universal health care essay conclusion

Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons

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Every citizen of every country in the world should be provided with free and high-quality medical services. Health care is a fundamental need for every human, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal health care is the provision of healthcare services by a government to all its citizens (insurancespecialists.com). This means each citizen can access medical services of standard quality. In the United States, about 25% of its citizens are provided with healthcare funded by the government. These citizens mainly comprise the elderly, the armed forces personnel, and the poor (insurancespecialists.com).

Introduction

Thesis statement.

• Universal Healthcare Pros
• Universal Healthcare Cons

Works Cited

In Russia, Canada, and some South American and European countries, the governments provide universal healthcare programs to all citizens. In the United States, the segments of society which do not receive health care services provided by the government usually pay for their health care coverage. This has emerged as a challenge, especially for middle-class citizens. Therefore, the universal health care provision in the United States is debatable: some support it, and some oppose it. This assignment is a discussion of the topic. It starts with a thesis statement, then discusses the advantages of universal health care provision, its disadvantages, and a conclusion, which restates the thesis and the argument behind it.

The government of the United States of America should provide universal health care services to its citizens because health care is a basic necessity to every citizen, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal Healthcare Provision Pros

The provision of universal health care services would ensure that doctors and all medical practitioners focus their attention only on treating the patients, unlike in the current system, where doctors and medical practitioners sped a lot of time pursuing issues of health care insurance for their patients, which is sometimes associated with malpractice and violation of medical ethics especially in cases where the patient is unable to adequately pay for his or her health care bills (balancedpolitics.org).

The provision of universal health care services would also make health care service provision in the United States more efficient and effective. In the current system in which each citizen pays for his or her health care, there is a lot of inefficiency, brought about by the bureaucratic nature of the public health care sector (balancedpolitics.org).

Universal health care would also promote preventive health care, which is crucial in reducing deaths as well as illness deterioration. The current health care system in the United States is prohibitive of preventive health care, which makes many citizens to wait until their illness reach critical conditions due to the high costs of going for general medical check-ups. The cost of treating patients with advanced illnesses is not only expensive to the patients and the government but also leads to deaths which are preventable (balancedpolitics.org).

The provision of universal health care services would be a worthy undertaking, especially due to the increased number of uninsured citizens, which currently stands at about 45 million (balancedpolitics.org).

The provision of universal health care services would therefore promote access to health care services to as many citizens as possible, which would reduce suffering and deaths of citizens who cannot cater for their health insurance. As I mentioned in the thesis, health care is a basic necessity to all citizens and therefore providing health care services to all would reduce inequality in the service access.

Universal health care would also come at a time when health care has become seemingly unaffordable for many middle income level citizens and business men in the United States. This has created a nation of inequality, which is unfair because every citizen pays tax, which should be used by the government to provide affordable basic services like health care. It should be mentioned here that the primary role of any government is to protect its citizens, among other things, from illness and disease (Shi and Singh 188).

Lastly not the least, the provision of universal health care in the United States would work for the benefit of the country and especially the doctors because it would create a centralized information centre, with database of all cases of illnesses, diseases and their occurrence and frequency. This would make it easier to diagnose patients, especially to identify any new strain of a disease, which would further help in coming up with adequate medication for such new illness or disease (balancedpolitics.org).

Universal Healthcare Provision Cons

One argument against the provision of universal health care in the United States is that such a policy would require enormous spending in terms of taxes to cater for the services in a universal manner. Since health care does not generate extra revenue, it would mean that the government would either be forced to cut budgetary allocations for other crucial sectors of general public concern like defense and education, or increase the taxes levied on the citizens, thus becoming an extra burden to the same citizens (balancedpolitics.org).

Another argument against the provision of universal health care services is that health care provision is a complex undertaking, involving varying interests, likes and preferences.

The argument that providing universal health care would do away with the bureaucratic inefficiency does not seem to be realistic because centralizing the health care sector would actually increase the bureaucracy, leading to further inefficiencies, especially due to the enormous number of clientele to be served. Furthermore, it would lead to lose of business for the insurance providers as well as the private health care practitioners, majority of whom serve the middle income citizens (balancedpolitics.org).

Arguably, the debate for the provision of universal health care can be seen as addressing a problem which is either not present, or negligible. This is because there are adequate options for each citizen to access health care services. Apart from the government hospitals, the private hospitals funded by non-governmental organizations provide health care to those citizens who are not under any medical cover (balancedpolitics.org).

Universal health care provision would lead to corruption and rent seeking behavior among policy makers. Since the services would be for all, and may sometimes be limited, corruption may set in making the medical practitioners even more corrupt than they are because of increased demand of the services. This may further lead to deterioration of the very health care sector the policy would be aiming at boosting through such a policy.

The provision of universal health care would limit the freedom of the US citizens to choose which health care program is best for them. It is important to underscore that the United States, being a capitalist economy is composed of people of varying financial abilities.

The provision of universal health care would therefore lower the patients’ flexibility in terms of how, when and where to access health care services and why. This is because such a policy would throw many private practitioners out of business, thus forcing virtually all citizens to fit in the governments’ health care program, which may not be good for everyone (Niles 293).

Lastly not the least, the provision of universal health care would be unfair to those citizens who live healthy lifestyles so as to avoid lifestyle diseases like obesity and lung cancer, which are very common in America. Many of the people suffering from obesity suffer due to their negligence or ignorance of health care advice provided by the government and other health care providers. Such a policy would therefore seem to unfairly punish those citizens who practice good health lifestyles, at the expense of the ignorant (Niles 293).

After discussing the pros and cons of universal health care provision in the United States, I restate my thesis that “The government of United States of America should provide universal health care to its citizens because health care is a basic necessity to every citizen, regardless of age, sex, race, religion, and socio economic status”, and argue that even though there are arguments against the provision of universal health care, such arguments, though valid, are not based on the guiding principle of that health care is a basic necessity to all citizens of the United States.

The arguments are also based on capitalistic way of thinking, which is not sensitive to the plight of many citizens who are not able to pay for their insurance health care cover.

The idea of providing universal health care to Americans would therefore save many deaths and unnecessary suffering by many citizens. Equally important to mention is the fact that such a policy may be described as a win win policy both for the rich and the poor or middle class citizens because it would not in any way negatively affect the rich, because as long as they have money, they would still be able to customize their health care through the employment family or personal doctors as the poor and the middle class go for the universal health care services.

Balanced politics. “Should the Government Provide Free Universal Health Care for All Americans?” Balanced politics: universal health . Web. Balanced politics.org. 8 august https://www.balancedpolitics.org/universal_health_care.htm

Insurance specialists. “Growing Support for Universal Health Care”. Insurance information portal. Web. Insurance specialists.com 8 august 2011. https://insurancespecialists.com/

Niles, Nancy. Basics of the U.S. Health Care System . Sudbury, MA: Jones & Bartlett Learning, 2010:293. Print.

Shi, Leiyu and Singh, Douglas. Delivering Health Care in America: A Systems Approach . Sudbury, MA: Jones & Bartlett Learning, 2004:188. Print.

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Bibliography

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Should the U.S. Government Provide Universal Health Care?

• History of Universal Health Care

27.5 million non-elderly Americans did not have health insurance in 2021, a decline from 28.9 million uninsured Americans in 2019. The largest group of Americans, almost 155 million non-elderly people, were covered by employer-sponsored health insurance. Less than 1% of Americans over 65 were uninsured, thanks to Medicaid, a government provided insurance for people over 65 years old.

The United States is the only nation among the 37 OECD (Organization for Economic Co-operation and Development) nations that does not have universal health care either in practice or by constitutional right. Read more background…

Pro & Con Arguments

Pro 1 The United States already has universal health care for some. The government should expand the system to protect everyone. A national health insurance is a universal health care that “uses public insurance to pay for private-practice care. Every citizen pays into the national insurance plan. Administrative costs are lower because there is one insurance company. The government also has a lot of leverage to force medical costs down,” according to economic expert Kimberly Amadeo. Canada, Taiwan, and South Korea all have national health insurance. In the United States, Medicare, Medicaid, and TRICARE function similarly. [ 178 ] Medicare is the “federal health insurance program for: people who are 65 or older, certain younger people with disabilities, [and] people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).” Patients pay a monthly premium for Medicare Part B (general health coverage). The 2023 standard Part B monthly premium is $164.90. Patients also contribute to drug costs via Medicare Part D. Most people do not pay a premium for Medicare Part A (“inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care”). More than 65.3 million people were enrolled in Medicare according to Feb. 2023 government data. [ 180 ] [ 181 ] Medicaid “provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.” More than 84.8 million people were enrolled in Medicaid as of Nov. 2022. [ 181 ] [ 182 ] [ 183 ] The Children’s Health Insurance Program (CHIP), often lumped in with Medicaid in these discussions, is a “low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program.” CHIP covers more than 6.9 million patients. [ 181 ] [ 182 ] [ 183 ] TRICARE is the “military health system that provides care to almost 10 million active-duty service members, retired personnel, and their families.” Active-duty military members pay $0 for health insurance, while retired members and their families paid a premium up to $1,165 per month (for a member and family) in 2021. [ 184 ] The United States already successfully maintains universal health care for almost 36% of the U.S. population, according to U.S. Census data released in Sep. 2022. As the Baby Boomer generation continues to age and more of the generation becomes eligible for Medicare, estimates suggest about 73.5 million people will use Medcare and about 47% of American health care costs will be paid for by public health services by 2027. [ 185 ] [ 186 ] If the government can successfully provide universal health care for 36% to almost 50% of the population, then the government can provide univeral health care for the rest of the population who are just as in need and deserving of leading healthy lives. Read More

Pro 2 Universal health care would lower costs and prevent medical bankruptcy. A June 2022 study found the United States could have saved $105.6 billion in COVID-19 (coronavirus) hospitalization costs with single-payer universal health care during the pandemic. That potential savings is on top of the estimated $438 billion the researchers estimated could be saved annually with universal health care in a non-pandemic year. [ 198 ] “Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households,” conclude researchers from the Yale School of Public Health and colleagues. [ 201 ] According to the National Bankruptcy Forum, medical debt is the number one reason people file for bankruptcy in the United States. In 2017, about 33% of all Americans with medical bills reported that they “were unable to pay for basic necessities like food, heat, or housing.” If all Americans were provided health care under a single-payer system medical bankruptcy would no longer exist, because the government, not private citizens, would pay all medical bills. [ 131 ] Further, prescription drug costs would drop between 4% and 31%, according to five cost estimates gathered by New York Times reporters. 24% of people taking prescription drugs reported difficulty affording the drugs, according to a Kaiser Family Foundation (KFF) poll. 58% of people whose drugs cost more than $100 a month, 49% of people in fair or poor health, 35% of those with annual incomes of less than $40,000, and 35% of those taking four or more drugs monthly all reported affordability issues. [ 197 ] [ 199 ] [ 200 ] Additionally, 30% of people aged 50 to 64 reported cost issues because they generally take more drugs than younger people but are not old enough to qualify for Medicare drug benefits. With 79% of Americans saying prescription drug costs are “unreasonable,” and 70% reporting lowering prescription drug costs as their highest healthcare priority, lowering the cost of prescription drugs would lead to more drug-compliance and lives not only bettered, but saved as a result. [ 197 ] [ 199 ] [ 200 ] Read More

Pro 3 Universal health care would improve individual and national health outcomes. Since 2020, the COVID-19 pandemic has underscored the public health, economic and moral repercussions of widespread dependence on employer-sponsored insurance, the most common source of coverage for working-age Americans…. Business closures and restrictions led to unemployment for more than 9 million individuals following the emergence of COVID-19. Consequently, many Americans lost their healthcare precisely at a time when COVID-19 sharply heightened the need for medical services,” argue researchers from the Yale School of Public Health and colleagues. The researchers estimated more than 131,000 COVID-19 (coronavirus) deaths and almost 78,000 non-COVID-19 deaths could have been prevented with universal health care in 2020 alone. [ 198 ] Another study finds a change to “single-payer health care would… save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.” [ 201 ] Meanwhile, more people would be able to access much-needed health care. A Jan. 2021 study concludes that universal health care would increase outpatient visits by 7% to 10% and hospital visits by 0% to 3%, which are modest increases when compared to saved and lengthened lives. [ 202 ] Other studies find that universal health coverage is linked to longer life expectancy, lower child mortality rates, higher smoking cessation rates, lower depression rates, and a higher general sense of well-being, with more people reporting being in “excellent health.” Further, universal health care leads to appropriate use of health care facilities, including lower rates of emergency room visits for non-emergencies and a higher use of preventative doctors’ visits to manage chronic conditions. [ 203 ] [ 204 ] [ 205 ] An American Hospital Association report argues, the “high rate of uninsured [patients] puts stress on the broader health care system. People without insurance put off needed care and rely more heavily on hospital emergency departments, resulting in scarce resources being directed to treat conditions that often could have been prevented or managed in a lower-cost setting. Being uninsured also has serious financial implications for individuals, communities and the health care system.” [ 205 ] Read More

Con 1 Universal health care for everyone in the United States promises only government inefficiency and health care that ignores the realities of the country and the free market. In addition to providing universal health care for the elderly, low-income individuals, children in need, and military members (and their families), the United States has the Affordable Care Act (the ACA, formerly known as the Patient Protection and Affordable Care Act), or Obamacare, which ensures that Americans can access affordable health care. the ACA allows Americans to chose the coverage appropriate to their health conditions and incomes. [ 187 ] Veterans’ Affairs, which serves former military members, is an example of a single-payer health care provider, and one that has repeatedly failed its patients. For example, a computer error at the Spokane VA hospital “failed to deliver more than 11,000 orders for specialty care, lab work and other services – without alerting health care providers the orders had been lost.” [ 188 ] [ 189 ] Elizabeth Hovde, Policy Analyst and Director of the Centers for Health Care and Worker Rights, argues, “The VA system is not only costly with inconsistent medical care results, it’s an American example of a single-payer, government-run system. We should run from the attempts in our state to decrease competition in the health care system and increase government dependency, leaving our health care at the mercy of a monopolistic system that does not need to be timely or responsive to patients. Policymakers should give veterans meaningful choices among private providers, clinics and hospitals, so vets can choose their own doctors and directly access quality care that meets their needs. Best of all, when the routine break-downs of a government-run system threaten to harm them again, as happened in Spokane, veterans can take their well-earned health benefit and find help elsewhere.” [ 188 ] [ 189 ] Further, the challenges of universal health care implementation are vastly different in the U.S. than in other countries, making the current patchwork of health care options the best fit for the country. As researchers summarize, “Though the majority of post-industrial Westernized nations employ a universal healthcare model, few—if any—of these nations are as geographically large, populous, or ethnically/racially diverse as the U.S. Different regions in the U.S. are defined by distinct cultural identities, citizens have unique religious and political values, and the populace spans the socio–economic spectrum. Moreover, heterogenous climates and population densities confer different health needs and challenges across the U.S. Thus, critics of universal healthcare in the U.S. argue that implementation would not be as feasible—organizationally or financially—as other developed nations.” [ 190 ] And, such a system in the United States would hinder medical innovation and entrepreneurship. “Government control is a large driver of America’s health care problems. Bureaucrats can’t revolutionize health care – only entrepreneurs can. By empowering health care entrepreneurs, we can create an American health care system that is more affordable, accessible, and productive for all,” explains Wayne Winegarden, Senior Fellow in Business and Economics, and Director of the Center for Medical Economics and Innovation at Pacific Research Institute. [ 190 ] [ 191 ] Read More

