Healthcare: Market Good or Right of Citizenship?

The news is so unbearable this week—Minneapolis, Venezuela, Iran, Greenland and NATO (though they all sort of take your mind off the Epstein files, no?)—that I’m going to take a step back and explore a policy issue from a more philosophical perspective.

That perspective examines assumptions underlying the arguments over extending the Affordable Care Act—i.e., Obamacare—subsidies. With the support of 17 Republicans (!), the House last week voted 230-196 to extend those subsidies; now it’s up to the Senate.

A November 18, 2025, article in The American Prospect provides a good account of the conventional Republican arguments: “Republicans have hated Medicare and Medicaid since the moment they were proposed, because they’re welfare programs” (indeed, see National Review, “The Fight Against the New Deal Never Ended”). Healthcare, in their view, should be a market good and not a right of citizenship.

As The Atlantic noted last month: “A largely unspoken article of faith for Republicans is that access to medical care is a matter of personal responsibility. They don’t generally advertise this belief, because it is not popular—a growing share of Americans believe that it is the government’s duty to ensure all citizens have health-care coverage, according to Gallup.”

Now consider this distinction. Owning a car is not a right of citizenship, nor is getting a haircut; they are market goods we pay for ourselves. On the other hand, a public—taxpayer supported—primary and secondary education is a right of citizenship, as is police and fire protection.

Which is healthcare?

To begin to understand, if not answer, this question, we need to distinguish between a liberal democracy and a social democracy, and this latter task implicates a distinction between what we call negative liberty and positive liberty.

Negative liberty is commonly understood as “freedom from”—the aspects of our lives where government does not interfere in what we do. A good example is the First Amendment’s provision that Congress “shall make no law prohibiting the free exercise” of religion, as is the famous saying that “that government is best which governs least.”

On this view of freedom as negative, I am completely free to do X if neither physical coercion nor legal coercion—i.e., a law—prohibits me from doing X. The market conservative’s argument against government intervention in the economy (see my previous column, “Why Liberalism Is Not Socialism”) is a version of this.

(An aside: if Axios is correct—“President Trump is reaching deeper than ever into the gears of the U.S. economy, attempting to harness state power to directly shape prices, markets, interest rates and corporate behavior,” with the consequence that “The economy’s ‘invisible hand’ is giving way to a clenched presidential fist.”—then Trump is no market conservative; his interventionist actions in the economy put the lie to that.)

The dominant conception of liberty in a liberal democracy, then, is negative freedom. This, though, raises the famous issue stated by Anatole France: “The law, in its majestic equality, forbids rich and poor alike to sleep under bridges, to beg in the streets, and to steal their bread.” From the standpoint of negative freedom, if no law prohibits me from buying groceries, a car, or a place to live, then I am free to buy any of these even if I have no money to do so.

On the other hand, if you believe that I am not truly free to buy any of these things if I have no money to do so, then you are presuming the concept of positive liberty—“freedom to.” From this standpoint, having a meaningful choice to buy or not to buy—having money in my pocket—is the necessary condition of real freedom to do X.

If you prefer this latter standpoint, then you have moved from the concept of liberal democracy to the concept of social democracy. The former argues that the absence of physical and legal coercion is both necessary and sufficient to make you free (negative liberty); the latter argues that the absence of physical and legal coercion is necessary but not sufficient to make you free (positive liberty).

Social democracy advocates a “thicker” conception of freedom, if you will, than liberal democracy. If you are not prevented by law from buying healthcare coverage even if you cannot afford to do so, on the “thicker conception” you would be less free than if you were guaranteed healthcare coverage as a right of citizenship. Having a right is meaningless if you can’t afford to exercise that right.

This is similar to Herbert Croly’s argument about equality of opportunity I noted in “Why Liberalism Is Not Socialism.” Croly was a Progressive, in its original early 20-century sense, and not a social democrat, but his argument speaks to this idea of positive liberty.

A social democracy, then, talks about social and economic rights as well as legal rights. It aims “to provide such social and economic rights as equal opportunities for basic education, adequate health care, acceptable housing, productive employment in the workforce, fair payment for workers, and guaranteed pension plans for people retired from the workforce” (Annenberg Classroom).

As Yahoo Finance puts it, “Social democracy is a political ideology that advocates for a balance between a market economy and social welfare programs.”

As distinct from democratic socialism, which seeks to transcend capitalism, social democracy supports the capitalist system; it doesn’t advocate overthrowing capitalism or simply having government own the means of production.

None of this is to ignore the fact that such social and economic rights can be extremely expensive (see this). The point, rather, is to explain that underlying the debate over Obamacare and healthcare in general are two related but distinct conceptions of liberty—the “thinner” idea of “freedom from” and the “thicker” idea of “freedom to.”

In these terms, then, the question is whether you think healthcare should be a market good like a car or a house, which you are legally free to buy whether or not you can afford it, or a right of citizenship like public education and police and fire protection, to which you are entitled regardless of your finances.

Where do you stand—and why?

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