In the United States, there is no guarantee you can receive health services. While we do have subsidies or programs for some people who are struggling financially, not everyone gets this support. Emergency rooms are not allowed to turn away people for lack of payment, but emergency rooms are mostly oriented toward stopping an emergency rather than helping you become healthy. If you are poor or lower-middle class, you simply might not be able to afford primary health care in the United States. In contrast, the perspective that health is a human right holds that anyone should be able to have their health needs addressed, regardless of how much money they have (or any other factors). Many countries across the world consider health to be a fundamental human right. But it is not our approach in US policy.
According to the World Health Organization, health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Health as a human right does not mean that everyone in a society is guaranteed to be healthy, only that everyone has the opportunity to be healthy. If you craft public policies with the idea that health is a human right, you guarantee medical care for everyone and take care of physical, mental, and social well-being.
In the United States, we have taken a different path.
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The idea of health as a human right was established in the tumult of the years at the end of World War II. Many countries were reeling and in shock by the atrocities committed against humans. In this aftermath, countries came together to form the United Nations (UN) and began working on developing norms, policies, and institutions that could prevent future harms. They were thinking with a prevention mindset: How do we create a world where this can never happen again?
In April 1945, thousands of delegates from 50 nations descended on San Francisco for the UN Conference on International Organization. This meeting would ultimately establish the first UN Charter and set many other initiatives in motion. Imagine the scene: people from all over the world, speaking different languages, trying to figure out what the new global order would look like. What institutions would they need? What values would they enshrine in policy? How would they make decisions? So much of what followed in 20th-century world governance was debated at that conference.
At this conference, three delegates who were doctors—Szeming Sze (China), Paula Souza (Brazil), and Karl Evang (Norway)—were trying to ensure that nations came together to establish an international health organization. They first tried to submit an amendment to the new UN charter, but it was too late. Then they tried to get one of the formal committees to take it up, but it got stuck there. Finally, during a chance dinner meeting with the secretary general of the conference, Dr. Sze received critical advice: the best way of getting the health organization established was through a declaration. The declaration was passed with overwhelming support and led to the establishment of the World Health Organization (WHO) the following year as an offshoot of the UN. In 1946, the WHO drafted its first constitution, which established “the highest attainable standard of health as a fundamental right of every human being without distinction of race, religion, political belief, economic or social condition.”
At the same time that the WHO was writing health as a human right into its constitution, another part of the emerging UN was trying to gain international agreement on fundamental human rights. In 1946, former US first lady Eleanor Roosevelt became chair of the commission that was tasked by the UN General Assembly with writing a declaration on human rights that all member nations could agree to. Eleanor Roosevelt took this charge extremely seriously, hoping that crafting a unanimous declaration would help prevent future wars or atrocities like the Holocaust. And this was all taking place during the start of the Cold War with Soviet—US tensions running high.
Roosevelt chaired over 3,000 hours of deliberations where delegates from around the world ultimately agreed on 30 articles to the UN Declaration on Human Rights. All 192 member states of the UN have signed onto the document; with over 500 translations, it has set the Guinness World Record for most translated document. Importantly, the declaration helped to further establish the idea of health as a human right as the global standard. Article 25 states:
“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
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In the United States, we have fallen quite short of this human rights declaration. US public policy has made access to health care a commodity. It is a privilege and not a right. While you can pay out of pocket for health care in the United States, most people pay a health insurance company (either directly or their employer pays); the insurer then pays health care costs. Well, sort of. Health insurance companies pay costs after you have already paid some costs (a deductible), and they put maximum limits on how much they will cover (a cap). A minority of Americans get their health insurance through government programs such as Medicaid or Medicare, or they receive health care at no cost through government-funded health care facilities like the Veterans Administration or federally qualified health centers. But this patchwork leaves many behind and creates some serious bureaucratic nightmares.
In 2023, about 9% of Americans ages 0–64 did not have health insurance. Medicaid provides health care coverage for low-income Americans, but state policies can place severe eligibility restrictions. In some states, adults without children or without disabilities are not eligible at all, regardless of their income level. The Affordable Care Act tried to expand eligibility for Medicaid across the country, but—as of 2024—10 states have made the decision to opt out, despite federal funding to support the expansion (several states made the decision to opt in years after initially opting out).