Con 2 Universal health care would raise costs for the federal government and, in turn, taxpayers. Medicare-for-all, a recent universal health care proposal championed by Senator Bernie Sanders (I-VT), would cost an estimated $30 to $40 trillion over ten years. The cost would be the largest single increase to the federal budget ever. [ 192 ] The Congressional Budget Office (CBO) estimates that by 2030 federal health care subsidies will increase by $1.5 to $3.0 trillion. The CBO concludes, “Because the single-payer options that CBO examined would greatly increase federal subsidies for health care, the government would need to implement new financing mechanisms—such as raising existing taxes or introducing new ones, reducing certain spending, or issuing federal debt. As an example, if the government required employers to make contributions toward the cost of health insurance under a single-payer system that would be similar to their contributions under current law, it would have to impose new taxes.” [ 193 ] Despite claims by many, the cost of Medicare for All, or any other universal health care option, could not be financed solely by increased taxes on the wealthy. “[T]axes on the middle class would have to rise in order to pay for it. Those taxes could be imposed directly on workers, indirectly through taxes on employers or consumption, or through a combination of direct or indirect taxes. There is simply not enough available revenue from high earners and businesses to cover the full cost of eliminating premiums, ending all cost-sharing, and expanding coverage to all Americans and for (virtually) all health services,” says the Committee for a Responsible Federal Budget. [ 195 ] An analysis of the Sanders plan “estimates that the average annual cost of the plan would be approximately $2.5 trillion per year creating an average of over a $1 trillion per year financing shortfall. To fund the program, payroll and income taxes would have to increase from a combined 8.4 percent in the Sanders plan to 20 percent while also retaining all remaining tax increases on capital gains, increased marginal tax rates, the estate tax and eliminating tax expenditures…. Overall, over 70 percent of working privately insured households would pay more under a fully funded single payer plan than they do for health insurance today.” [ 196 ] Read More

Con 3 Universal health care would increase wait times for basic care and make Americans’ health worse. The Congressional Budget Office explains, “A single-payer system with little cost sharing for medical services would lead to increased demand for care in the United States because more people would have health insurance and because those already covered would use more services. The extent to which the supply of care would be adequate to meet that increased demand would depend on various factors, such as the payment rates for providers and any measures taken to increase supply. If coverage was nearly universal, cost sharing was very limited, and the payment rates were reduced compared with current law, the demand for medical care would probably exceed the supply of care–with increased wait times for appointments or elective surgeries, greater wait times at doctors’ offices and other facilities, or the need to travel greater distances to receive medical care. Some demand for care might be unmet.” [ 207 ] As an example of lengthy wait times associated with universal coverage, in 2017 Canadians were on waiting lists for an estimated 1,040,791 procedures, and the median wait time for arthroplastic surgery was 20–52 weeks. Similarly, average waiting time for elective hospital-based care in the United Kingdom is 46 days, while some patients wait over a year. Increased wait times in the U.S. would likely occur—at least in the short term—as a result of a steep rise in the number of primary and emergency care visits (due to eliminating the financial barrier to seek care), as well as general wastefulness, inefficiency, and disorganization that is often associated with bureaucratic, government-run agencies. [ 17 ] [ 190 ] Joshua W. Axene of Axene Health Partners, LLC “wonder[s] if Americans really could function under a system that is budget based and would likely have increased waiting times. In America we have created a healthcare culture that pays providers predominantly on a Fee for Service basis (FFS) and allows people to get what they want, when they want it and generally from whoever they want. American healthcare culture always wants the best thing available and has a ‘more is better’ mentality. Under a government sponsored socialized healthcare system, choice would become more limited, timing mandated, and supply and demand would be controlled through the constraints of a healthcare budget…. As much as Americans believe that they are crockpots and can be patient, we are more like microwaves and want things fast and on our own terms. Extended waiting lines will not work in the American system and would decrease the quality of our system as a whole.” [ 206 ] Read More

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Universal Healthcare in the United States of America: A Healthy Debate

Gabriel zieff.

1 Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; ude.cnu.liame@rrekz (Z.Y.K.); [email protected] (L.S.)

Zachary Y. Kerr

Justin b. moore.

2 Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; ude.htlaehekaw@eroomsuj

This commentary offers discussion on the pros and cons of universal healthcare in the United States. Disadvantages of universal healthcare include significant upfront costs and logistical challenges. On the other hand, universal healthcare may lead to a healthier populace, and thus, in the long-term, help to mitigate the economic costs of an unhealthy nation. In particular, substantial health disparities exist in the United States, with low socio–economic status segments of the population subject to decreased access to quality healthcare and increased risk of non-communicable chronic conditions such as obesity and type II diabetes, among other determinants of poor health. While the implementation of universal healthcare would be complicated and challenging, we argue that shifting from a market-based system to a universal healthcare system is necessary. Universal healthcare will better facilitate and encourage sustainable, preventive health practices and be more advantageous for the long-term public health and economy of the United States.

1. Introduction

Healthcare is one of the most significant socio–political topics in the United States (U.S.), and citizens currently rank “healthcare” as the most important issue when it comes to voting [ 1 ]. The U.S. has historically utilized a mixed public/private approach to healthcare. In this approach, citizens or businesses can obtain health insurance from private (e.g., Blue Cross Blue Shield, Kaiser Permanente) insurance companies, while individuals may also qualify for public (e.g., Medicaid, Medicare, Veteran’s Affairs), government-subsidized health insurance. In contrast, the vast majority of post-industrial, Westernized nations have used various approaches to provide entirely or largely governmentally subsidized, universal healthcare to all citizens regardless of socio–economic status (SES), employment status, or ability to pay. The World Health Organization defines universal healthcare as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship” [ 2 ]. Importantly, the Obama-era passage of the Affordable Care Act (ACA) sought to move the U.S. closer to universal healthcare by expanding health coverage for millions of Americans (e.g., via Medicaid expansion, launch of health insurance marketplaces for private coverage) including for citizens across income levels, age, race, and ethnicity.

Differing versions of universal healthcare are possible. The United Kingdom’s National Health Services can be considered a fairly traditional version of universal healthcare with few options for, and minimal use of, privatized care [ 3 ]. On the other hand, European countries like Switzerland, the Netherlands, and Germany have utilized a blended system with substantial government and market-based components [ 4 , 5 ]. For example, Germany uses a multi-payer healthcare system in which subsidized health care is widely available for low-income citizens, yet private options—which provide the same quality and level of care as the subsidized option—are also available to higher income individuals. Thus, universal healthcare does not necessarily preclude the role of private providers within the healthcare system, but rather ensures that equity and effectiveness of care at population and individual levels are a reference and expectation for the system as a whole. In line with this, versions of universal healthcare have been implemented by countries with diverse political backgrounds (e.g., not limited to traditionally “socialist/liberal” countries), including some with very high degrees of economic freedom [ 6 , 7 ].

Determining the degree to which a nation’s healthcare is “universal” is complex and is not a “black and white” issue. For example, government backing, public will, and basic financing structure, among many other factors must be extensively considered. While an in-depth analysis of each of these factors is beyond the scope of this commentary, there are clear advantages and disadvantages to purely private, market-based, and governmental, universal approaches to healthcare, as well as for policies that lie somewhere in-between. This opinion piece will highlight arguments for and against universal healthcare in the U.S., followed by the authors’ stance on this issue and concluding remarks.

2. Argument against Universal Healthcare

Though the majority of post-industrial Westernized nations employ a universal healthcare model, few—if any—of these nations are as geographically large, populous, or ethnically/racially diverse as the U.S. Different regions in the U.S. are defined by distinct cultural identities, citizens have unique religious and political values, and the populace spans the socio–economic spectrum. Moreover, heterogenous climates and population densities confer different health needs and challenges across the U.S. [ 8 ]. Thus, critics of universal healthcare in the U.S. argue that implementation would not be as feasible—organizationally or financially—as other developed nations [ 9 ]. There is indeed agreement that realization of universal healthcare in the U.S. would necessitate significant upfront costs [ 10 ]. These costs would include those related to: (i) physical and technological infrastructural changes to the healthcare system, including at the government level (i.e., federal, state, local) as well as the level of the provider (e.g., hospital, out-patient clinic, pharmacy, etc.); (ii) insuring/treating a significant, previously uninsured, and largely unhealthy segment of the population; and (iii) expansion of the range of services provided (e.g., dental, vision, hearing) [ 10 ].

The cost of a universal healthcare system would depend on its structure, benefit levels, and extent of coverage. However, most proposals would entail increased federal taxes, at least for higher earners [ 4 , 11 , 12 ]. One proposal for universal healthcare recently pushed included options such as a 7.5% payroll tax plus a 4% income tax on all Americans, with higher-income citizens subjected to higher taxes [ 13 ]. However, outside projections suggest that these tax proposals would not be sufficient to fund this plan. In terms of the national economic toll, cost estimations of this proposal range from USD 32 to 44 trillion across 10 years, while deficit estimations range from USD 1.1 to 2.1 trillion per year [ 14 ].

Beyond individual and federal costs, other common arguments against universal healthcare include the potential for general system inefficiency, including lengthy wait-times for patients and a hampering of medical entrepreneurship and innovation [ 3 , 12 , 15 , 16 ]. Such critiques are not new, as exemplified by rhetoric surrounding the Clinton Administration’s Health Security Act which was labeled as “government meddling” in medical care that would result in “big government inefficiency” [ 12 , 15 ]. The ACA has been met with similar resistance and bombast (e.g., the “repeal and replace” right-leaning rallying cry) as a result of perceived inefficiency and unwanted government involvement. As an example of lengthy wait times associated with universal coverage, in 2017 Canadians were on waiting lists for an estimated 1,040,791 procedures, and the median wait time for arthroplastic surgery was 20–52 weeks [ 17 ]. Similarly, average waiting time for elective hospital-based care in the United Kingdom is 46 days, while some patients wait over a year (3). Increased wait times in the U.S. would likely occur—at least in the short term—as a result of a steep rise in the number of primary and emergency care visits (due to eliminating the financial barrier to seek care), as well as general wastefulness, inefficiency, and disorganization that is often associated with bureaucratic, government-run agencies.

3. Argument for Universal Healthcare

Universal healthcare in the U.S., which may or may not include private market-based options, offer several noteworthy advantages compared to exclusive systems with inequitable access to quality care including: (i) addressing the growing chronic disease crisis; (ii) mitigating the economic costs associated with said crisis; (iii) reducing the vast health disparities that exist between differing SES segments of the population; and (iv) increasing opportunities for preventive health initiatives [ 18 , 19 , 20 , 21 ]. Perhaps the most striking advantage of a universal healthcare system in the U.S. is the potential to address the epidemic level of non-communicable chronic diseases such as cardiovascular diseases, type II diabetes, and obesity, all of which strain the national economy [ 22 , 23 ]. The economic strain associated with an unhealthy population is particularly evident among low SES individuals. Having a low SES is associated with many unfavorable health determinants, including decreased access to, and quality of health insurance which impact health outcomes and life expectancies [ 24 ]. Thus, the low SES segments of the population are in most need of accessible, quality health insurance, and economic strain results from an unhealthy and uninsured low SES [ 25 , 26 ]. For example, diabetics with low SES have a greater mortality risk than diabetics with higher SES, and the uninsured diabetic population is responsible for 55% more emergency room visits each year than their insured diabetic counterparts [ 27 , 28 ]. Like diabetes, hypertension—the leading risk factor for death worldwide [ 29 ], has a much higher prevalence among low SES populations [ 30 ]. It is estimated that individuals with uncontrolled hypertension have more than USD 2000 greater annual healthcare costs than their normotensive counterparts [ 31 ]. Lastly, the incidence of obesity is also much greater among low SES populations [ 32 ]. The costs of obesity in the U.S., when limited to lost productivity alone, have been projected to equate to USD 66 billion annually [ 33 ]. Accessible, affordable healthcare may enable earlier intervention to prevent—or limit risk associated with—non-communicable chronic diseases, improve the overall public health of the U.S., and decrease the economic strain associated with an unhealthy low-SES.

Preventive Initiatives within A Universal Healthcare Model

Beyond providing insurance coverage for a substantial, uninsured, and largely unhealthy segment of society—and thereby reducing disparities and unequal access to care among all segments of the population—there is great potential for universal healthcare models to embrace value-based care [ 4 , 20 , 34 ]. Value-based care can be thought of as appropriate and affordable care (tackling wastes), and integration of services and systems of care (i.e., hospital, primary, public health), including preventive care that considers the long-term health and economy of a nation [ 34 , 35 ]. In line with this, the ACA has worked in parallel with population-level health programs such as the Healthy People Initiative by targeting modifiable determinants of health including physical activity, obesity, and environmental quality, among others [ 36 ]. Given that a universal healthcare plan would force the government to pay for costly care and treatments related to complications resulting from preventable, non-communicable chronic diseases, the government may be more incentivized to (i) offer primary prevention of chronic disease risk prior to the onset of irreversible complications, and (ii) promote wide-spread preventive efforts across multiple societal domains. It is also worth acknowledging here that the national public health response to the novel Coronavirus-19 virus is a salient and striking contemporary example of a situation in which there continues to be a need to expeditiously coordinate multiple levels of policy, care, and prevention.

Preventive measures lessen costs associated with an uninsured and/or unhealthy population [ 37 ]. For example, investing USD 10 per person annually in community-based programs aimed at combatting physical inactivity, poor nutrition, and smoking in the U.S. could save more than USD 16 billion annually within five years, equating to a return of USD 5.60 for every dollar spent [ 38 ]. Another recent analysis suggests that if 18% more U.S. elementary-school children participated in 25 min of physical activity three times per week, savings attributed to medical costs and productivity would amount to USD 21.9 billion over their lifetime [ 39 ]. Additionally, simple behavioral changes can have major clinical implications. For example, simply brisk walking for 30 min per day (≥15 MET-hours/week) has been associated with a 50% reduction in type II diabetes [ 40 ]. While universal healthcare does not necessarily mean that health policies supporting prevention will be enacted, it may be more likely to promote healthy (i) lifestyle behaviors (e.g., physical activity), (ii) environmental factors (e.g., safe, green spaces in low and middle-income communities), and (iii.) policies (e.g., banning sweetened beverages in public schools) compared to a non-inclusive system [ 34 , 35 , 36 ].

Nordic nations provide an example of inclusive healthcare coupled with multi-layered preventive efforts [ 41 ]. In this model, all citizens are given the same comprehensive healthcare while social determinants of health are targeted. This includes “mobilizing and coordinating a large number of players in society,” which encourages cooperation among “players” including municipal political bodies, voluntary organizations, and educational institutions [ 41 ]. Developmental and infrastructural contributions from multiple segments of society to a healthcare system may also better encourage government accountability compared to a system in which a select group of private insurers and citizens are the only “stakeholders.” Coordinated efforts on various non-insurance-related fronts have focused on obesity, mental health, and physical activity [ 41 ]. Such coordinated efforts within the Nordic model have translated to positive health outcomes. For example, the Healthcare Access and Quality (HAQ) Index provides an overall score of 0–100 (0 being the worst) for healthcare access and quality across 195 countries and reflects rates of 32 preventable causes of death. Nordic nations had an average HAQ score of 95.4, with four of the five nations achieving scores within the top 10 worldwide [ 42 ]. Though far more heterogenous compared to Nordic nations, (e.g., culturally, geographically, racially, etc.), the U.S. had a score of 89 (29th overall) [ 42 ]. To provide further context, other industrialized nations, which are more comparable to the U.S. than Nordic nations, also ranked higher than the U.S. including Germany (92, 19th overall), Canada (94, 14th overall), Switzerland (96, 7th overall), and the Netherlands (96, 3rd overall) [ 42 ].

4. Conclusions

Non-inclusive, inequitable systems limit quality healthcare access to those who can afford it or have employer-sponsored insurance. These policies exacerbate health disparities by failing to prioritize preventive measures at the environmental, policy, and individual level. Low SES segments of the population are particularly vulnerable within a healthcare system that does not prioritize affordable care for all or address important determinants of health. Failing to prioritize comprehensive, affordable health insurance for all members of society and straying further from prevention will harm the health and economy of the U.S. While there are undoubtedly great economic costs associated with universal healthcare in the U.S., we argue that in the long-run, these costs will be worthwhile, and will eventually be offset by a healthier populace whose health is less economically burdensome. Passing of the Obama-era ACA was a positive step forward as evident by the decline in uninsured U.S. citizens (estimated 7–16.4 million) and Medicare’s lower rate of spending following the legislation [ 43 ]. The U.S. must resist the current political efforts to dislodge the inclusive tenets of the Affordable Care Act. Again, this is not to suggest that universal healthcare will be a cure-all, as social determinants of health must also be addressed. However, addressing these determinants will take time and universal healthcare for all U.S. citizens is needed now. Only through universal and inclusive healthcare will we be able to pave an economically sustainable path towards true public health.

