The lengthy contest surrounding the passage and implementation of the Affordable Care Act, the Republican crusade to repeal it in all or part, and the multiple proposals as to what should replace or complement it fanned the long-smoldering debate in the US about whether health care can be considered a right of citizenship. Gunnar Almgren's new book engages with this debate firmly in the affirmative, and offers both an historical and a philosophical interrogation of the meaning of a right to health care in the American context.

Almgren's normative unpacking of the philosophical implications of a citizenship right to health care in the United States is careful and subtle. He distinguishes the concept of health care as a “basic human right” (grounded in humanistic, religious or social-justice arguments) from the concept of health care as a citizenship right in democratic societies. The key features of democratic societies for this purpose are institutional: a constitution that takes the form “formal social contract” established through the consent of the governed that establishes the “rights and responsibilities of citizenship”, and a market economy in which the production and distribution of material resources occurs through the “aggregate private interactions of individuals acting in their own self-interest” (p. 62). In his most important contribution, Almgren then contextualizes the meaning of the concept in the US on both theoretical and empirical grounds.

As to theory, he principally draws upon the work of T.H. Marshall and John Rawls, showing how perspectives of these two towering figures arose in their societal contexts (British and American respectively) but how they nonetheless converged on a concept of “social rights” as “structural requisites of democratic citizenship” (p. 74). Although Marshall's inclusion of a right to health care among such social rights is at best implicit, Rawls includes a right to health care within the class of social rights as essential to equality of opportunity. Almgren then considers what this means in the context of what he terms, following Bruce Jansson, America's “reluctant” welfare state (p. 136), which imposes both ideational and structural boundaries on the scope of a social right to health. Ideationally, the “high tolerance of social and economic inequalities” and an insistence on respecting individual preferences support heterogeneity in health care coverage. Structurally, the embedding of employer-based private insurance in the political economy of health care establishes barriers to the extension of the role of the state as a vehicle of coverage.

In this context, a social right to health can stretch only to a “soft” two-tiered system. In the first tier, a universal program would cover a basic set of services (which would include insurance against catastrophic costs as well as a range of essential services). A second tier would comprise “a vibrant voluntary complementary insurance market that caters to individual and social class demands for more convenience and a broader array of health insurance benefits” (p. 144). Such a distinction is, of course, as Almgren notes, common to many OECD nations – the discriminating features are what services are included in each tier, whether privately-insured care can be accessed as a substitute for rather than a complement to publicly-financed services and whether “convenience” can be defined as including faster access to essential services. Almgren carefully adapts the design of his proposal to what he believes is feasible in the US context. Nonetheless, the introduction of a common universal tier of public insurance in the US would mark a dramatic policy shift. Almgren moreover assumes that such a common tier would take the form of a “single-payer” system. Other nations such as the Netherlands, however, insure a compulsory comprehensive package of essential services through heavily regulated and subsidized private insurance, and it is somewhat surprising that Almgren does not explore this alternative in light of his arguments about the embedding of employer-based insurance in the US context.

Almgren then turns to examining the feasibility of instituting his proposed model in the US. Fiscal feasibility receives remarkably short shrift. Only a single example is referenced of an analysis of a piece of “Medicare for All” legislation. Though not described in detail by Almgren, that analysis (by Gerald Friedman) estimated, on the basis of some heroic assumptions about administrative savings and consolidated purchasing power, that a single-payer system could be financed by a mix of surtaxes on upper incomes and payroll taxes (the latter substituting in part for existing premiums for employer-based coverage) together with the taxation of remaining employer-based benefits.

