Book Review: Health Care as a Right of Citizenship: The Continuing Evolution of Reform

Health Care as a Right of Citizenship: The Continuing Evolution of Reform, by Gunnar Almgren, Columbia University Press, New York, NY, ISBN 9780231170130 , 2017, 342 pages, $35.00 paperback.

    Almgren is an associate professor of social work at the University of Washington. The basic premise of his third book on health care policy is that the Affordable Care Act (ACA) is an intermediary step toward some form of universal health insurance coverage. From this perspective, the most significant contribution of ACA is not in the specific provisions, but in the implied declaration that there is a social right to health care in America. Unfortunately and despite the slight delay in the projected insolvency of the Medicare Hospital Insurance Trust Fund from 2017 to 2030, ACA is simply not up to this task. The first two chapters make these arguments and provide a brief history of health care policy in America.  

     The title of the book comes largely from the third chapter, a complex synthesis of John Rawls’ moral powers of citizenship and T. H. Marshall’s understanding of social rights as essential to political democracy in the context of social stratification. This synthesis understands the viability of a liberal society to rest not only in the civil and political rights shared, but also in the social rights (i.e., economic security and human capital investments) that serve as the glue that holds a diverse and democratic society together.   

     A critique of the ACA follows in chapter four, which underlies the unsustainability of this legislation as a solution to the problem of escalating health care costs, and the fifth chapter presents Almgren’s proposal to reform health care financing. Labeling this proposal as radical may be a stretch, because Almgren accepts as unavoidable the existing social stratification (e.g., the wealthy will never accept health care treatment in common wards), social heterogeneity (e.g., varying levels of health care insurance will be desired by consumers), and insurance industry priorities in his presentation of a soft two-tiered system of health care: a publicly funded tier like Medicare and a privately funded tier for discretionary and concierge medical services. The two-tier approach eliminates the stigma and inadequacies of Medicaid.  

     Implementation challenges of health care reform are discussed in the sixth chapter, including access disparities; integrated health care systems; global budgeting challenges; and resource provision for a health care labor force, facilities, and data infrastructure development. Assessment of health care delivery is described in considerable detail in the seventh chapter, one quite unlikely to be accessible to the casual reader. The concluding chapter briefly addresses the rights of noncitizens to health care, boundaries on the provision of health care services when normal human functioning cannot be restored, intergenerational equity in health care, and the special cases of health care for Native Americans and veterans.  

     Health care policy is a complicated subject that Almgren addresses in a thorough manner. His progressive pragmatism forms a compelling series of arguments worthy of serious consideration by the socialist and Tea Party extremes; however, this is not a light and breezy read. Almgren writes as a policy wonk to other policy wonks. Prepare to do some heavy lifting when engaging this text. 

Reviewed by Peter A. Kindle, Ph.D., CPA. LMSW, associate professor, The University of South Dakota. Peter Kindle can be contacted by email at Peter.Kindle@usd.edu.