Author Contributions

Conceptualization, G.Z., Z.Y.K., J.B.M., and L.S.; writing-original draft preparation, G.Z.; writing-review and editing, Z.Y.K., J.B.M., and L.S.; supervision, L.S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Argumentative Essay On Universal Healthcare

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Universal Healthcare in the United States

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Works Cited

• Cecere, David. “The Harvard Gazette.” 17 September 2009. Harvard News. 11 December 2018. .
• Edwards, Sweetland Haley. “The Health Care Voters.” TIME 12 November 2018: 41.
• “Formosa.” 17 March 2018. Formosa Post. 12 November 2018. .
• Gawande, Atul. “The United States Can Achieve Universal Health Care Without Dismantling the Existing Health Care System.” Universal Health Care . Detroit: Greenhaven Press, 2010. 190.
• Jackson Jr., Jesse L. “The United States Should Guarantee the Right to Health Care Through a Constitutional Amendment.” Grover, Jan. Healthcare . Detroit: Greenhaven Press, 2007. 28.
• “NIMH.” November 2017. National Institute of Mental Health. 12 December 2018. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
• Salyer, Kirsten. “TIME.” 1 July 2016. TIME Web Site. 5 November 2018.
• Tanner, Michael D. “CATO.” 23 February 2009. CATO Institute. 12 November 2018. .
• Wilper, Andrew P., et al. “U.S. National Library of Medicine.” December 2009. U.S. National Library of Medicine. 11 December 2018.

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Health Care Comes Home: The Human Factors (2011)

Chapter: 7 conclusions and recommendations.

7 Conclusions and Recommendations

Health care is moving into the home increasingly often and involving a mixture of people, a variety of tasks, and a broad diversity of devices and technologies; it is also occurring in a range of residential environments. The factors driving this migration include the rising costs of providing health care; the growing numbers of older adults; the increasing prevalence of chronic disease; improved survival rates of various diseases, injuries, and other conditions (including those of fragile newborns); large numbers of veterans returning from war with serious injuries; and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as its quality and cost.

The committee was charged with examining this major trend in health care delivery and resulting challenges from only one of many perspectives: the study of human factors. From the outset it was clear that the dramatic and evolving change in health care practice and policies presents a broad array of opportunities and problems. Consequently the committee endeavored to maintain focus specifically on how using the human factors approach can provide solutions that support maximizing the safety and quality of health care delivered in the home while empowering both care recipients and caregivers in the effort.

The conclusions and recommendations presented below reflect the most critical steps that the committee thinks should be taken to improve the state of health care in the home, based on the literature reviewed in this report examined through a human factors lens. They are organized into four areas: (1) health care technologies, including medical devices and health information technologies involved in health care in the home; (2)

caregivers and care recipients; (3) residential environments for health care; and (4) knowledge gaps that require additional research and development. Although many issues related to home health care could not be addressed, applications of human factors principles, knowledge, and research methods in these areas could make home health care safer and more effective and also contribute to reducing costs. The committee chose not to prioritize the recommendations, as they focus on various aspects of health care in the home and are of comparable importance to the different constituencies affected.

HEALTH CARE TECHNOLOGIES

Health care technologies include medical devices that are used in the home as well as information technologies related to home-based health care. The four recommendations in this area concern (1) regulating technologies for health care consumers, (2) developing guidance on the structure and usability of health information technologies, (3) developing guidance and standards for medical device labeling, and (4) improving adverse event reporting systems for medical devices. The adoption of these recommendations would improve the usability and effectiveness of technology systems and devices, support users in understanding and learning to use them, and improve feedback to government and industry that could be used to further improve technology for home care.

Ensuring the safety of emerging technologies is a challenge, in part because it is not always clear which federal agency has regulatory authority and what regulations must be met. Currently, the U.S. Food and Drug Administration (FDA) has responsibility for devices, and the Office of the National Coordinator for Health Information Technology (ONC) has similar authority with respect to health information technology. However, the dividing line between medical devices and health information technology is blurring, and many new systems and applications are being developed that are a combination of the two, although regulatory oversight has remained divided. Because regulatory responsibility for them is unclear, these products may fall into the gap.

The committee did not find a preponderance of evidence that knowledge is lacking for the design of safe and effective devices and technologies for use in the home. Rather than discovering an inadequate evidence base, we were troubled by the insufficient attention directed at the development of devices that account, necessarily and properly, for users who are inadequately trained or not trained at all. Yet these new users often must

rely on equipment without ready knowledge about limitations, maintenance requirements, and problems with adaptation to their particular home settings.

The increased prominence of the use of technology in the health care arena poses predictable challenges for many lay users, especially people with low health literacy, cognitive impairment, or limited technology experience. For example, remote health care management may be more effective when it is supported by technology, and various electronic health care (“e-health”) applications have been developed for this purpose. With the spectrum of caregivers ranging from individuals caring for themselves or other family members to highly experienced professional caregivers, computer-based care management systems could offer varying levels of guidance, reminding, and alerting, depending on the sophistication of the operator and the criticality of the message. However, if these technologies or applications are difficult to understand or use, they may be ignored or misused, with potentially deleterious effects on care recipient health and safety. Applying existing accessibility and usability guidelines and employing user-centered design and validation methods in the development of health technology products designed for use in the home would help ensure that they are safe and effective for their targeted user populations. In this effort, it is important to recognize how the line between medical devices and health information technologies has become blurred while regulatory oversight has remained distinct, and it is not always clear into which domain a product falls.

Recommendation 1. The U.S. Food and Drug Administration and the Office of the National Coordinator for Health Information Technology should collaborate to regulate, certify, and monitor health care applications and systems that integrate medical devices and health information technologies. As part of the certification process, the agencies should require evidence that manufacturers have followed existing accessibility and usability guidelines and have applied user-centered design and validation methods during development of the product.

Guidance and Standards

Developers of information technologies related to home-based health care, as yet, have inadequate or incomplete guidance regarding product content, structure, accessibility, and usability to inform innovation or evolution of personal health records or of care recipient access to information in electronic health records.

The ONC, in the initial announcement of its health information technology certification program, stated that requirements would be forthcom-

ing with respect both to personal health records and to care recipient access to information in electronic health records (e.g., patient portals). Despite the importance of these requirements, there is still no guidance on the content of information that should be provided to patients or minimum standards for accessibility, functionality, and usability of that information in electronic or nonelectronic formats.

Consequently, some portals have been constructed based on the continuity of care record. However, recent research has shown that records and portals based on this model are neither understandable nor interpretable by laypersons, even by those with a college education. The lack of guidance in this area makes it difficult for developers of personal health records and patient portals to design systems that fully address the needs of consumers.

Recommendation 2. The Office of the National Coordinator for Health Information Technology, in collaboration with the National Institute of Standards and Technology and the Agency for Healthcare Research and Quality, should establish design guidelines and standards, based on existing accessibility and usability guidelines, for content, accessibility, functionality, and usability of consumer health information technologies related to home-based health care.

The committee found a serious lack of adequate standards and guidance for the labeling of medical devices. Furthermore, we found that the approval processes of the FDA for changing these materials are burdensome and inflexible.

Just as many medical devices currently in use by laypersons in the home were originally designed and approved for use only by professionals in formal health care facilities, the instructions for use and training materials were not designed for lay users, either. The committee recognizes that lack of instructional materials for lay users adds to the level of risk involved when devices are used by populations for whom they were not intended.

Ironically, the FDA’s current premarket review and approval processes inadvertently discourage manufacturers from selectively revising or developing supplemental instructional and training materials, when they become aware that instructional and training materials need to be developed or revised for lay users of devices already approved and marketed. Changing the instructions for use (which were approved with the device) requires manufacturers to submit the device along with revised instructions to the FDA for another 510(k) premarket notification review. Since manufacturers can find these reviews complicated, time-consuming, and expensive, this requirement serves as a disincentive to appropriate revisions of instructional or training materials.

Furthermore, little guidance is currently available on design of user

training methods and materials for medical devices. Even the recently released human factors standard on medical device design (Association for the Advancement of Medical Instrumentation, 2009), while reasonably comprehensive, does not cover the topic of training or training materials. Both FDA guidance and existing standards that do specifically address the design of labeling and ensuing instructions for use fail to account for up-to-date findings from research on instructional systems design. In addition, despite recognition that requirements for user training, training materials, and instructions for use are different for lay and professional users of medical equipment, these differences are not reflected in current standards.

Recommendation 3. The U.S. Food and Drug Administration (FDA) should promote development (by standards development organizations, such as the International Electrotechnical Commission, the International Organization for Standardization, the American National Standards Institute, and the Association for the Advancement of Medical Instrumentation) of new standards based on the most recent human factors research for the labeling of and ensuing instructional materials for medical devices designed for home use by lay users. The FDA should also tailor and streamline its approval processes to facilitate and encourage regular improvements of these materials by manufacturers.

Adverse Event Reporting Systems

The committee notes that the FDA’s adverse event reporting systems, used to report problems with medical devices, are not user-friendly, especially for lay users, who generally are not aware of the systems, unaware that they can use them to report problems, and uneducated about how to do so. In order to promote safe use of medical devices in the home and rectify design problems that put care recipients at risk, it is necessary that the FDA conduct more effective postmarket surveillance of medical devices to complement its premarket approval process. The most important elements of their primarily passive surveillance system are the current adverse event reporting mechanisms, including Maude and MedSun. Entry of incident data by health care providers and consumers is not straightforward, and the system does not elicit data that could be useful to designers as they develop updated versions of products or new ones that are similar to existing devices. The reporting systems and their importance need to be widely promoted to a broad range of users, especially lay users.

Recommendation 4. The U.S. Food and Drug Administration should improve its adverse event reporting systems to be easier to use, to collect data that are more useful for identifying the root causes of events

related to interactions with the device operator, and to develop and promote a more convenient way for lay users as well as professionals to report problems with medical devices.

CAREGIVERS IN THE HOME

Health care is provided in the home by formal caregivers (health care professionals), informal caregivers (family and friends), and individuals who self-administer care; each type of caregiver faces unique issues. Properly preparing individuals to provide care at home depends on targeting efforts appropriately to the background, experience, and knowledge of the caregivers. To date, however, home health care services suffer from being organized primarily around regulations and payments designed for inpatient or outpatient acute care settings. Little attention has been given to how different the roles are for formal caregivers when delivering services in the home or to the specific types of training necessary for appropriate, high-quality practice in this environment.

Health care administration in the home commonly involves interaction among formal caregivers and informal caregivers who share daily responsibility for a person receiving care. But few formal caregivers are given adequate training on how to work with informal caregivers and involve them effectively in health decision making, use of medical or adaptive technologies, or best practices to be used for evaluating and supporting the needs of caregivers.

It is also important to recognize that the majority of long-term care provided to older adults and individuals with disabilities relies on family members, friends, or the individual alone. Many informal caregivers take on these responsibilities without necessary education or support. These individuals may be poorly prepared and emotionally overwhelmed and, as a result, experience stress and burden that can lead to their own morbidity. The committee is aware that informational and training materials and tested programs already exist to assist informal caregivers in understanding the many details of providing health care in the home and to ease their burden and enhance the quality of life of both caregiver and care recipient. However, tested materials and education, support, and skill enhancement programs have not been adequately disseminated or integrated into standard care practices.

Recommendation 5. Relevant professional practice and advocacy groups should develop appropriate certification, credentialing, and/or training standards that will prepare formal caregivers to provide care in the home, develop appropriate informational and training materials

for informal caregivers, and provide guidance for all caregivers to work effectively with other people involved.

RESIDENTIAL ENVIRONMENTS FOR HEALTH CARE

Health care is administered in a variety of nonclinical environments, but the most common one, particularly for individuals who need the greatest level and intensity of health care services, is the home. The two recommendations in this area encourage (1) modifications to existing housing and (2) accessible and universal design of new housing. The implementation of these recommendations would be a good start on an effort to improve the safety and ease of practicing health care in the home. It could improve the health and safety of many care recipients and their caregivers and could facilitate adherence to good health maintenance and treatment practices. Ideally, improvements to housing design would take place in the context of communities that provide transportation, social networking and exercise opportunities, and access to health care and other services.

Safety and Modification of Existing Housing

The committee found poor appreciation of the importance of modifying homes to remove health hazards and barriers to self-management and health care practice and, furthermore, that financial support from federal assistance agencies for home modifications is very limited. The general connection between housing characteristics and health is well established. For example, improving housing conditions to enhance basic sanitation has long been part of a public health response to acute illness. But the characteristics of the home can present significant barriers to autonomy or self-care management and present risk factors for poor health, injury, compromised well-being, and greater dependence on others. Conversely, physical characteristics of homes can enhance resident safety and ability to participate in daily self-care and to utilize effectively health care technologies that are designed to enhance health and well-being.

Home modifications based on professional home assessments can increase functioning, contribute to reducing accidents such as falls, assist caregivers, and enable chronically ill persons and people with disabilities to stay in the community. Such changes are also associated with facilitating hospital discharges, decreasing readmissions, reducing hazards in the home, and improving care coordination. Familiar modifications include installation of such items as grab bars, handrails, stair lifts, increased lighting, and health monitoring equipment as well as reduction of such hazards as broken fixtures and others caused by insufficient home maintenance.

Deciding on which home modifications have highest priority in a given

setting depends on an appropriate assessment of circumstances and the environment. A number of home assessment instruments and programs have been validated and proven to be effective to meet this need. But even if needed modifications are properly identified and prioritized, inadequate funding, gaps in services, and lack of coordination between the health and housing service sectors have resulted in a poorly integrated system that is difficult to access. Even when accessed, progress in making home modifications available has been hampered by this lack of coordination and inadequate reimbursement or financial mechanisms, especially for those who cannot afford them.

Recommendation 6. Federal agencies, including the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services, along with the U.S. Department of Housing and Urban Development and the U.S. Department of Energy, should collaborate to facilitate adequate and appropriate access to health- and safety-related home modifications, especially for those who cannot afford them. The goal should be to enable persons whose homes contain obstacles, hazards, or features that pose a home safety concern, limit self-care management, or hinder the delivery of needed services to obtain home assessments, home modifications, and training in their use.

Accessibility and Universal Design of New Housing

Almost all existing housing in the United States presents problems for conducting health-related activities because physical features limit independent functioning, impede caregiving, and contribute to such accidents as falls. In spite of the fact that a large and growing number of persons, including children, adults, veterans, and older adults, have disabilities and chronic conditions, new housing continues to be built that does not account for their needs (current or future). Although existing homes can be modified to some extent to address some of the limitations, a proactive, preventive, and effective approach would be to plan to address potential problems in the design phase of new and renovated housing, before construction.

Some housing is already required to be built with basic accessibility features that facilitate practice of health care in the home as a result of the Fair Housing Act Amendments of 1998. And 17 states and 30 cities have passed what are called “visitability” codes, which currently apply to 30,000 homes. Some localities offer tax credits, such as Pittsburgh through an ordinance, to encourage installing visitability features in new and renovated housing. The policy in Pittsburgh was impetus for the Pennsylvania Residential VisitAbility Design Tax Credit Act signed into law on October 28, 2006, which offers property owners a tax credit for new construction

and rehabilitation. The Act paves the way for municipalities to provide tax credits to citizens by requiring that such governing bodies administer the tax credit (Self-Determination Housing Project of Pennsylvania, Inc., n.d.).

Visitability, rather than full accessibility, is characterized by such limited features as an accessible entry into the home, appropriately wide doorways and one accessible bathroom. Both the International Code Council, which focuses on building codes, and the American National Standards Institute, which establishes technical standards, including ones associated with accessibility, have endorsed voluntary accessibility standards. These standards facilitate more jurisdictions to pass such visitability codes and encourage legislative consistency throughout the country. To date, however, the federal government has not taken leadership to promote compliance with such standards in housing construction, even for housing for which it provides financial support.