But Almgren is most concerned to demonstrate the political feasibility of his proposal, on the basis of what he purports is the evolution of an acceptance of a social right to health in America. It is that aspect of his argument, grounded in the empirical historical elements of the book, that is – at least for this reader – the least persuasive. Almgren describes the contemporary American health care state as grounded in an “unsustainable compromise” between public and private insurance, reached with the adoption of the Medicare and Medicaid programs for selected groups of the population. He traces a history of unsuccessful attempts to resolve the contradictions of that compromise, culminating in the passage of the Affordable Care Act. More important for his argument, he also seeks to trace the evolution of a concept of health care as a right of citizenship through that succession of attempts. One can indeed find evidence in the American experience of attempts to present health care explicitly as a right of citizenship, with all of the connotations of a quasi-constitutional social contract that that formulation connotes. Franklin Delano Roosevelt, toward the end of his presidency in 1944, included health care in a “Second Bill of Rights,” and his successor Harry Truman echoed this language a year later to embark on an attempt to introduce universal health insurance. In a later episode described by David Blumenthal and James Morone (and which, strangely, Almgren does not adduce), Harris Wofford, the Democratic candidate in a special Senate election in Pennsylvania in 1991, made health care the central plank in his platform by “waving a copy of the Constitution and asking, ‘If the Constitution guarantees criminals the right to a lawyer, shouldn't it guarantee working Americans the right to a doctor as well?’” But the linkage of health care and citizenship in this way is in fact highly contested and deeply polarized by partisanship in the US, in a way that we do not observe in nations with universal coverage.

Like a number of other advocates, Almgren infers broad support for the concept of a right to health care from public opinion polling showing (fluctuating) majority support for the argument that government ought to ensure access to health care for all Americans, and from the periodic election of presidents whose campaign platforms have included a commitment to universal health care. But there are several problems with this inference. First, levels of support for the proposition of a government responsibility to ensure access to health care are lower and, most importantly, much more polarized by partisanship in the US than in other Anglo-American democracies such as Canada and Britain. Support for a single-payer system is closely divided and malleable depending on the phrasing of the question. Second, even the positing of such a government responsibility does not carry the moral and constitutional weight of the concept of an individual “right” – as Almgren's own philosophical exegesis reveals. Third, presidential elections rarely turn on one issue to the extent that their results can be interpreted as equivalent to support for a particular policy. The 2010 congressional elections and the 2012 presidential elections may be exceptions to that rule. But the results of those two elections cut in different directions, and cannot support the proposition of widespread support for the concept of a right to health care. In 2010, negative attitudes toward the Affordable Care Act strongly contributed to Republican gains. In 2012, on the other hand, supporters of the winning candidate, Barack Obama, the ACA's principal face, were far more likely to cite health care as opposed to any other issue as the most important in the campaign, and much more likely to do so than Romney supporters. On Almgrem's argument, this would imply that voters rejected a citizenship right to health care in 2010 and accepted it two years later.

Almgren can hardly be blamed for failing to foresee the Republicans’ use of the vehicle of tax reform to repeal the ACA's tax penalties enforcing the “individual mandate” that (almost) all American residents have health insurance. But his claim that “the idea of universal health insurance as a social right of citizenship, as affirmed by the ACA being signed into law as an Act of Congress, is here to stay” can be criticized as a direct result of his over-estimation of the level of support for the concept, and his under-estimation of its strong links to partisanship. The individual mandate never achieved majority support in public opinion – only among Democrats was that the case. Although other elements of the ACA did attract majority popular support on a piecemeal basis, the enactment of the Act itself was an entirely Democratic project, and the assault on it was entirely Republican. No common concept of social citizenship bridges that divide.

There is more to the book that space precludes exploring here. Almgren extends his “principled approach” beyond his main focus on the financing of health care coverage to assess health-system delivery reforms aimed at reducing disparities in health care and health outcomes. This discussion is enlightening, but owes somewhat less to the particular parsing of the meaning of a citizenship right to health care than do his arguments about coverage.

Almgren's book makes a forceful contribution to thinking about what a citizenship right to health care would mean in the US. It will appeal to advocates and strongly challenge opponents of compulsory universal coverage. In short, it will inform a debate that is unlikely to abate in the foreseeable future.