Health Care: Private or Public?


article-1108763-02FA1BC4000005DC-843_468x323Most of my friends instinctively think of health care as a “private” matter, if only because so many health-related problems deal with the most intimate aspects of life. You want the right to choose your own doctor and to select the kind of medical care you need, when you need it. In this sense, it’s like buying a car … you want to choose the make and model that suits you best.

But many people also see health care as a “public” concern, much as education, sewage treatment, public parks, and fire departments are public concerns.

What makes health care a public concern?

One answer is that the benefits of individual good health accrue to the society as a whole. Healthier individuals make better students and more productive workers, which results in a higher standard of living for everyone over time. Widespread immunization reduces the probability of contracting infectious diseases that can be debilitating or deadly. Public programs to curtail smoking, drinking and drug abuse reduce the risks of second-hand smoke and accidents caused by incapacitated drivers. Preventative health care (e.g., an annual check-up or a flu shot) helps people to live better and longer.

Another is that health care, like education or sewage treatment, requires an upfront investment—in hospitals and clinics as well as diagnostic and treatment equipment—that is often too large for any one individual or corporation to make, given the uncertain period to generate a reasonable return.

A third is that the demand for much of our health care is relatively insensitive to price. It’s a pretty simple concept if you think about, say, end-of-summer or Black Friday sales when crowds line up to purchase cars, TVs, and computers that they wouldn’t buy—and maybe couldn’t afford—at the pre-sale price.

You can’t do that with health care. If your budget is tight, you may forego discretionary items like getting your teeth cleaned or getting a tummy tuck. But when your kid has a broken leg or your spouse has a heart attack, you don’t stop to ask how much it will cost to set the bone or have surgery to put in a stent. You get it taken care and worry about the cost later. Unlike on Black Friday, the health care services you purchase are based on your medical condition, while the price you pay is determined by a doctor, hospital or drug company without regard for your financial circumstances at the time.

The consequences for the public

This is a “public” issue because those who are most price sensitive to health care — perhaps because they do not have adequate (or any) insurance — tend to forego those discretionary items that have broader social consequences. Their kids don’t get glasses or regular dental care, so they have problems concentrating at school, which affects their learning capacity and often creates disruptive situations in the classroom. Adults — our teachers, our co-workers, our employees—don’t get the preventive care, including drugs and therapy, that would  prevent more serious and costly illness at a later time.

It is a public issue because the uninsured—regardless of age and overall health—are still at risk of serious accidents or illness. All too many people—again, people in our community that we rely for services and support—suffer or die from medical issues that could have been prevented or cured if they had had the benefits of appropriate medical care.

It is a public issues because the uninsured or under-insured often labor under enormous debt as a result of medical bills; indeed, medical debt has been estimated to be the number one cause of consumer bankruptcies in 2013.

The community pays for these health care costs one way or another. Sometimes it will be in dollars-and-cents (e.g., local businessmen hurt by customer bankruptcies or taxpayers who have to make up the shortfall in public hospital receipts). Other times, it will be through lost productivity in the work place or in our schools. Whichever way it happens, there is little doubt that your continued good health costs you substantially more than the amount you pay directly in premiums and deductibles for your own health care.

It is the balance between health care as a private or public good that lies behind much of the debate about our health care system. If you see health care as a public good, you will tend to favor a single payer nationalized health care system (as Europe and Canada have or the U.S. has with Medicare); if you see it as a private good, you may prefer the private payer system (as we have in the U.S.)

What do you think?


  1. Interesting post, Mary. I never thought of the issue quite this way. It does seem that it is a bit of a mixture–there are the private concerns of individuals, but that in order for a nation to be strong and healthy (physically, economically, morally, etc.) its citizens–all of its citizens–must also be healthy. I heard an educator talking on NPR recently saying a big problem that hinders education is children who need healthcare. As he said, you can’t learn if you’re in pain or can’t see.

    • Mary Gottschalk says

      Merril … there are a lot of angles to this “public vs private” that I’d like to address in the next couple of blogs. But you’ve honed in on one of the key concerns … the impact on education of children in bad health … not only their own learning experience, but the potential disruption to the learning experience of other children.

  2. I tend to agree with Merril: “there are the private concerns of individuals, but that in order for a nation to be strong and healthy (physically, economically, morally, etc.) its citizens–all of its citizens–must also be healthy.”

    The push/pull of these competing concerns are what makes the issue of healthcare so controversial in this country. I believe you are teaching a course now related to healthcare concerns. Yes? Your students are fortunate to have a prof willing to delve into the ramifications of various choices and explore a sensitive issue.

    • Mary Gottschalk says

      Marian … the course I’m teaching now tends to focus more on the potential conflict between religious traditions and modern medicine, so we don’t delve into the economics in depth. But there is surprising unanimity among widely diverse religious traditions on the need to weigh the value of life against the cost and benefits of prolonging when the quality of life is poor.

  3. Excellent series, Mary. This public-private dichotomy is an important one in many arenas of life and I’m glad you’ve brought it into the health care conversation. For me, it’s always come down to what sort of society I want to live in. What does that look like and how best can I help us get there. Keep up the good work.

  4. Mary Gottschalk says

    Janet … you are absolutely right that the ultimate question is what a kind of a society we want to live in … one in private interests take precedence over public interests, or whether they find some kind of balance. I don’t think we’ve quite found the answer yet.