the creation of a universal program in which everyone has a vested interest. For policy and law to promote health justice, we must create “a regulatory and jurisprudential approach that consistently and reliably considers the health ramifications of judicial and legislative decision making.”32 Health justice is also promoted when programs are universal, and thus less subject to political whims subsequent to their implementation. Stability and universality also promotes health justice in multiple ways. The more people who benefit from a program, the more politically popular it becomes, thus making it incredibly politically risky to undermine or cut back. 33

Take, as an example, the top issue of U.S. voters in the 2020 election: preventing cuts to Social Security benefits.34 Of course, Social Security benefits are not truly universal, in that individuals must accrue enough work credits to obtain Social Security Retirement benefits in old age, but Social Security benefits are entitlements for those eligible and 48.9 million retirees (about one-sixth of the U.S. population) and their dependents currently receive Retirement,35 with tens of millions more counting on the benefit in the future.36 The more people who count on a benefit, the less likely it is that a political class hostile to the benefit can find a constituency to oppose it. Simply put, universal programs are popular, and individuals are likely to see programs that promote health and livelihoods in a positive light. Notably, voters’ second-most reported top issue in the 2020 election was “[a]chieving universal health care.”37 The universality of public programs, then, is a hallmark of health justice promotion because it promotes the preservation of those programs.

C. Single-Payer as a Stepping Stone to Achieving Health Justice A single-payer system would, of course, not cause health justice to materialize immediately in the United States, but single-payer is a means to achieving health justice in a number of ways. First and most straightforwardly, single-payer begins to address health disparities by removing one of the primary obstacles to care— cost—from the equation. Costs are a barrier to healthcare for both insured and uninsured people, meaning even primary and preventive care are largely out of the reach of people who cannot afford the high out-of-pocket costs now associated with healthcare. This often leads people who need complex chronic care, or even simple primary care, to rely on emergency rooms and urgent care when health problems come to a head. These individuals and families have less access to the kind of personalized primary care that improves health outcomes and prevents emergencies. When a patient is making the choice between a routine checkup or an appointment to address a persistent but non-emergency health issue and paying for rent, food, transportation, etc., health concerns get pushed to the back burner. And, of course, when making that choice, the current healthcare system lends itself to information asymmetry—few people can predict the actual cost of a healthcare encounter, and many cannot risk being saddled with an unexpected bill. A national single-payer program that provides healthcare free at the point of service would eliminate these out-of-pocket cost strains and promote health justice by eliminating cost considerations from people’s decisions to seek care. More importantly, though, a universal program like single payer promotes health justice by changing our social notions of who “deserves” healthcare, social notions currently reinforced by the hybrid unequal system of care in the U.S.38 “Through Black health gains via universal healthcare . . . the (often unstated) myth that White people ‘earn’ their high rates of positive health status and outcomes relative to Black people, by virtue of some attention to care to their bodies and minds that other groups, including Black people, do not employ, would fall.”39 In this way, a single-payer system—by providing care based on need rather than ability to pay—contributes to a sense of social solidarity that had been undermined and combatted by existing health finance policy. As a beneficiary of Britain’s NHS put it, “I think it's also a great pleasure certainly to me, you walk into a room in your surgery. And it’s full of all sorts of people . . . . I wouldn't like to be thrown out of a place because I wasn't rich enough. But I also don't want to be in a place which everybody poorer than me is not getting access.”40

To illuminate the meaning of health justice and how singlepayer might promote it, it is worth examining why the United States government—unlike more than seventy countries in the world that provide universal healthcare—has been so resistant to single-payer despite popular calls for such a program. As Ampson Hagan puts it, “[The] U.S. healthcare debate is hardly just about health. Healthcare, representing a politics by other means, helps determine the socio-political and economic futures of women, Black people, and Black women, beyond the intrinsic health outcomes it directly produces. . . .” The system, in other words, reinforces and perpetuates ideas about who deserves care and who is to blame for their own health outcomes. “A Medicare For All program may prompt us to examine notions of merit and deservingness that have up to now, been deployed to entrench racial inequality within existing American social structures.”41 Such a reexamination would be incredibly threatening to other oppressive structures in the U.S., where, “[w]hile other nations focused on access and equality, our deep-seated attachment to America’s racial hierarchy tied us to a health care system encompassing racial disparities by design.”42 That is, a national single-payer program, through the implication that all U.S. residents deserve healthcare, upsets and undermines a history of U.S. public policy enforcing an oppressive racial and class order. As discussed in more detail later, this is starkly illustrated in how states have administered public healthcare programs. “When we hone in on the demographics of the American populace and think critically about who is currently underserved by the current medical system in the U.S., and who stands to benefit from an improved and more accessible system,” it becomes clear “the healthcare debate has come to resemble a proxy war of sorts, pitting social welfare proponents against capitalist hawks who believe in little government and every man for himself [every person for themselves].”43 Additionally, related to its elimination of out-of-pocket costs and private intermediaries, single-payer system also builds a more equitable health finance system by removing the insurance company/provider mismatches that prohibit individuals and families from seeking the most appropriate care due to insurance network limitations and restrictions on covered care. Right now, each private insurance company makes private decisions about when, where, how, and how much people can seek care, and these rationing decisions are based on profit motivation and financial risk assessment, rather than on what a patient’s provider deems medically necessary. As explained in greater detail later, public health programs are required to give far more deference to providers’ recommendations.

Finally, a single payer that covers all U.S. residents is far better positioned to bargain not just for better prices, but for higher standards of care, than individual private insurance companies, and even than the current large federal payers. The ability of a large single payer to bargain with providers, manufacturers, and suppliers, is unmatched in the current private-public hybrid U.S. healthcare system. This bargaining power inheres in the public as well. A single-payer healthcare program weaves together a single crossdemographic interest group (the U.S. population) out of currently disconnected constituencies and disease-specific advocacy groups. This increases the bargaining power of the public as to the healthcare payer, promoting greater accountability of the payer to patients than is present in the current system, particularly among patients with private insurance who must face down private insurance companies on their own through individualized advocacy and appeals. Essentially, single-payer is a healthcare financing proposal that also prioritizes and promotes health justice. And, in the inequitable U.S. healthcare system, supporters of reform must key in on whether and how reforms will promote health justice rather than continuing the process of expanding health coverage piecemeal while maintaining an untenably unjust and fragmented system.

Beyond the more obvious effects on individual and family budgets, a national single-payer program lays the groundwork for healthcare solidarity across the population. By eliminating meanstesting and creating a universal program that covers all residents— and thus signaling universal deservingness—the terrain of health struggle is changed in a way that allows for more mass organizing around health justice demands. When everyone benefits, everyone has something to lose, and it becomes less and less politically viable to eliminate programs the closer those programs come to being universal. Currently, patient power is widely dispersed, and grows even more so after every effort to provide healthcare or insurance coverage to some new specific group succeeds.