Get Rich or Die Trying: Why Merit-Based Healthcare Systems Will Always Fail Us

A system that distributes healthcare based on one’s ability to compete in an open marketplace is fundamentally flawed, because it denies individuals the resources needed to compete equally in the first place. Healthcare cannot be a commodity used to reward productivity, and we cannot continue to withhold it from those who require it for their chance at a competitive advantage. Nurses Announcements Archive


In a society where the allocation of healthcare resources is determined by political powers, access to those resources is controlled by several, often conflicting factors. How these factors interact to influence the framework for delivering healthcare tests the ethical and moral authority of professionals involved in that delivery, particularly nurses, who are most often at the front lines of caring for patients. Principles of distributive justice offer perspectives we can use to advocate for our patients' access to healthcare resources on a systemic scale and give us important context for why change is needed now more than ever.

Much of the opposition to a universal healthcare system, which is otherwise embraced by all other advanced economies (in one form or another), is founded on the principle of each according to their ability to compete in the open marketplace. The basic tenets of this principle assign value to individuals based on their economic contributions or productivity, resulting in a system that awards resources rather than guaranteeing them (Mason, Gardner, Outlaw, & O'Grady, 2016). This principle views the distribution of resources to individuals who do not meet social productivity standards as an injustice to people who perceivably work hard to earn them. Take, for instance, Republicans' recent efforts to enforce employment requirements as part of food stamp benefits (Weixel, 2018).

The main problem with this is that a significant proportion of any society consists of individuals with circumstances out of their control that limit their ability to work. This premise also takes for granted that the marketplace can truly be considered "open"- are all opportunities open to all people? In what ways do historically discriminatory policies continue to create barriers to equal economic opportunities?

A system that distributes healthcare based on one's ability to compete in an open marketplace is fundamentally flawed, because it denies individuals the resources needed to compete equally in the first place. A lesson in the compounding effect that healthcare access has on economic mobility is the relationship between medical debt and foreclosures. Research has shown that housing instability is strongly related to healthcare debt in communities that experience racial disparities (Lichtenstein & Weber, 2016), particularly in the Deep South which largely failed to adopt Medicaid expansion policies (Kaiser Family Foundation, 2018). This poses the basic question- how can people be rewarded for something they can't do without those rewards?

Another, more intimate example are the issues faced by the Oglala Lakota population in South Dakota. On the Pine Ridge Indian Reservation, unemployment rates are twice that of the rest of the state and 40.7% of the population lives below the federal poverty level (United States Census Bureau, 2018). By many measures, Oglala Lakota County, where the reservation is located, is the poorest in the country. Employment and educational opportunities are scarce, public transportation is non-existent, and an estimated 33% of houses lack electricity or running water (Friends of Pine Ridge Indian Reservation, 2018). Meanwhile, the reservation faces significant health disparities when it comes to chronic health disease (diabetes, heart failure, obesity), premature births, life expectancy, and suicide (County Health Rankings, 2018). The health and economic vulnerabilities faced by the Oglala Lakota Tribe are overwhelming.

In the practice setting, we are able to treat these patients without regard for their ability to pay for services through the Indian Health Service. They face many other barriers to accessing healthcare, such as a distrust in the medical community, lack of transportation from remote locations, etc., so incidentally, the system does not distribute resources based on their economic contributions. If the distributive justice principle of each according to their ability to compete in the open marketplace were applied to the Oglala Lakota community, the effects would be disastrous. Not only would the increased lack of access lead directly to more patient deaths, but the financial burden of healthcare would compound the economic disparity faced by the tribe. The relationship between economic and health disparities cannot be overstated.

Affluent communities and individuals who can be rewarded for their ability to compete economically may indeed find this system fair and just, but this is hardly serves the greater good. The ethical imperative of creating a system based on need- within a context of cultural awareness- must be considered. Healthcare cannot be a commodity used to reward productivity, and we cannot continue to withhold it from those who require it for any chance at a competitive advantage.


County Health Rankings (2018). Oglala Lakota County Demographics.

Friends of Pine Ridge Indian Reservation (2018). Statistics About Pine Ridge Reservation.

Kaiser Family Foundation (2018). Current Status of Medicaid Expansion Decisions.

Lichtenstein, B., and Weber, J. (2016). Losing Ground: Racial Disparities in Medical Debt and Home Forclosure in the Deep South. Family & Community Health 39(3).

Mason, D.J., Gardner, D. B., Outlaw, F.H., & O'Grady E.T. (2016). Policy & Politics in Nursing and Healthcare. St. Louis, MO: Elsevier.

United States Census Bureau (2018). Small Area Income and Poverty Estimates.

Weixel, Nathan (2018, April 27). Food stamp reform slowly gains momentum in the House. The Hill.


2,121 Posts

The ACA has improved access to and the ability to obtain insurance and health care for many people, and this is true in my state, which expanded Medicaid. Of course, the ACA is not perfect, and it is not inexpensive for people who do not receive subsidies, and no system will be; the cost/risk is distributed whether we pay for our health care through insurance or taxation. By comparison, a friend in the UK told me that one third of their pay check goes towards National Insurance contributions, which covers health care by the NHS. Significant monies are spent by the federal government on Medicare, which covers the majority of elderly people.

Two significant problems are: 1) The way that the ACA has been implemented in some states; however the lack of expansion of Medicaid in those states is not the fault of the ACA but lies with the politicians and electorate in those states; 2) In some states there exist considerable monopolies in health care, with a few health care organizations dominating the health care market, which affects the insurance markets, in particular the individual market, and ultimately increases the cost of health care and thus access to health care in those states. These problems need to be resolved politically in order for more people to have access to affordable health care.

RobbiRN, RN

8 Articles; 205 Posts

Specializes in ER.

Excellent article. Is there anyone out there who would like to argue that our current systems is fair and just?

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