Universal design, a broader and more comprehensive approach than visitability, is intended to suit the needs of persons of all ages, sizes, and abilities, including individuals with a wide range of health conditions and activity limitations. Steps toward universal design in renovation could include such features as anti-scald faucet valve devices, nonslip flooring, lever handles on doors, and a bedroom on the main floor. Such features can help persons and their caregivers carry out everyday tasks and reduce the incidence of serious and costly accidents (e.g., falls, burns). In the long run, implementing universal design in more homes will result in housing that suits the long-term needs of more residents, provides more housing choices for persons with chronic conditions and disabilities, and causes less forced relocation of residents to more costly settings, such as nursing homes.

Issues related to housing accessibility have been acknowledged at the federal level. For example, visitability and universal design are in accord with the objectives of the Safety of Seniors Act (Public Law No. 110-202, passed in 2008). In addition, implementation of the Olmstead decision (in which the U.S. Supreme Court ruled that the Americans with Disabilities Act may require states to provide community-based services rather than institutional placements for individuals with disabilities) requires affordable and accessible housing in the community.

Visitability, accessibility, and universal design of housing all are important to support the practice of health care in the home, but they are not broadly implemented and incentives for doing so are few.

Recommendation 7. Federal agencies, such as the U.S. Department of Housing and Urban Development, the U.S. Department of Veterans Affairs, and the Federal Housing Administration, should take a lead role, along with states and local municipalities, to develop strategies that promote and facilitate increased housing visitability, accessibil-

ity, and universal design in all segments of the market. This might include tax and other financial incentives, local zoning ordinances, model building codes, new products and designs, and related policies that are developed as appropriate with standards-setting organizations (e.g., the International Code Council, the International Electrotechnical Commission, the International Organization for Standardization, and the American National Standards Institute).

RESEARCH AND DEVELOPMENT

In our review of the research literature, the committee learned that there is ample foundational knowledge to apply a human factors lens to home health care, particularly as improvements are considered to make health care safe and effective in the home. However, much of what is known is not being translated effectively into practice, neither in design of equipment and information technology or in the effective targeting and provision of services to all those in need. Consequently, the four recommendations that follow support research and development to address knowledge and communication gaps and facilitate provision of high-quality health care in the home. Specifically, the committee recommends (1) research to enhance coordination among all the people who play a role in health care practice in the home, (2) development of a database of medical devices in order to facilitate device prescription, (3) improved surveys of the people involved in health care in the home and their residential environments, and (4) development of tools for assessing the tasks associated with home-based health care.

Health Care Teamwork and Coordination

Frail elders, adults with disabilities, disabled veterans, and children with special health care needs all require coordination of the care services that they receive in the home. Home-based health care often involves a large number of elements, including multiple care providers, support services, agencies, and complex and dynamic benefit regulations, which are rarely coordinated. However, coordinating those elements has a positive effect on care recipient outcomes and costs of care. When successful, care coordination connects caregivers, improves communication among caregivers and care recipients and ensures that receivers of care obtain appropriate services and resources.

To ensure safe, effective, and efficient care, everyone involved must collaborate as a team with shared objectives. Well-trained primary health care teams that execute customized plans of care are a key element of coordinated care; teamwork and communication among all actors are also

essential to successful care coordination and the delivery of high-quality care. Key factors that influence the smooth functioning of a team include a shared understanding of goals, common information (such as a shared medication list), knowledge of available resources, and allocation and coordination of tasks conducted by each team member.

Barriers to coordination include insufficient resources available to (a) help people who need health care at home to identify and establish connections to appropriate sources of care, (b) facilitate communication and coordination among caregivers involved in home-based health care, and (c) facilitate communication among the people receiving and the people providing health care in the home.

The application of systems analysis techniques, such as task analysis, can help identify problems in care coordination systems and identify potential intervention strategies. Human factors research in the areas of communication, cognitive aiding and decision support, high-fidelity simulation training techniques, and the integration of telehealth technologies could also inform improvements in care coordination.

Recommendation 8 . The Agency for Healthcare Research and Quality should support human factors–based research on the identified barriers to coordination of health care services delivered in the home and support user-centered development and evaluation of programs that may overcome these barriers.

Medical Device Database

It is the responsibility of physicians to prescribe medical devices, but in many cases little information is readily available to guide them in determining the best match between the devices available and a particular care recipient. No resource exists for medical devices, in contrast to the analogous situation in the area of assistive and rehabilitation technologies, for which annotated databases (such as AbleData) are available to assist the provider in determining the most appropriate one of several candidate devices for a given care recipient. Although specialists are apt to receive information about devices specific to the area of their practice, this is much less likely in the case of family and general practitioners, who often are responsible for selecting, recommending, or prescribing the most appropriate device for use at home.

Recommendation 9. The U.S. Food and Drug Administration, in collaboration with device manufacturers, should establish a medical device database for physicians and other providers, including pharmacists, to use when selecting appropriate devices to prescribe or recommend

for people receiving or self-administering health care in the home. Using task analysis and other human factors approaches to populate the medical device database will ensure that it contains information on characteristics of the devices and implications for appropriate care recipient and device operator populations.

Characterizing Caregivers, Care Recipients, and Home Environments

As delivery of health care in the home becomes more common, more coherent strategies and effective policies are needed to support the workforce of individuals who provide this care. Developing these will require a comprehensive understanding of the number and attributes of individuals engaged in health care in the home as well as the context in which care is delivered. Data and data analysis are lacking to accomplish this objective.

National data regarding the numbers of individuals engaged in health care delivery in the home—that is, both formal and informal caregivers—are sparse, and the estimates that do exist vary widely. Although the Bureau of Labor Statistics publishes estimates of the number of workers employed in the home setting for some health care classifications, they do not include all relevant health care workers. For example, data on workers employed directly by care recipients and their families are notably absent. Likewise, national estimates of the number of informal caregivers are obtained from surveys that use different methodological approaches and return significantly different results.

Although numerous national surveys have been designed to answer a broad range of questions regarding health care delivery in the home, with rare exceptions such surveys reflect the relatively limited perspective of the sponsoring agency. For example,

• The Medicare Current Beneficiary Survey (administered by the Centers for Medicare & Medicaid Services) and the Health and Retirement Survey (administered by the National Institute on Aging) are primarily geared toward understanding the health, health services use, and/or economic well-being of older adults and provide no information regarding working-age adults or children or information about home or neighborhood environments.
• The Behavioral Risk Factors Surveillance Survey (administered by the Centers for Disease Control and Prevention, CDC), the National Health Interview Survey (administered by the CDC), and the National Children’s Study (administered by the U.S. Department of Health and Human Services and the U.S. Environmental Protection Agency) all collect information on health characteristics, with limited or no information about the housing context.
• The American Housing Survey (administered by the U.S. Department of Housing and Urban Development) collects detailed information regarding housing, but it does not include questions regarding the health status of residents and does not collect adequate information about home modifications and features on an ongoing basis.

Consequently, although multiple federal agencies collect data on the sociodemographic and health characteristics of populations and on the nation’s housing stock, none of these surveys collects data necessary to link the home, its residents, and the presence of any caregivers, thus limiting understanding of health care delivered in the home. Furthermore, information is altogether lacking about health and functioning of populations linked to the physical, social, and cultural environments in which they live. Finally, in regard to individuals providing care, information is lacking regarding their education, training, competencies, and credentialing, as well as appropriate knowledge about their working conditions in the home.

Better coordination across government agencies that sponsor such surveys and more attention to information about health care that occurs in the home could greatly improve the utility of survey findings for understanding the prevalence and nature of health care delivery in the home.

Recommendation 10. Federal health agencies should coordinate data collection efforts to capture comprehensive information on elements relevant to health care in the home, either in a single survey or through effective use of common elements across surveys. The surveys should collect data on the sociodemographic and health characteristics of individuals receiving care in the home, the sociodemographic attributes of formal and informal caregivers and the nature of the caregiving they provide, and the attributes of the residential settings in which the care recipients live.

Tools for Assessing Home Health Care Tasks and Operators

Persons caring for themselves or others at home as well as formal caregivers vary considerably in their skills, abilities, attitudes, experience, and other characteristics, such as age, culture/ethnicity, and health literacy. In turn, designers of health-related devices and technology systems used in the home are often naïve about the diversity of the user population. They need high-quality information and guidance to better understand user capabilities relative to the task demands of the health-related device or technology that they are developing.

In this environment, valid and reliable tools are needed to match users with tasks and technologies. At this time, health care providers lack the

tools needed to assess whether particular individuals would be able to perform specific health care tasks at home, and medical device and system designers lack information on the demands associated with health-related tasks performed at home and the human capabilities needed to perform them successfully.

Whether used to assess the characteristics of formal or informal caregivers or persons engaged in self-care, task analysis can be used to develop point-of-care tools for use by consumers and caregivers alike in locations where such tasks are encouraged or prescribed. The tools could facilitate identification of potential mismatches between the characteristics, abilities, experiences, and attitudes that an individual brings to a task and the demands associated with the task. Used in ambulatory care settings, at hospital discharge or other transitions of care, and in the home by caregivers or individuals and family members themselves, these tools could enable assessment of prospective task performer’s capabilities in relation to the demands of the task. The tools might range in complexity from brief screening checklists for clinicians to comprehensive assessment batteries that permit nuanced study and tracking of home-based health care tasks by administrators and researchers. The results are likely to help identify types of needed interventions and support aids that would enhance the abilities of individuals to perform health care tasks in home settings safely, effectively, and efficiently.

Recommendation 11. The Agency for Healthcare Research and Quality should collaborate, as necessary, with the National Institute for Disability and Rehabilitation Research, the National Institutes of Health, the U.S. Department of Veterans Affairs, the National Science Foundation, the U.S. Department of Defense, and the Centers for Medicare & Medicaid Services to support development of assessment tools customized for home-based health care, designed to analyze the demands of tasks associated with home-based health care, the operator capabilities required to carry them out, and the relevant capabilities of specific individuals.

Association for the Advancement of Medical Instrumentation. (2009). ANSI/AAMI HE75:2009: Human factors engineering: Design of medical devices. Available: http://www.aami.org/publications/standards/HE75_Ch16_Access_Board.pdf [April 2011].

Self-Determination Housing Project of Pennsylvania, Inc. (n.d.) Promoting visitability in Pennsylvania. Available: http://www.sdhp.org/promoting_visitability_in_pennsy.htm [March 30, 2011].

In the United States, health care devices, technologies, and practices are rapidly moving into the home. The factors driving this migration include the costs of health care, the growing numbers of older adults, the increasing prevalence of chronic conditions and diseases and improved survival rates for people with those conditions and diseases, and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as in its quality and cost.

Health Care Comes Home reviews the state of current knowledge and practice about many aspects of health care in residential settings and explores the short- and long-term effects of emerging trends and technologies. By evaluating existing systems, the book identifies design problems and imbalances between technological system demands and the capabilities of users. Health Care Comes Home recommends critical steps to improve health care in the home. The book's recommendations cover the regulation of health care technologies, proper training and preparation for people who provide in-home care, and how existing housing can be modified and new accessible housing can be better designed for residential health care. The book also identifies knowledge gaps in the field and how these can be addressed through research and development initiatives.

Health Care Comes Home lays the foundation for the integration of human health factors with the design and implementation of home health care devices, technologies, and practices. The book describes ways in which the Agency for Healthcare Research and Quality (AHRQ), the U.S. Food and Drug Administration (FDA), and federal housing agencies can collaborate to improve the quality of health care at home. It is also a valuable resource for residential health care providers and caregivers.

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Dylan Scott answers 9 key questions about universal health care around the world

Vox policy reporter Dylan Scott traveled to Taiwan, Australia, and the Netherlands to see their health systems.

by Lauren Katz

Vox policy reporter Dylan Scott traveled the world last fall to explore what the US can learn from other countries’ health systems , visiting Taiwan, Australia, and the Netherlands. His trips were the foundation for Everybody Covered , a Vox series on health care that also reported on health systems in the United Kingdom and Maryland .

Dylan did a Reddit Ask Me Anything session on Wednesday, January 29, discussing everything from how countries pay for universal health care to what it will take to achieve further health care reform in America. Here’s a roundup of some of the most interesting questions and answers, lightly edited for clarity.

1) How do countries pay for public health insurance?

Icantnotthink: Where does the payment for public health care come from in other countries?

Dylan: Most of these countries use some mix of 1) payroll taxes for individuals, 2) employer contributions, and 3) general government revenue and progressive/sin taxes. To be honest, there isn’t one model to follow. Each country had its own health funding plan that has since been reformed to meet the needs of their current system, just as the US would. But other countries are looking for health care dollars in many of the same places Medicare-for-all supporters think we should here.

2) When it comes to covering everyone, is a country’s population density important?

Verybalnduser: How important would you say a country’s population density is to keeping total cost down?

Dylan Scott: It’s a huge asset. Taiwan has been able to keep its overall spending low — people on the left would say their single-payer program is actually underfunded — and cost sharing low for patients in large part because its urbanized nature makes it easier for a smaller workforce to meet the needs of its patient population. The Netherlands has been very innovative in delivery reforms, meant to keep costs in check, something that’s clearly been aided by its density. Australia , on the other hand, even with a universal public insurance plan, has still struggled with access in its more rural areas.

3) Is there a lot of paperwork in a single-payer system?

ZenBacle: How much paperwork do patients in single-payer systems have to fill out? And how much time do those patients have to spend fighting with health care providers to get them to honor their coverage?

Dylan Scott: One of the benefits of single-payer is there’s a lot less administration. We visited a hospital in Taipei, Taiwan, and while all the clinic lobbies were full, the cashier’s desk was basically empty. One survey finding that stuck out to me showed the doctors in the Netherlands (with private insurance) are more annoyed about paperwork than their peers in more socialized systems. So while I wouldn’t want to try to quantify it off the top of my head, there seems to be less of a paperwork headache.

The Pandemic Playbook Vox explores the successes — and setbacks — in six nations as they fought Covid-19.

• Taiwan’s single-payer success story — and its lessons for America
• Two sisters. Two different journeys through Australia’s health care system.
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• In the UK’s health system, rationing isn’t a dirty word

4) Between Taiwan, Australia, and the Netherlands, which policy would translate most easily to the US?

Doctor_YOOOOU: Which of these universal health care systems is “closest” in terms of the amount of reform required to the United States?

Dylan: This is a tricky one — no country looks much like the US status quo. The Netherlands does have a lot of the same features as Obamacare (ban on preexisting conditions, individual mandate, government assistance to cover the costs), but it’s available to everybody and it’s stricter. The mandate penalty is harsher, the government rules on cost sharing are more stringent, and the government actually helps set prices and an overall budget for health care. So it’s much more involved than the US government is in administering that private health insurance. And almost all of the insurers are nonprofits.

So we’re talking about huge changes to move the US system to something that looks more like the Dutch — and that’s one I’d name as closest (along with Japan) to what we have right now.

5) Do solutions exist within the US that can be applied to the rest of the country?

Blakestonefeather: You traveled the world to explore what the US can learn, but did you also travel the US to learn if the US can learn? [In other words,] what are the barriers we in America face to learning/being able to learn?

Dylan Scott: We actually did one story in the US, on Maryland’s unique system for paying hospitals . (Every insurer — private, Medicare and Medicaid — pays the same rates for the same services.)

But there is a huge challenge in translating policies from abroad to the US. Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.

Then you’ve got political differences; Princeton economist Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in Congress in the face of industry opposition is certainly a warning sign to any aspiring reformers.

So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.

• 9 things Americans need to learn from the rest of the world’s health care systems

6) What does the American health care system get right?

taksark: What’s something good about the American health care system that could be kept and improved on in a better version?

Dylan Scott: The geographic immensity of the US has forced a lot of experimentation with telemedicine, and that is both a necessity and an area where other countries have tried to draw from what the US has done. I heard a lot from doctors about coming to the US to learn the latest on best practices for delivering care.

I think the US is still seen as a leader in innovative medicine — the question is why can’t we give more people access to it?

7) Besides America, what other countries have private health insurance?

To_Much_Too_Soon: How many other countries besides America have private health insurance?