In states that did not expand Medicaid eligibility, low-income adults without dependent children are simply not eligible for this government-funded health insurance, and that has life-and-death consequences. Texas was one of the states that made a choice to not expand Medicaid coverage. In the initial years since opting out, researchers estimate that about 2,900 Texans ages 55–64 died due to that policy choice. They would have still been alive if Texas had opted in.50 Thousands of families lost a loved one, workplaces lost a colleague, and communities lost a neighbor all because Texan policymakers chose to make health care a commodity that some people could not access. Those 2,900 deaths are roughly the same number of people who died on September 11, 2001.
In contrast, there are an estimated 19,000 people across the United States who were alive in 2022 only because they were lucky enough to live in one of the 33 states that expanded Medicaid coverage.50 If you live in one of the Medicaid expansion states, it is very possible that one of your family members, neighbors, kid’s teachers, colleagues, or friends is alive today because they were able to access health services through the Medicaid expansion.
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Our current commodity-based health care system is a root cause of the deaths and financial ruin of some people. But it is important to note that these harms are not distributed equally across society. As you can imagine, they disproportionately affect poor Americans. About 80% of people who are uninsured have an income that puts them below 400% of the poverty line. In 2021, for an individual, below 400% of the poverty line would mean earning less than $51,520 annually.
Because the United States is a deeply racialized society, these harms are also patterned by race. People from racially marginalized groups are more likely to be uninsured: 21% of American Indians/Alaska Natives, 21% of Native Hawaiians/Pacific Islanders, 19% of Latinos, and 11% of Black Americans are uninsured compared to only 7% of whites. About 28% of Black households and 22% of Hispanic households had medical debt that they could not pay, compared to about 17% for white households.
So how does this deeply unequal commodity-based system stack up in terms of overall spending and health outcomes compared to other wealthy countries that take a “health as human right” approach? Well, the percentage that the United States spends on health care as a share of its economy is more than twice the average of other nations in the Organization for Economic Cooperation and Development (OECD). Compared with 10 other high-income countries that all have government-sponsored universal health care, the United States had the lowest life expectancy, highest suicide rates, highest chronic disease burden, highest number of hospitalizations from preventable causes, and highest rate of avoidable deaths. It is hardly a ringing endorsement for a commodity-based system for health care.
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Universal health care coverage is essential for reducing the worst outcomes of death, illness, medical bankruptcy, and inequities. But it is only a portion of the equation. Health care usually treats health issues after they occur, but a prevention mindset would aim to prevent them before they happen. We can look to Costa Rica as an example of a country that has effectively incorporated a prevention mindset into its health care system. In 2019, life expectancy in Costa Rica was 80 years compared to 79 years in the United States, despite Costa Rica only spending $922 per person per year on health care compared to US spending of $10,921 per person per year. What’s their secret?
In 2021, noted doctor and health care expert Atul Gawande went searching for an answer to that exact question. In a New Yorker article from that year, he concluded:
The country has made public health—measures to improve the health of the population as a whole—central to the delivery of medical care. Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals. In Costa Rica, though, public health has been a priority for decades.
In other words, medical care is only part of the equation for good health. Access to preventative measures that are well integrated into the health care system are essential for promoting good health and longevity.
What does this mean, practically speaking? It means that the health care system should not only focus on patient health but also on the health of the entire surrounding community. A clinic or hospital would not wait for patients to call them to set up a flu shot; instead, they would be visiting their patients’ homes, local employers, or otherwise making it easy for their community to prevent disease through flu shots. The current US health care system is not set up for that because the financial incentive is not there. It is set up for patients to come to medical providers and define what their medical needs are, rather than for doctors and clinics to try to prevent those issues before they happen.
Our current system is set up to consider profits—of doctors, hospitals, insurance companies, and pharmaceutical companies—as a fundamental factor in determining how the system works. Imagine if we transformed our health care system to consider population health as the fundamental factor that determined how the system worked?
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Health care is one of the most obvious areas where the policies we choose are about life and death. The current US system is not producing the health outcomes that peer countries are enjoying. Frankly, it is producing more deaths than it should, given how much US taxpayer money goes to it. To get the life and health benefits we deserve, we need to use our imagination, envision a different system, and work toward integrating a prevention mindset to transform the system at the roots.
Authored by Paul J. Fleming
Paul J. Fleming is an Associate Professor at the University of Michigan School of Public Health where he teaches and leads research focused on advancing health equity. In his book Imagine Doing Better, Fleming paints a hopeful—yet urgent—picture of what’s possible when societies invest in solutions that prioritize human dignity, equity, and sustainability.
Excerpted from Imagine Doing Better: Why Policies Backfire and How Prevention Thinking Can Change Everything by Paul J Fleming. Copyright 2025. Published with permission of Johns Hopkins University Press.