Dylan: The US relies much more on private health insurance than any other country I’m aware of. About half of US citizens depend on private insurance as their primary coverage, and about 8 percent of our GDP is private health spending; most other developed economies don’t top 4 percent of GDP for private spending.

There are countries like the Netherlands with universal private insurance. But their private insurance is a lot different than ours: Almost all of the insurers are nonprofits, the government sets rules about premiums and cost sharing, there is a global budget for health care costs, etc.

Some countries with single-payer programs, like Australia, allow private insurance as a supplement — so you can get more choice in doctor or can skip the line for surgery. But no developed economy I know of is so dependent on private insurance as the US and with comparatively few regulations about its benefits.

8) What surprised you the most throughout your reporting?

JoseyGunner: What shocked you the most during your travels?

Dylan Scott: I was surprised how often people I talked to were shocked by the worst parts of US health care. The uninsured rates, the deductibles we have to pay, the very idea of a surprise medical bill — all of it was unfathomable to many of the people I met.

9) What are the biggest hurdles to any future health reforms in the US?

Flogopickles: What do you see as America’s biggest hurdle to achieving any sort of movement in affordable care for our citizens?

Dylan Scott: The status quo is powerful for two reasons: One, it’s good enough for enough people that big change feels like a risky proposition to a lot of the population and, two, health industry interests are so influential in Washington, DC. Overcoming those two things — people’s inherent aversion to risk in health care and the power of industry to constrain policymaking, especially price constraints for medical care — are the biggest hurdles to any future health reforms.

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Healthcare is a human right – but not in the United States

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The Supreme Court’s ruling on Dobbs v. Jackson in June is just the latest blow to health rights in the United States. National medical associations in the U.S. agree that abortion is essential to reproductive healthcare. So why would abortion not be protected as such? Because the U.S. does not, and never has, protected a right to health.  

Good health is the foundation of a person’s life and liberty. Injury and disease are always disruptive, and sometimes crippling. We might have to stop working, cancel plans, quarantine, hire help, and in cases of long-term disability, build whole new support systems to accommodate a new normal.

The U.S. remains the only high-income nation in the world without universal access to healthcare. However, the U.S. has signed and ratified one of the most widely adopted international treaties that includes the duty to protect the right to life. Under international law, the right to life simply means that humans have a right to live, and that nobody can try to kill another. Healthcare, the United Nations says, is an essential part of that duty. In 2018, the U.N. Committee on Civil and Political Rights said the right to life cannot exist without equal access to affordable healthcare services (including in prisons), mental health services, and notably, access to abortion. The U.N. committee mentioned health more than a dozen times in its statement on the right to life.

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The bottom line is: the U.S. can’t claim to protect life if it fails to protect health. And it has consistently failed on all three of the U.N.’s measures— the latest being access to abortion.

In the U.S., our debates around healthcare, and especially abortion, are hampered by a lack of right to health. Instead, the Supreme Court in 1973 protected access to abortion through the rights to privacy and due process, not health. Privacy is mentioned only twice by the U.N. committee commentary on the right to life.

Since Dobbs, several state legislatures have declared it fair game to criminalize abortion procedures even in cases where pregnancy threatens maternal health or life. Despite ample evidence that restrictive abortion laws lead to spikes in maternal mortality and morbidity—core public health indicators—the Court prior to the Dobb’s decision has defended abortion as merely a matter of privacy, not health or life. We know this is a myth. Abortion is deeply tied to the ability to stay healthy and in some cases, alive.

Regardless, our political parties remain deeply polarized on access to healthcare, including abortion. But lawmakers should know there is historical backing in the U.S. for elevating a right to health. None other than U.S. president Franklin D. Roosevelt, first proposed healthcare as a human right in his State of the Union address in 1944, as part of his ‘Second Bill of Rights.’ His list featured aspirational economic and social guarantees to the American people, like the right to a decent home and, of course, the right to adequate medical care.

Eleanor Roosevelt later took the Second Bill of Rights to the U.N., where it contributed to the right to health being included in the Universal Declaration of Human Rights in 1948. The right to health is now accepted international law, and is part of numerous treaties, none of which the U.S. Senate has seen fit to ratify. The U.S. conservative movement has historically declared itself averse to adopting rights that might expand government function and responsibility. In contrast, state legislatures in red states are keen to expand government responsibility when it comes to abortion. The conservative movement condemns government interference in the delivery of healthcare—except when it comes to reproductive health. The American Medical Association has called abortion bans a “direct attack” on medicine, and a “brazen violation of patients’ rights to evidence-based reproductive health services.”

Excepting access to abortion, U.S. lawmakers have largely left healthcare to the markets, rather than government. True, the government funds programs like Medicaid and Medicare but these programs vary significantly in quality and access by state, falling far short of providing fair, equitable, universal access to good healthcare.

The only two places where the U.S. government accepts some responsibility for the provision of healthcare are 1) in prisons and mental health facilities; and 2) in the military. While healthcare services in the U.S. prison system are notoriously deficient, they nevertheless exist and are recognized as an entitlement, underpinning the right to life. As an example, in 2005 a federal court seized control of the failing healthcare system in California’s Department of Corrections citing preventable deaths. In the military, free healthcare is an entitlement, and the quality of that care is deemed good enough even for the U.S. president.

So why doesn’t everyone in the U.S. have the same rights?

It is an uphill battle in a country that sees health and healthcare as a private matter for markets and individuals to navigate. But if we want to improve public health in the U.S. we need to start legislating healthcare as a right—and recognize that achieving the highest possible standards of public health is a legitimate government function.

photo: Tony Gutierrez / AP Photo

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15.10 Persuasive Essay

Learning objective.

• Read an example of the persuasive rhetorical mode.

Universal Health Care Coverage for the United States

The United States is the only modernized Western nation that does not offer publicly funded health care to all its citizens; the costs of health care for the uninsured in the United States are prohibitive, and the practices of insurance companies are often more interested in profit margins than providing health care. These conditions are incompatible with US ideals and standards, and it is time for the US government to provide universal health care coverage for all its citizens. Like education, health care should be considered a fundamental right of all US citizens, not simply a privilege for the upper and middle classes.

One of the most common arguments against providing universal health care coverage (UHC) is that it will cost too much money. In other words, UHC would raise taxes too much. While providing health care for all US citizens would cost a lot of money for every tax-paying citizen, citizens need to examine exactly how much money it would cost, and more important, how much money is “too much” when it comes to opening up health care for all. Those who have health insurance already pay too much money, and those without coverage are charged unfathomable amounts. The cost of publicly funded health care versus the cost of current insurance premiums is unclear. In fact, some Americans, especially those in lower income brackets, could stand to pay less than their current premiums.

However, even if UHC would cost Americans a bit more money each year, we ought to reflect on what type of country we would like to live in, and what types of morals we represent if we are more willing to deny health care to others on the basis of saving a couple hundred dollars per year. In a system that privileges capitalism and rugged individualism, little room remains for compassion and love. It is time that Americans realize the amorality of US hospitals forced to turn away the sick and poor. UHC is a health care system that aligns more closely with the core values that so many Americans espouse and respect, and it is time to realize its potential.

Another common argument against UHC in the United States is that other comparable national health care systems, like that of England, France, or Canada, are bankrupt or rife with problems. UHC opponents claim that sick patients in these countries often wait in long lines or long wait lists for basic health care. Opponents also commonly accuse these systems of being unable to pay for themselves, racking up huge deficits year after year. A fair amount of truth lies in these claims, but Americans must remember to put those problems in context with the problems of the current US system as well. It is true that people often wait to see a doctor in countries with UHC, but we in the United States wait as well, and we often schedule appointments weeks in advance, only to have onerous waits in the doctor’s “waiting rooms.”

Critical and urgent care abroad is always treated urgently, much the same as it is treated in the United States. The main difference there, however, is cost. Even health insurance policy holders are not safe from the costs of health care in the United States. Each day an American acquires a form of cancer, and the only effective treatment might be considered “experimental” by an insurance company and thus is not covered. Without medical coverage, the patient must pay for the treatment out of pocket. But these costs may be so prohibitive that the patient will either opt for a less effective, but covered, treatment; opt for no treatment at all; or attempt to pay the costs of treatment and experience unimaginable financial consequences. Medical bills in these cases can easily rise into the hundreds of thousands of dollars, which is enough to force even wealthy families out of their homes and into perpetual debt. Even though each American could someday face this unfortunate situation, many still choose to take the financial risk. Instead of gambling with health and financial welfare, US citizens should press their representatives to set up UHC, where their coverage will be guaranteed and affordable.

Despite the opponents’ claims against UHC, a universal system will save lives and encourage the health of all Americans. Why has public education been so easily accepted, but not public health care? It is time for Americans to start thinking socially about health in the same ways they think about education and police services: as rights of US citizens.

Online Persuasive Essay Alternatives

Martin Luther King Jr. writes persuasively about civil disobedience in Letter from Birmingham Jail :

• http://www.stanford.edu/group/King/frequentdocs/birmingham.pdf
• http://web.cn.edu/kwheeler/documents/Letter_Birmingham_Jail.pdf
• http://www.oak-tree.us/stuff/King-Birmingham.pdf

Michael Levin argues The Case for Torture :

• http://people.brandeis.edu/~teuber/torture.html

Alan Dershowitz argues The Case for Torture Warrants :

• http://blogs.reuters.com/great-debate/2011/09/07/the-case-for-torture-warrants/

Alisa Solomon argues The Case against Torture :

• http://www.villagevoice.com/2001-11-27/news/the-case-against-torture/1

Writing for Success Copyright © 2015 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Billions left behind on the path to universal health coverage

The World Health Organization (WHO) and the World Bank have jointly published the 2023 Universal Health Coverage (UHC) Global Monitoring Report, revealing an alarming stagnation in the progress towards providing people everywhere with quality, affordable, and accessible health care.

Released ahead of the High-Level Meeting on UHC at the 78 th United Nations General Assembly, this report exposes a stark reality based on the latest available evidence – more than half of the world’s population is still not covered by essential health services. Furthermore, 2 billion people face severe financial hardship when paying out-of-pocket for the services and products they needed. 

"The COVID-19 pandemic was a reminder that healthy societies and economies depend on healthy people," said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. "The fact that so many people cannot benefit from affordable, quality, essential health services not only puts their own health at risk, it also puts the stability of communities, societies and economies at risk, We urgently need stronger political will, more aggressive investments in health, and a decisive shift to transform health systems based on primary health care."

The 2023 report found that, over the past two decades, less than a third of countries have improved health service coverage and reduced catastrophic out-of-pocket health spending. Moreover, most countries for which data are available on both UHC dimensions (96 out of 138) are off-track in either service coverage, financial protection, or both.

“We know that achieving universal health coverage is a critical step in helping people escape and stay out of poverty, yet there continues to be increased financial hardship, especially for the poorest and most vulnerable people,” said Mamta Murthi, Vice President for Human Development, World Bank. “This report paints a dire picture, but also offers evidence on ways to prioritize health in government budgets and strengthen health systems for greater equity in both the delivery of essential quality health services and financial protection.”

Slowing expansion of essential health services

While health service coverage improved since the beginning of the century, progress has slowed since 2015, when the Sustainable Development Goals were adopted. Notably, there was no improvement from 2019 to 2021. While services for infectious diseases saw significant gains since 2000, there has been little to no improvement in service coverage for noncommunicable diseases and reproductive, maternal, newborn, and child health services in recent years. In 2021, about 4.5 billion people, more than half of the global population, were not fully covered by essential health services. And this estimate does not yet reflect the potential long-term impacts of the COVID-19 pandemic.

Financial hardship due to out-of-pocket health spending is worsening

Catastrophic out-of-pocket health spending, defined as exceeding 10% of a household budget, continues to rise. More than one billion people, about 14% of the global population, experienced such large out-of-pocket payments relative to their budgets. But even small expenditures in absolute terms can be devastating for low-income families; approximately 1.3 billion individuals were pushed or further pushed into poverty by such payments, including 300 million people who were already living in extreme poverty.

Out-of-pocket health payments can also cause individuals to forego essential care and force families to choose between paying for a visit to the doctor, buying food and water, or sending their children to school. Such trade-offs can spell the difference between the early treatment of a preventable disease and, at a later stage, suffering severe illness or even death. Addressing this problem requires progressive health financing policies that exempt those with limited ability to pay for health services.

Getting back on track

Achieving universal health coverage by 2030 is crucial for fulfilling the promise of the 2030 Agenda for Sustainable Development and realizing the fundamental human right to health.

To reach the goal of UHC, substantial public sector investment and accelerated action by governments and development partners are essential. Key actions include a radical reorientation of health systems towards a primary health care approach, advancing equity in health-care access and financial protection, and investing in robust health information systems.

These shifts are essential to counter the impact of COVID-19 on health systems and the health workforce globally, as well as the new challenges posed by macroeconomic, climate, demographic, and political trends that threaten hard-won health gains worldwide.

The 2023 UHC Global Monitoring Report serves as a wake-up call to the global community, highlighting the urgent need to prioritize and invest in UHC to ensure that everyone gains access to quality, affordable, and accessible healthcare without suffering financial hardship.

Read the full report:   Universal Health Coverage Global Monitoring Report 2023

Watch the launch:   Universal Health Coverage Global Monitoring Report 2023

Watch the video:  2023 Universal Health Coverage Global Monitoring Report

About the World Health Organization  

Dedicated to the well-being of all people and guided by science, the World Health Organization leads and champions global efforts to give everyone, everywhere an equal chance at a safe and healthy life. We are the UN agency for health that connects nations, partners and people on the front lines in 150+ locations – leading the world’s response to health emergencies, preventing disease, addressing the root causes of health issues and expanding access to medicines and health care. Our mission is to promote health, keep the world safe and serve the vulnerable.

www.who.int    

About the World Bank

The World Bank provides financing, global knowledge, and long-term commitment to help low- and middle-income countries end poverty, achieve sustainable growth, and invest in opportunity for all. We comprise the International Bank for Reconstruction and Development (IBRD), the world’s largest development bank, and the International Development Association (IDA), one of the largest sources of funding for the world’s poorest countries. With the other World Bank institutions as well as partners across the public and private sectors, we are helping build solutions to the global challenges of the 21st century in all major sectors of development. A world where no one lives in poverty and everyone has the opportunity for a better life is within our reach.

www.worldbank.org

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World Bank Washington DC

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Guest Essay

We’re Already Paying for Universal Health Care. Why Don’t We Have It?

By Liran Einav and Amy Finkelstein

Dr. Einav is a professor of economics at Stanford. Dr. Finkelstein is a professor of economics at the Massachusetts Institute of Technology.

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured, and more than twice that number will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance; make sure all insurance plans meet some minimum standards; change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde.

The risk of losing coverage is an inevitable consequence of a lack of universal coverage. Whenever there are varied pathways to eligibility, there will be many people who fail to find their path.

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Home — Essay Samples — Nursing & Health — Health Care — Universal Health Care

Universal Health Care Essay Examples

Writing an essay about Universal Health Care can help you understand the issues and come up with solutions to improve healthcare for all. It's a hot topic that needs attention, so why not dive into it and make a difference with your words?

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Now, let's talk about the different types of essays you can write about Universal Health Care. If you're into debating and presenting different viewpoints, an argumentative essay might be right up your alley. For those who like to explore the causes and effects of an issue, a cause and effect essay could be a great choice. If you want to express your personal thoughts and feelings, an opinion essay might be the way to go. And if you're all about providing facts and information, an informative essay could be your best bet.

Let's say you're ready to dive into writing your essay. You might be wondering how to structure it and what to include. Well, let me give you a few examples. For a thesis statement on Universal Health Care, you could focus on topics like the impact of Universal Health Care on the economy, the ethical implications of providing healthcare for all, or the importance of accessibility to healthcare services. And when it comes to the , you could start by discussing the current state of healthcare and then lead into your thesis statement. Finally, for the , you could summarize your main points and reiterate the importance of Universal Health Care for the well-being of society. With these examples, you'll be well on your way to writing a stellar essay on Universal Health Care.

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MIA   >  Archive   >  Pashukanis

Evgeny Pashukanis

Marksistskaia teoriia gosudarstva i prava , pp.9-44 in E. B. Pashukanis (ed.), Uchenie o gosudarstve i prave (1932), Partiinoe Izd., Moscow. From Evgeny Pashukanis, Selected Writings on Marxism and Law (eds. P. Beirne & R. Sharlet), London & New York 1980, pp.273-301. Translated by Peter B. Maggs . Copyright © Peter B. Maggs. Published here by kind permission of the translator. Downloaded from home.law.uiuc.edu/~pmaggs/pashukanis.htm Marked up by Einde O’Callaghan for the Marxists’ Internet Archive .

Introductory Note

In the winter of 1929-1930, during the first Five Year Plan, the national economy of the USSR underwent dramatic and violent ruptures with the inauguration of forced collectivization and rapid heavy industrialization. Concomitantly, it seemed, the Party insisted on the reconstruction and realignment of the appropriate superstructures in conformity with the effectuation of these new social relations of production. In this spirit Pashukanis was no longer criticized but now overtly attacked in the struggle on the “legal front”. In common with important figures in other intellectual disciplines, such as history, in late 1930 Pashukanis undertook a major self-criticism which was qualitatively different from the incremental changes to his work that he had produced earlier. During the following year, 1931, Pashukanis outlined this theoretical reconstruction in his speech to the first conference of Marxist jurists, a speech entitled Towards a Marxist-Leninist Theory of Law . The first results appeared a year later in a collective volume The Doctrine of State and Law .

Chapter I of this collective work is translated below, The Marxist Theory of State and Law , and was written by Pashukanis himself It should be noted that this volume exemplifies the formal transformations which occurred in Soviet legal scholarship during this heated period. Earlier, Pashukanis and other jurists had authored their own monographs; the trend was now towards a collective scholarship which promised to maximize individual safety. The source of authority for much of the work that ensued increasingly became the many expressions of Stalin’s interpretation of Bolshevik history, class struggle and revisionism, most notably his Problems of Leninism . Last, but not least, the language and vocabulary of academic discourse in the 1920s had been rich, open-ended and diverse, and varied tremendously with the personal preferences of the individual author; this gave way to a standardized and simplified style of prose devoid of nuance and ambiguity, and which was very much in keeping with the new theoretical content which comprised official textbooks on the theory of state and law. The reader will perhaps discover that The Marxist Theory of State and Law is a text imbued with these tensions. Pashukanis’ radical reconceptualization of the unity of form and content, and of the ultimate primacy of the relations of production, is without doubt to be preferred to his previous notions. But this is a preference guided by the advantages of editorial hindsight, and we feel that we cannot now distinguish between those reconceptualizations which Pashukanis may actually have intended and those which were produced by the external pressures of political opportunism.

CHAPTER I Socio-economic Formations, State, and Law

1. the doctrine of socio-economic formations as a basis for the marxist theory of state and law.

The doctrine of state and law is part of a broader whole, namely, the complex of sciences which study human society. The development of these sciences is in turn determined by the history of society itself, i.e. by the history of class struggle.

It has long since been noted that the most powerful and fruitful catalysts which foster the study of social phenomena are connected with revolutions. The English Revolution of the seventeenth century gave birth to the basic directions of bourgeois social thought, and forcibly advanced the scientific, i.e. materialist, understanding of social phenomena.

It suffices to mention such a work as Oceana – by the English writer Harrington, and which appeared soon after the English Revolution of the seventeenth century – in which changes in political structure are related to the changing distribution of landed property. It suffices to mention the work of Barnave – one of the architects of the great French Revolution – who in the same way sought explanations of political struggle and the political order in property relations. In studying bourgeois revolutions, French restorationist historians – Guizot, Mineaux and Thierry – concluded that the leitmotif of these revolutions was the class struggle between the third estate (i.e. the bourgeoisie) and the privileged estates of feudalism and their monarch. This is why Marx, in his well-known letter to Weydemeyer, indicates that the theory of the class struggle was known before him. “As far as I am concerned”, he wrote,

no credit is due to me for discovering the existence of classes in modern society, or the struggle between them. Long before me bourgeois historians had described the historical development of this class struggle, and bourgeois economists the economic anatomy of the classes.

What I did that was new was to prove: (1) that the existence of classes is only bound up with particular historical forms of struggle in the development of production ...; (2) that the class struggle inevitably leads to the dictatorship of the proletariat; (3) that this dictatorship itself only constitutes the transition to the abolition of all classes and the establishment of a classless society. [1]

[ Section 2 omitted – eds. ]

  Top of the page  

3. The class type of state and the form of government

The doctrine of socio-economic formations is particularly important to Marx’s theory of state and law, because it provides the basis for the precise and scientific delineation of the different types of state and the different systems of law.

Bourgeois political and juridical theorists attempt to establish a classification of political and legal forms without scientific criteria; not from the class essence of the forms, but from more or less external characteristics. Bourgeois theorists of the state, assiduously avoiding the question of the class nature of the state, propose every type of artificial and scholastic definition and conceptual distinction. For instance, in the past, textbooks on the state divided the state into three “elements”: territory, population and power.

Some scholars go further. Kellen – one of the most recent Swedish theorists of the state – distinguishes five elements or phenomena of the state: territory, people, economy, society and, finally, the state as the formal legal subject of power. All these definitions and distinctions of elements, or aspects of the state, are no more than a scholastic game of empty concepts since the main point is absent: the division of society into classes, and class domination. Of course, the state cannot exist without population, or territory, or economy, or society. This is an incontrovertible truth. But, at the same time, it is true that all these “elements” existed at that stage of development when there was no state. Equally, classless communist society – having territory, population and an economy – will do without the state since the necessity of class suppression will disappear.

The feature of power, or coercive power, also tells one exactly nothing. Lenin, in his polemic of the 1890s with Struve asserted that: “he most incorrectly sees the distinguishing feature of the state as coercive power. Coercive power exists in every human society – both in the tribal structure and in the family, but there was no state.” And further, Lenin concludes: “The distinguishing feature of the state is the existence of a separate class of people in whose hands power is concentrated. Obviously, no one could use the term ‘State’ in reference to a community in which the ‘organization of order’ is administered in turn by all of its members.” [2]

Struve’s position, according to which the distinguishing feature of a state is coercive power, was not without reason termed “professorial” by Lenin. Every bourgeois science of the state is full of conclusions on the essence of this coercive power. Disguising the class character of the state, bourgeois scholars interpret this coercion in a purely psychological sense. “For power and subordination”, wrote one of the Russian bourgeois jurists (Lazarevsky), “two elements are necessary: the consciousness of those exercising power that they have the right to obedience, and the consciousness of the subordinates that they must obey.”

From this, Lazarevsky and other bourgeois jurists reached the following conclusion: state power is based upon the general conviction of citizens that a specific state has the right to issue its decrees and laws. Thus, the real fact-concentration of the means of force and coercion in the hands of a particular class-is concealed and masked by the ideology of the bourgeoisie. While the feudal landowning state sanctified its power by the authority of religion, the bourgeoisie uses the fetishes of statute and law. In connection with this, we also find the theory of bourgeois jurists-which now has been adopted in its entirety by the Social Democrats whereby the state is viewed as an agency acting in the interests of the whole society. “If the source of state power derives from class”, wrote another of the bourgeois jurists (Magaziner), “then to fulfil its tasks it must stand above the class struggle. Formally, it is the arbiter of the class struggle, and even more than that: it develops the rules of this struggle.”

It is precisely this false theory of the supra-class nature of the state that is used for the justification of the treacherous policy of the Social Democrats. In the name “of the general interest”, Social Democrats deprive the unemployed of their welfare payments, help in reducing wages, and encourage shooting at workers’ demonstrations.

Not wishing to recognize the basic fact, i.e. that states differ according to their class basis, bourgeois theorists of the state concentrate all their attention on various forms of government. But this difference by itself is worthless. Thus, for instance, in ancient Greece and ancient Rome we have the most varied forms of government. But all the transitions from monarchy to republic, from aristocracy to democracy, which we observe there, do not destroy the basic fact that these states, regardless of their different forms, were slave-owning states. The apparatus of coercion, however it was organized, belong to the slave-owners and assured their mastery over the slaves with the help of armed force, assured the right of the slave-owners to dispose of the labour and personality of the slaves, to exploit them, to commit any desired act of violence against them.

Distinguishing between the form of rule and the class essence of the state is particularly important for the correct strategy of the working class in its struggle with capitalism. Proceeding from this distinction, we establish that to the extent that private property and the power of capital remain untouchable, to this extent the democratic form of government does not change the essence of the matter. Democracy with the preservation of capitalist exploitation will always be democracy for the minority, democracy for the propertied; it will always mean the exploitation and subjugation of the great mass of the working people. Therefore theorists of the Second International such as Kautsky, who contrast “democracy” in general with “dictatorship”, entirely refuse to consider their class nature. They replace Marxism with vulgar legal dogmatism, and act as the scholarly champions and lackeys of capitalism.

The different forms of rule had already arisen in slave-owning society. Basically, they consist of the following types: the monarchic state with an hereditary head, and the republic where power is elective and where there are no offices which pass by inheritance. In addition, aristocracy, or the power of a minority (i.e. a state where participation in the administration of the state is limited by law to a definite and rather narrow circle of privileged persons) is distinguished from democracy (or, literally, the rule of the people), i.e. a state where by law all take part in deciding public affairs either directly or through elected representatives. The distinction between monarchy, aristocracy and democracy had already been established by the Greek philosopher Aristotle in the fourth century. All the modern bourgeois theories of the state could add little to this classification.

Actually the significance of one form or another can be gleaned only by taking into account the concrete historical conditions under which it arose and existed, and only in the context of the class nature of a specific state. Attempts to establish any general abstract laws of the movement of state forms – with which bourgeois theorists of the state have often been occupied – have nothing in common with science.

In particular, the change of the form of government depends on concrete historical conditions, on the condition of the class struggle, and on how relationships are formed between the ruling class and the subordinate class, and also within the ruling class itself

The forms of government may change although the class nature of the state remains the same. France, in the course of the nineteenth century, and after the revolution of 1830 until the present time, was a constitutional monarchy, an empire and a republic, and the rule of the bourgeois capitalist state was maintained in all three of these forms. Conversely, the same form of government (for instance a democratic republic) which was encountered in antiquity as one of the variations of the slave-owning state, is in our time one of the forms of capitalist domination.

Therefore, in studying any state, it is very important primarily to examine not its external form but its internal class content, placing the concrete historical conditions of the class struggle at the very basis of scrutiny.

The question of the relationship between the class type of the state and the form of government is still very little developed. In the bourgeois theory of the state this question not only could not be developed, but could not even be correctly posed, because bourgeois science always tries to disguise the class nature of all states, and in particular the class nature of the capitalist state. Often therefore, bourgeois theorists of the state, without analysis, conflate characteristics relating to the form of government and characteristics relating to the class nature of the state.

As an example one may adduce the classification which is proposed in one of the newest German encyclopaedias of legal science.

The author [Kellreiter] distinguishes: (a) absolutism and dictatorship, and considers that the basic characteristic of these forms is that state powers are concentrated in the hands of one person. As an example, he mentions the absolute monarchy of Louis XIV in France, tsarist autocracy in Russia and the dictatorial power which was invested by the procedure of extraordinary powers in the one person, for instance the president of the German Republic on the basis of Art.48 of the Weimar Constitution; (b) constitutionalism, characterized by the separation of powers, their independence and their checks and balances, thereby weakening the pressure exerted by state power on the individual (examples: the German Constitution before the 1918 revolution, and the USA, where the President and Congress have independent powers); (c) democracy, whose basic premise is monism of power and a denial in principle of the difference between power and the subject of power (popular sovereignty, exemplified by the German Republic); and (d) the class-corporative state and the Soviet system where as opposed to formal democracy, the people appear not as an atomized mass of isolated citizens but as a totality of organized and discrete collectives. [3]

This classification is very typical of the confusion which bourgeois scholars consciously introduce into the question of the state. Starting with the fact that the concept of dictatorship is interpreted in the formal legal sense, deprived of all class content, the bourgeois jurist deliberately avoids the question: the dictatorship of which class and directed against whom ? He blurs the distinction between the dictatorship of a small group of exploiters and the dictatorship of the overwhelming majority of the working people; he distorts the concept of dictatorship, for he cannot avoid defining it without a relevant law or paragraph, while “the scientific concept of dictatorship means nothing less than power resting directly upon force, unlimited by laws, and unconstricted by absolute rules”. [4] Further it is sufficient to indicate, for instance, that under the latter heading the author includes: (a) a new type of state, never encountered before in history, where power belongs to the proletariat; (b) the reactionary dreams of certain professors and so-called guild socialists, about the return to the corporations and shops of the Middle Ages; and, finally (c) the fascist dictatorship of capital which Mussolini exercises in Italy.

This respected scholar consciously introduces confusion, consciously ignores the concrete historical conditions under which the working people actually can exercise administration of the state, acting as organized collectives. But such conditions are only the proletarian revolution and the establishment of the dictatorship of the proletariat.

4. The class nature of law

Bourgeois science confuses the question of the essence of law no less than the question of the state. Here, Marxism-Leninism opposes the diverse majority of bourgeois, petit bourgeois and revisionist theories which, proceeding from the explanation of the historical and class nature of law, consider the state as a phenomenon essential to every human society. They thus transform law into a supra-historical category.

It is not surprising, therefore, that bourgeois philosophy of law serves as the main source for introducing confusion both into the concept of law and into the concept of state and society.

The bourgeois theory of the state is 90% the legal theory of the state. The unattractive class essence of the state, most often and most eagerly, is hidden by clever combinations of legal formalism, or else it is covered by a cloud of lofty philosophical legal abstractions.

The exposure of the class historical essence of law is not, therefore, an unimportant part of the Marxist-Leninist theory of society, of the state and of law.

The most widespread approach of bourgeois science to the solution of the question of the essence of law consists in the fact that it strives to embrace, through the concept of law, the existence of any consciously ordered human relationships, of any social rules, of any phenomenon of social authority or social power. Thus, bourgeois scholars easily transfer law to pre-class society, find it in the pre-state life of primitive tribes, and conclude that communism is unthinkable without law. They turn law as an empty abstraction into a universal concept devoid of historical content. Law, for bourgeois sociologists, becomes an empty form which is unconnected with concrete reality, with the relationships of production, with the antagonistic character of these relationships in class society, [and] with the presence of the state as a particular apparatus of power in the hands of the ruling class.

Representatives of idealist philosophy of law go still further. They begin with “the idea of law”, which stands above social history as something eternal, immutable and independent of space and time.

Here, for example, is the conclusion of one of the most important representatives of the ideological neo-Kantian philosophy of law – Stammler:

Through all the fates and deeds of man there extends a single unitary idea, the idea of law. All languages have a designation for this concept, and the direction of definitions and judgements expressed by it amount, upon careful study, to one and the same meaning.

Having made this discovery, it cost Stammler nothing “to prove” that regardless of the difference between the “life and activity of nations” and “the objects of legal consideration”, we observe the unity of the legal idea and its equal appearance and intervention.

This professorial rubbish is presented without the least attempt at factual proof In actuality it would be rather difficult to explain how this “unity of the legal idea and its equal appearance” gave birth to the laws of the Twelve Tablets of slave-owning Rome, the serf customs of the Middle Ages, the declarations of rights of capitalist democracies, and our Soviet Constitution.

But Stammler is not embarrassed by the scantiness of factual argument. He deals just as simply with the proof of the eternity of law. He begins from those legendary Cyclops described in the Odyssey; even these mythical wonders were the fathers of families and, according to Stammler, could not do without law. On the other hand, however, while Stammler is ready to admit that the pigmy tribes of Africa and the Eskimos did not know the state, he simply denies as deceptive all reports about peoples not knowing law. Moreover, Stammler immediately replaces the concrete historical consideration of the question with scholastic formal-logical tightrope walking, which among bourgeois professors is presented as a methodological precision. We present these conclusions, for they typify the whole trend and, moreover, are most fashionable in the West.

Stammler proposes that the concrete study of legal phenomena is entirely unable to provide anything in the understanding of the essence of law. For if we assign any phenomenon to the list of legal ones, this means that we already know that this is law and what its characteristics are. The definition of law which precedes the facts presupposes knowledge of what is law and what is not law. Accordingly, in the opinion of Stammler, in considering the concept of law, it is necessary to exclude all that is concrete and encountered in experience and to understand “that the legal idea is a purely methodological means for the ordering of spiritual life”.

This conclusion, which confronts one with its scholasticism, is nothing other than a Kantian ideological thesis embodied in the context of Stammler’s legal stupidity. It shows that the so-called forms of knowledge do not express the objective characteristics of matter, are determined a priori, and precede all human experience and its necessary conditions.

Having turned law into a methodological idea, Stammler tries to locate it not in the material world where everything is subordinate to the law of cause and effect, but in the area of goals. Law, according to Stammler, is a definition which proceeds not from the past (from cause to effect), but from the future (from goal to means). Finally, adding that law deals not with the internal procedure of thoughts as such, but with human interaction, Stammler gives this agonizing and thoroughly scholastic definition:

The concept of law is a pure form of thought. It methodically divides the endlessly differentiated material of human desires apprehended by the senses, and defines it as an inviolable and independent connecting will.

This professorial scholasticism has the attractive feature for the bourgeoisie that verbal and formalistic contrivances can hide the ugly reality of [their] exploiting society and exploiting law.

If law is “a pure form of thought”, then it is possible to avoid the ugly fact that the capitalist law of private property means the misery of unemployment, poverty and hunger for the proletarian and his family; and that in defence of this law stand police armed to the teeth, fascist bands, hangmen and prison guards; and that this law signifies a whole system of coercion, humiliation and oppression in colonies.

Such theories allow the disguising of the fact that the class interest of the bourgeoisie lies at the basis of bourgeois law. Instead of class law, philosophers such as Stammler dream up abstractions, “pure forms”, general human “ideas”, “whole and durable bonds of will” – and other entirely shameless things.

This philosophy of law is calculated to blunt the revolutionary class consciousness of the proletariat, and to reconcile it with bourgeois society and capitalist exploitation.

It is not without reason that the social fascists speak out as such zealous exponents of neo-Kantianism; it is not without reason that Social Democratic theorists on questions of law largely subscribe to neo-Kantian philosophy and re-hash the same Stammler in different ways.

In our Soviet legal literature, a rather wide dissemination has been achieved by bourgeois legal theories. In particular, there have been attempts to spread the idealist teaching of Stammler in the works of Pontovich and Popov-Ladyzhensky. The criticism and unmasking of this eructation is necessary for the purpose of eradicating this bourgeois ideological infection.

Thus, we know that the state is an historical phenomenon limited by the boundaries of class society. A state is a machine for the maintenance of the domination of one class over another. It is an organization of the ruling class, having at its disposal the most powerful means of suppression and coercion. Until the appearance of classes the state did not exist. In developed communism there will be no state.

In the same way as the state, law is inseparably tied to the division of society into classes. Every law is the law of the ruling class. The basis of law is the formulation and consolidation of the relationship to the means of production, owing to which in exploitative society, one part of the people can appropriate to itself the unpaid labour of another.

The form of exploitation determines the typical features of a legal system. In accordance with the three basic socio-economic formations of class society, we have three basic types of legal superstructure: slave-owning law, feudal law and bourgeois law. This of course does not exclude concrete historical national differences between each of the systems. For instance, English law is distinguished by many peculiarities in comparison with French bourgeois law as contained in the Napoleonic Code . Likewise, we do not exclude the presence of survivals of the past – transitional or mixed forms – which complicate the concrete picture.

However, the essential and basic – that which provides the guiding theme for the study of different legal institutions – is the difference between the position of the slave, the position of the serf and the position of the wage labourer. The relationship of exploitation is the basic lynchpin, around which all other legal relationships and legal institutions are arranged. From this it follows that the nature of property has decisive significance for each system of law. According to Lenge, the brilliant and cynical reactionary of the eighteenth century, the spirit of the laws is property.

5. Law as an historical phenomenon: definition of law

The appearance and withering away of law, similar to the appearance and withering of the state, is connected with two extremely important historical limitations. Law (and the state) appears with the division of society into classes. Passing through a long path of development, full of revolutionary leaps and qualitative changes, law and the state will wither away under communism as a result of the disappearance of classes and of all survivals of class society.

Nevertheless, certain authors, who consider themselves Marxists, adopt the viewpoint that law exists in pre-class society, that in primitive communism we meet with legal forms and legal relationships. Such a point of view is adopted for instance by Reisner. Reisner gives the term “law” to a whole series of institutions and customs of tribal society: marriage taboos and blood feud, customs regulating relationships between tribes, and customs relating to the use of the means of production belonging to a tribe. Law in this manner is transformed into an eternal institution, inherent to all forms of human society. From here it is just one step to the understanding of law as an eternal idea; and Reisner in essence leans towards such an understanding.

This viewpoint of course fundamentally contradicts Marxism. The customs of a society not knowing class divisions, property inequality and exploitation, differ qualitatively from the law and the statutes of class society. To categorize them together means to introduce an unlikely confusion. Every attempt to avoid this qualitative difference inevitably leads to scholasticism, to the purely external combination of phenomena of different types, or to abstract idealist constructs in the Stammlerian spirit.

We should not be confused by the fact that Engels, in The Origin of the Family, Private Property and the State , uses the expression “the eternal law”; or, that he cites, without particular qualification, Morgan’s description of the member of a tribal community as having “equality of rights”, and of a person violating tribal customs as having placed himself “outside the law”.

It is clear that the terms “right” and “law” are used here not in their direct sense, but by analogy. This does not mean, however, that in classless society we will be dealing only with purely technical rules. Such an argument was put forward by Stuchka in his dispute with Reisner. To assign the customs and the norms of pre-class society to the area of technology would mean to give the concept of technology a very extended and undefined sense. Marriage prohibitions, customs relating to the organization of the tribe, the power of the elders, blood feud etc. – all this of course is not technology and not technical methods, but the customs and norms of social order. The content and character of these customs corresponded of course to the level of productive forces and the production relationships erected on it. These social forms should be considered as a superstructure upon the economic base. But the basic qualitative difference between this superstructure and the political and legal superstructures of class society, consists in the absence of property inequality, exploitation, and organized class coercion.

While Marxism strives to give a concrete historical meaning to law, the characteristic feature of bourgeois philosophers of law is, on the contrary, the conclusion that law in general is outside classes, outside any particular socio-economic formation. Instead of deriving a concept of law from the study of historical facts, bourgeois scholars are occupied with the concoction of theories and definitions from the empty concept or even the word “law”.

We already saw how Stammler, with the help of scholastic contrivances, tries to show that concrete facts have no significance for the definition of law. We, however, say the opposite. It is impossible to give a general definition of law without knowing the law of slave-owning, feudal and capitalist societies. Only by studying the law of each of these socio-economic formations can we identify those characteristics which are in fact most general and most typical. In doing so we must not forget Engels’ warning to those who tend to exaggerate the significance of these general definitions.

For example, in Chapter VI of the first part of Anti-Dühring , having given a definition of life, Engels speaks of the inadequacy of all definitions because they are necessarily limited to the most general and simplistic areas. In the preface to Anti-Dühring , Engels formulated this thought still more clearly, indicating that “the only real definition is the development of the essence of the matter, and that is not a definition”. However, Engels at once states that for ordinary practical use, definitions which indicate the most general and characteristic features of a category are very convenient. We cannot do without them. It is also wrong to demand more from a definition than it can give; it is wrong to forget the inevitability of its insufficiency.

These statements by Engels should be kept in mind in approaching any general definition, including a definition of law. It is necessary to remember that it does not replace, and cannot replace, the study of all forms and aspects of law as a concrete historical phenomenon. In identifying the most general and characteristic features we can define law as the form of regulation and consolidation of production relationships and also of other social relationships of class society; law depends on the apparatus of state power of the ruling class, and reflects the interests of the latter.

This definition characterizes the role and significance of law in class society. But it is nevertheless incomplete. In contradistinction to all normative theories – which are limited to the external and formal side of law (norms, statutes, judicial positions etc.) – Marxist-Leninist theory considers a law as a unity of form and content. The legal superstructure comprises not only the totality of norms and actions of agencies, but the unity of this formal side and its content, i.e. of the social relationships which law reflects and at the same time sanctions, formalizes and modifies. The character of formalization does not depend on the “free will of the legislator”; it is defined by economics, but on the other hand the legal superstructure, once having arisen, exerts a reflexive effect upon the economy.

This definition stresses three aspects of the matter. First is the class nature of law: every law is the law of the ruling class. Attempts to consider law as a social relationship which transcends class society, lead either to superficial categorization of diverse phenomena, or to speculative idealistic constructs in the spirit of the bourgeois philosophy of law. Second is the basic and determinant significance of production relationships in the content that is implemented by law. Class interests directly reflect their relationship to the means of production. Property relationships occupy the prominent place in the characterization of a specific legal order. Communist society, where classes disappear, where labour becomes the primary want, where the effective principle will be from each according to his abilities, to each according to his needs: this does not require law. The third aspect consists of the fact that the functioning of a legal superstructure demands a coercive apparatus. When we say that social relationships have assumed a legal expression, this means inter alia that they have been given a coercive nature by the state power of the ruling class. Withering away of the law can only occur simultaneously with the withering away of the state.

Relationships which have received legal expression are qualitatively different from those relationships which have not received this expression. The form of this expression may be different, as was indicated by Engels [5] ; it may sometimes be good and sometimes be bad. It may support the progressive development of these relationships or, on the contrary, retard them. Everything depends on whether power is in the hands of a revolutionary or a reactionary class. Here the real significance of the legal superstructure appears. However, the degree of this reality is a question of fact; it can be determined only by concrete study and not by any a priori calculations. Bourgeois jurists characteristically concentrate their attention on form, and utterly ignore content. They turn their backs on life and actual history. As Engels showed, “they consider public and private law as independent areas, which have their own independent development and which must and may be subjected to independent systematic elaboration by the consistent elimination of all internal contradictions.” [6]

Bourgeois jurists usually define law as the totality of norms to which a state has given coercive power. This view of law typifies so-called legal positivism. The most consistent representatives of this trend are the English jurists: of the earliest Blackstone (eighteenth century), and thereafter Austin. In other European countries legal positivism also won itself a dominant position in the nineteenth century, because the bourgeoisie either gained state power or everywhere achieved sufficient influence in the state so as not to fear the identification of law with statute. At the same time nothing was better for legal professionals, for judges, [and] for defence counsel since this definition fully satisfied their practical needs. If law in its entirety was the complex of orders proceeding from the state, and consolidated by sanction in the case of disobedience, then the task of jurisprudence was defined with maximum clarity. The work of the jurist, according to the positivists, did not consist in justifying law from some external point of view – philosophers were occupied with this; the task of the jurists did not include explaining from where a norm emerged, and what determined its content – this was the task of political scientists and sociologists. The role of the jurist remained the logical interpretation of particular legal provisions, the establishment of an internal logical connection between them, combining them into larger systematic units in legal institutions, and finally in this way the creation of a system of law.

The definition of law as the totality of norms is the starting point for supporting the so-called dogmatic method. This consists of using formal logical conclusions in order to move from particular norms to more general concepts and back, proceeding from general positions to propose the solution of concrete legal cases or disputes. It is obvious that the practical part of this role developing especially luxuriantly in the litigious circumstances of bourgeois society – has nothing in common with a scientific theory of law. Applications of so-called legal logic are not only theoretically fruitless, they are not only incapable of revealing the essence of law and thus of showing its connection with other phenomena-with economics, with politics, with class struggle – but they are also harmful and impermissible in the practice of our Soviet courts and other state institutions. We need decisions of cases, not formally, but in their essence; the state of the working people, as distinct from the bourgeois state, does not hide either its class character or its goal – the construction of socialism. Therefore, the application of norms of Soviet law must not be based on certain formal logical considerations, but upon the consideration of all the concrete features of the given case, of the class essence of those relationships to which it becomes necessary to apply a general norm, and of the general direction on of the policy of Soviet power at the given moment. In the opposite case a result would be obtained which Lenin defined as: “Correct in form, a mockery in substance.”

The denial of formal legal logic cultivated by the bourgeoisie does not mean a denial of revolutionary legality, does not mean that judicial cases and questions of administration must be decided chaotically in the Soviet state, systematically on the basis of the random whims of individuals, or on the basis of local influences. The struggle for revolutionary legality is a struggle on two fronts: against legal formalism and the transfer to Soviet soil of bourgeois chicanery, and against those who do not understand the organizational significance of Soviet decrees as one of the methods of the uniform conduct of the policy of the dictatorship of the proletariat.

Thus, the law is the means of formulating and consolidating the production relationships of class society and the social relationships which are connected with them. In the legal superstructure, these relationships appear as property relations and as relations of domination and subordination. They appear, in particular, as relations of an ideological nature, i.e. as relations which are formed in connection with certain views and are supported by the conscious will of the people.

We shall not touch upon the question of the degree to which the legal ideology of the exploiting classes is capable of correctly reflecting reality, and in what measure it inevitably distorts it (representing the interest of the exploiting class as the social interest in order, legality, freedom etc.). Here, we merely emphasize the fact that without the work of legislators, judges, police and prison guards (in a word, of the whole apparatus of the class state), law would become a fiction. “Law is nothing without an apparatus capable of enforcing observation of the norms of law” (Lenin).

The conscious will – towards the formulation and consolidation of production and other relationships – is the will of the ruling class which finds its expression in custom, in law, in the activity of the court and in administration. The legal superstructure exists and functions because behind it stands an organization of the ruling class, namely the apparatus of coercion and power in the form of the army, the police, court bailiffs, prison guards and hangmen. This does not mean that the ruling class has to use physical force in every case. Much is achieved by simple threat, by the knowledge of helplessness and of the futility of struggle, by economic pressure, and finally by the fact that the working classes are in the ideological captivity of the exploiters. It is sufficient to mention the narcotic of the religious ideology of humility and meekness, or the genuflection before the idol of bourgeois legality preached by the reformist.

But the ultimate argument for, and the basis of, the legal order is always the means of physical force. Only by depending on them could the slaveowner of antiquity or the modern capitalist enjoy his right.

The attempts by certain bourgeois jurists to separate law from the state, or to contrast “law” and “force”, are dictated by the attempt to hide and conceal the class essence of law.

Often these proofs that law is independent of the state bear a truly laughable character. Thus, for instance, Stammler claims that he has proved this thesis relying on the fact that on a dirigible which flies over the North Pole, i.e. outside the sphere of action of any state power, the emergence of legal relationships is possible.

By such empty dogmatic chicanery the scientific question of the relationship of state and law is decided. Can one be surprised at Lenin’s sharp reaction to Stammler when he says that: “From stupid arguments, Stammler draws equally stupid conclusions.”

The dependence of law on the state, however, does not signify that the state creates the legal superstructure by its arbitrary will. For the state itself, as Engels says, is only a more or less complex reflection of the economic needs of the dominant class in production.

The proletariat, having overthrown the bourgeoisie and consolidated its dictatorship, had to create Soviet law in conformity with the economy, in particular the existence of many millions of small and very small peasant farms. After the victory of the proletarian revolution the realization of socialism is not an instantaneous act but a long process of construction under the conditions of acute class struggle.

From the policy of limiting its exploitative tendencies and the elimination of its front ranks, we moved to the policy of liquidating the kulaks as a class by widespread collectivization. A successful fulfilment of the first Five Year Plan; the creation of our own base for the technical reconstruction of the whole national economy; the transfer of the basic mass of the peasantry to collectivization; these events enabled the basic task of the second Five Year Plan to be:

the final liquidation of capitalist elements and classes in general, the full elimination of the causes of class differences and exploitation, the overcoming of the survivals of capitalism in the economy and the consciousness of the people, the transformation of the whole working population of the country into conscious and active builders of a classless society. [7]

At each of these stages Soviet law regulated and formulated production relationships differently.

Soviet law in each of the stages was naturally different from the law of capitalist states. For law under the proletarian dictatorship has always had the goal of protecting the interest of “the working majority, the suppression of class elements hostile to the proletariat, and the defence of socialist construction. Those individual Soviet jurists who considered law as the totality of norms (i.e. externally and formally) are not in a position to understand this. Finding identically formulated norms in the system of bourgeois and Soviet law, these jurists began to speak of the similarity between bourgeois and Soviet law, to search out “general” institutions, and to trace the development of certain “general” bases for bourgeois and Soviet law. This tendency was very strong in the first years of NEP. The identification of Soviet with bourgeois law derived from an understanding of NEP as a return to capitalism, which found expression in the Marxist ranks.

If NEP, as the Zinoviev opposition asserted at the XIVth Party Congress, is “capitalism which holds the proletarian state on a chain”, then Soviet law must be presented as bourgeois law, in which certain limitations are introduced, to the extent in the period of imperialism that the capitalist state also regulates and limits the freedom of disposition of property, contractual freedom etc.

Such a distortion in the description of NEP led directly to an alliance with bourgeois reformists in the understanding of Soviet law.

In fact, NEP “is a special policy of the proletarian state intended to permit capitalism while the commanding heights are held by the proletarian state, intended for the struggle between the capitalist and socialist elements, intended for the growth of the role of the socialist elements at the expense of the capitalist elements, intended for the victory of the socialist elements over the capitalist elements, intended for the elimination of classes and for the construction of the foundation of a socialist economy.” [8]

Soviet law as a special form of policy followed by the proletariat and the proletarian state, was intended precisely for the victory of socialism. As such, it is radically different from bourgeois law despite the formal resemblance of individual statutes.

Juridicial formalism, which conceives of nothing other than the norm and reduces law to the purely logical operation of these norms, appears as a variety of reformism, as a Soviet “juridical socialism”. By confining themselves only to the norm and the purely juridical (i.e. formal ideas and concepts), they ignored the socio-economic and political essence of the matter. As a result, these jurists arrive at the conclusion that the transformation of property from an arbitrary and unrestricted right into a “social function” (i.e. a tendency which is “peculiar to the law of the advanced”, that is, capitalist, countries), finds its “fullest” expression in Soviet legislation. Making this contention, the Jurists “forgot” such a trifle as the October Revolution and the dictatorship of the proletariat.

It is not only important to “read” the norm, but also to know what class, what state, and what state apparatus is applying this norm.

6. Law and production relationships

Production relationships form the basis of society. It is necessary to begin with these relationships in order to comprehend the complex picture presented by the history of mankind.

To search for the basic characteristic of society and social relations in an area other than production relationships means to deprive oneself of the possibility of a scientific understanding of the laws of development of social formations. However, it by no means follows from this that, according to Marx, only relations of production and exchange are social relations. Such a concept is a caricature of Marxism. The equation of social relations with production relations in this case is understood purely mechanically. However, a number of times Lenin noted that Marx’s great service was that he did not limit himself to the description of the economic “skeleton” of capitalist society, but that:

in explaining the construction and development of a definite social formation “exclusively” by production relations, he nonetheless thoroughly and constantly studied the superstructure corresponding to these production relations, which clothed the skeleton with flesh and blood. The reason that Das Kapital had such enormous success was that this book (“by a German economist”) showed the capitalist social formation as a living thing-with its everyday aspects, with the actual social phenomena essential to the production relations between antagonistic classes, with the bourgeois political superstructure protecting the domination of the capitalist class, with the bourgeois ideas of freedom, equality etc., with bourgeois family relations. [9]

Stuchka looks differently at the matter. In his opinion, Marx considered only relations of production and exchange to be social relations. But this would mean affirming that Marx limited himself to the “skeleton” alone, as if having indicated the basic and eventually determinant in social life and social relations he then passed by that which is derivative and requires explanation. However, more than once Marx directly points out the existence of social relationships which are not production relations but which merely derive from them and correspond to them. Characterizing revolutionary proletarian socialism in France in 1848, Marx wrote:

This socialism is the proclamation of the permanence of the revolution , a proclamation of the class dictatorship of the proletariat as a necessary transition toward the elimination of class differences altogether, toward the elimination of all production relations upon which these differences are based, toward the elimination of all social relationships corresponding to these production relations, toward a revolution in the entire world of ideas arising from these relationships. [10]

Nevertheless, Comrade Stuchka firmly defends his understanding of the term “social relationships”:

We proceed from social relationships; I emphasize the word “social”, for here my critics are desperately confused. I thus selected the word “social” and a whole chapter in my first book was dedicated to it only in the sense of relations of production and exchange (as Marx and every Marxist understands this). [11]

Proceeding from the equation of production and social relationships, Stuchka defined law as a “system (or order) of social relations corresponding to the interests of the ruling class and protected by its organized force”. In this definition, as he himself indicated, there was room only for the law of property and the law of obligations.

As earlier, so even now [he wrote] I consider basic law , law in general, to be civil law , understanding thereby the form of organization of social relationships in the narrow and specific sense of the word (i.e. relations of production and exchange). I consider that all the remaining areas of law are either of a subordinate or derivative character, and that only bourgeois law (subjecting to its influence all the remaining areas of law) created a legal state, or state law and criminal law, as an equivalent norm for crime and punishment, not even mentioning administrative, financial etc., and finally international law or even the law of war. [12]

The positions outlined in this excerpt contain a series of mistakes. There is no doubt that the formulation and conformation of social relationships to the means of production is basic to law. Proceeding from the economic basis, from different forms of exploitation, we differentiate slaveowning, feudal and capitalist systems of law. But, in the first place, it is incorrect to subsume the property relations of slaveowning or feudal society under the concept of civil, i.e. bourgeois, law as “law in general”. In the second place, state law may not be equated with the so-called Rechtsstaat of the bourgeoisie. If one takes this point of view then one must either deny the existence of a distinctive feudal state law, or show that despite the existence of a Soviet state we do have Soviet state law. At the same time, in other places in his textbook, Stuchka proceeds from the existence of different class systems of law: feudal, bourgeois, Soviet. Here he argues for a “general law” which is equated with the civil law of bourgeois society. At the same time state law is equated with the theory of bourgeois jurists of the so-called Rechtsstaat , and criminal law (i.e. formalized class repression) with the ideology of equivalent retribution.

The basic question – do relationships exist that enter into the content of law, which are not, however, relations of production and exchange? – is avoided by Stuchka; he cites the subsidiary, derivative etc. character of state, criminal etc. law. However, it is clear that the structure of family relationships, the formalization of class domination in the state organization, the formalization of class repression, all this is embraced by the different branches of law (family, state and criminal).

The content of this legal intermediary is the social and political relationships which, in the final analysis, are reducible to the same production relationships, but by no means correspond to them.

Stuchka’s subsequent definition of law suffers from the shortcoming that he limits the area of law merely to production relations. This definition also introduces confusion because it confuses law with economics. Proceeding from the indisputable position that not all which is stated in a norm (in a statute) is realized in fact, Stuchka has made the incorrect conclusion that law is indeed the very relation of production and exchange. Stuchka has therefore declared Marx’s teaching – that law is an ideological superstructure to be a tribute to the “volitional theory” of the old jurists.

Whoever has mastered the form of theorizing of Marx and Engels that capital, money etc., are social relationships, will at once understand my views on the system of social relationships. This will be hardest of all for a jurist for whom law is a purely technical and artificial superstructure, strangely enough, holding sway over its base. Even Karl Marx gave a small tribute to this concept when he spoke of law as an ideological superstructure. But Marx was raised on Roman law and in general on the juridic concepts of the 1830s, considering it an expression “of the general will” ( Volkswillen ), and he was [therefore] accustomed to its terminology. [13]

In conducting the struggle with the narrow, formal legal concept of law as a totality of norms, we cannot deny the real existence of the legal superstructure, i.e. of relationships formulated and consolidated by the conscious will of the ruling class. Only to the extent that this process of formulation and consolidation proceeds may one speak of law. To study law only as totality of norms means to follow the path of formalism and dogmatism. But to study law only as relationships of production and exchange means to confuse law with economics, to retard the understanding of the reciprocal action of the legal superstructure and its active role. At the same time as production relations are imposed on people regardless of their will, legal relationships are impossible without the participation of the conscious will of the ruling class. The teaching of Marx, Engels and Lenin on law as an ideological superstructure needs no correction. Law cannot be understood unless we consider it as the basic form of the policy of the ruling class. In the later editions of The Revolutionary Role of State and Law , Stuchka supplemented his definition of law, developing the theory of the so-called three forms of law. The first, or in Stuchka’s words, the concrete form of law, is a legal relationship which corresponds to a production relationship and, with it, constitutes the base [or] reality. On the contrary, the two “abstract” forms – statute and legal ideology as Stuchka expresses it – are the essence of “the manifest superstructure”. [14]

This approach is also incorrect and non-dialectical. A legal relationship is a form of production relations because the active influence of the class organization of the ruling class transforms the factual relationship into a legal one, gives it a new quality, and thus includes it in the construction of the legal superstructure. This result is not achieved automatically by laissez faire , in the same way that prices are established under free competition. Even in the case of so-called customary law, the ruling class – through its special agencies, through the courts – ensures that the relations correspond to obligatory rules. This is all the more true with respect to the legislative creation of norms.

In particular, the revolutionary role of the legal superstructure is enormous in the transitional period when its active and conscious influence upon production and other social relationships assumes exceptional significance. Soviet law, like any law, will cease to exist if it is not applied. But the application of law is an active and conscious process by which the state apparatus plays the decisive role as a powerful weapon of class struggle. Would it be possible, for instance, to speak of Soviet law which did not somehow recognize the Soviet state, the Soviet agencies of power, Soviet courts etc.? It is clear that while an individual statute may be removed from the real legal order and remain a pious wish, concrete legal relationships may never be removed from the consciousness and will of the ruling class, may never be transferred from the superstructure to the base without parting from the heart of historical materialism.

From all that has been said above it is clear that the definition of law as a formal intermediary of the economy must be recognized as insufficient and incorrect. The different branches of law are connected differently with the economy; this must never be forgotten, and this is not expressed in the above-mentioned definition. On the contrary it can lead to the notion that the area of law is limited to property relationships alone. Then all the other types of law must be declared non-existent. Stuchka would, in fact, have had to reach this conclusion. But he speaks of criminal and state law, not entirely consistently with his other position, i.e. by referring to them he recognizes their existence.

There is no doubt that economics is at the base of political, familial and all other social relations. [15] But the election law of any capitalist country facilitates the economy differently from civil law or the Criminal Code. To try to force all the varied branches of law into one formula is to give preference to empty abstractions.

Law as a formal facilitation of social and (primarily) production relationships must be studied concretely. This study may not be replaced with ready citations from Hegel with respect to the “transformation of form into substance and substance into form”. The dialectical method, which teaches that every truth is concrete, becomes in this instance its own opposite-dead scholasticism, barren arguments and disputes on the theme that “form is not without content and content not without form”. However, the matter really consists of showing the role and character of law as form in specific and concrete branches of law and concrete historial conditions with a relation to concrete content. Only in this manner can the real relation of form and content be established and can one be convinced that it is far from identical in different instances. Often legal form hides economic content directly contrary to it (thus in the period when we conducted the policy of restricting the kulak, the leasing of a horse or tools by a poor peasant to a rich one often hid the sale of the first’s labour power to the second). A transaction of purchase and sale can hide the most diverse economic content. The same could be said about any other relationships within the so-called law of obligations. Here we meet with a phenomenon whose form is relatively indifferent to its content, but it is improper to conclude from this that in civil law we have a “faceless instrumentality” which must be used independently of the economic class content of the relationships which it implements. On the contrary, the significance of form is recognized only through content, through economics, through politics and through relations between classes.

Therefore, it is a flagrant error to equate law as an historical phenomenon – including various class systems – with the totality of those features of bourgeois law that derive from the exchange of commodities of equal value. [16] Such a concept of law minimizes the class coercion essential to bourgeois law, essential to feudal law and to all law. Law in bourgeois society serves not only the facilitation of exchange, but simultaneously and mainly supports and consolidates the unequal distribution of property and the monopoly of the capitalist in production. Bourgeois property is not exhausted by the relationships between commodity owners. These [owners – eds. ] are tied by exchange and the contractual relationship is the form of this exchange. Bourgeois property includes in a masked form the same relationship of domination and subordination which, in feudal property, appears chiefly as personal subordination.

This methodological mistake was related to the relegation of the class repressive role of law, and to an incorrect presentation of the relation between state and law (the state as the guarantor of exchange), and to mistakes in questions of morality (the denial of proletarian morality) and in questions of criminal law.

The attempts to distinguish between formal characteristics and abstract legal concepts expressing the relationship between commodity owners, and to proclaim this “form of law” as the subject of the Marxist theory of law, should be recognized as grossly mistaken. This paves the way to the separation of form and content, and diverts theory from the task of socialist construction to scholasticism.

The immediate relation, in practice, between the proletariat (as the ruling class) and law (as a weapon with whose help the tasks of class struggle at any given stage are decided) is in this case replaced by the abstract theoretical denial of the “narrow horizons of bourgeois law” in the name of developed communism.

From this perspective Soviet law is seen exclusively as a legacy of class society imposed on the proletariat and which haunts it until the second phase of communism. The abstract theoretical exposure of “bourgeois” law hides the task of the concrete analysis of Soviet law at different stages of the revolution. Accordingly, it gives insufficient concrete indication of the practical struggle against bourgeois influences, and against opportunist distortions of the Party’s general line on Soviet law.

The theoretical mistake of exaggerating the importance of market relations can be the basis for right opportunist conclusions about always preserving the bourgeois forms of law corresponding to private exchange. Conversely, to ignore exchange in considering the problems of Soviet law leads to “leftist” positions about the withering away of law which is now in the process of socializing the means of production, and about the withering away of economic accountability and the principle of payment according to labour, i.e. to the defence of the elimination of individual responsibility and wage egalitarianism.

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1. K. Marx, Letter to Weydemeyer (March 5, 1852), MESW , vol.1, p.528.

2. V. I. Lenin, The Economic Content of Narodnism (1895), LCW , vol.1, p.419.

3. See Kellreiter’s article The State ;, in D. Elster et al. (eds), Handwörterbuch der Rechtswissenschaft (1923), Fischer, Jena, p.599.

4. V.I. Lenin, A Contribution to the History of the Question of Dictatorship (1920), LCW , vol.31, p.353.

5. F. Engels, Ludwig Feuerbach and the End of Classical German Philosophy (1888), MESW , vol.3, p.371.

6. ibid. , p.371.

7. From a resolution of the XVIIth Party Conference (1932).

8. J. Stalin, The Fourteenth Congress of the CPSU (1925), Stalin: Works, Foreign Languages Publishing House, Moscow (1954), vol.7, p.374.

9. V.I. Lenin, What the “Friends of the People” Are (1894), LCW , vol.1, pp.141-42.

10. K. Marx, The Class Struggles in France (1850), MESW , vol.1, p.282.

11. P.I. Stuchka, A Course on Soviet Civil Law (1927), Communist Academy, vol.1, p.13.

12. ibid. , pp.78-79.

13. P.I. Stuchka, The Revolutionary Role of Law and State (1921), Moscow, p.15.

14. ibid. (3rd edition); and P.I. Stuchka’s article Law in Encyclopaedia of State and Law, (1925-1927), vol.3, pp.415-430.

15. “The state and law are determined by economic relations. Of course, the same must be said of civil law whose role in essence consists of the legislative clarification of the existing economic relations between individuals which are normal in the given circumstances” F. Engels, Ludwig Feuerbach and the End of Classical German Philosophy (1888), op. cit. p.370.

16. This erroneous conception was developed in E.B. Pashukanis, The General Theory of Law and Marxism (1927), 3rd edition. See also E.B. Pashukanis, The Situation on the Legal Theory Front , Soviet State and the Revolution of Law (1930), no.11-12; and For a Marxist-Leninist Theory of State and Law (1931) Moscow, where a critique of this mistaken conception is given.  

Last updated on 13.5.2004