For three months at the peak of COVID-19, I treated some of New York City’s sickest patients at Bellevue Hospital, the city’s historic public hospital. There, extraordinary clinicians delivered heroic care to the most at-risk patients. While there, I couldn’t help but compare Bellevue to the gleaming NYU Langone Tisch Hospital — a nonprofit private facility almost next door where patients with robust insurance predominantly received care. The hospital even maintained a quasi-VIP room in its emergency department, a feature that had ignited controversy in 2022 for symbolizing stratified care.
Rich and poor patients receive starkly different treatment in New York City — and nationwide. It’s exactly these types of disparities that infuriate newly elected New York City Mayor Zohran Mamdani, who vows to eradicate them in the name of equity.
The mayor-elect wants to increase access to healthcare. His administration has prioritized affordability and expansion of public services, building on a campaign that mobilized young voters and progressives toward a vision of universal rights.
Democratic socialists champion healthcare as a universal right, yet this vision confronts an intractable barrier: will the government compel physicians, nurses, or hospitals to participate? Insurance coverage, however robust, remains meaningless without actual access and delivery. Expanding coverage alone does not guarantee providers will accept patients, especially when financial realities favor higher-paying private plans.
A concrete example is joint arthroplasty, such as hip or knee replacement. Abundant data confirm that, for appropriate candidates, surgery dramatically enhances quality of life and functional status. Studies consistently show improvements in mobility, pain reduction, and overall patient-reported outcomes, making it a benchmark for assessing equitable access to elective procedures.
Countries with socialized medicine, like Canada, treat healthcare as a positive right and provide universal coverage — yet they falter on universal access. Canada sets a national benchmark of 26 weeks for hip replacement; according to the Fraser Institute, only 66 percent of patients undergo surgery within that timeframe. Wait times also reflect resource allocation challenges in single-payer systems, where rationing occurs through queues rather than price, often delaying care for non-urgent but life-improving interventions.
In the United States, Medicaid patients — covered by the government’s safety-net insurance — are less likely to receive arthroplasty and face longer surgical waits than those with commercial insurance. Research from national databases reveals that Medicaid enrollees not only access these procedures less frequently but also experience barriers in specialist referrals and pre- and post-operative optimization.
Surgeons struggle to treat Medicaid patients for several reasons, chief among them reimbursement. Medicaid pays far less for identical work: if Medicare reimburses a physician $1.00 per procedure, private insurance averages $1.43, while New York Medicaid pays just 76 cents.
To achieve equity, Mayor Mamdani will have to lobby Governor Hochul and the federal government to increase Medicaid reimbursement rates.
Medicaid patients also experience higher rates of complications, readmissions, prolonged hospital stays, and worse patient-reported outcomes. They face 81.7 percent greater odds of emergency department visits compared to privately insured patients.
The new city administration campaigned on a pledge to “expand access” and “lower costs for everyone.” To achieve this, Mayor Mamdani will need to substantially increase physician and provider participation in safety-net hospitals and insurance. What if physicians don’t want to participate?
The uncomfortable (and usually unspoken) reality is this: Achieving true healthcare equity will require the forcible appropriation of physicians’ property — their time, expertise, and professional autonomy.
At its core, the conflict pits positive rights (entitlements to goods and services) against negative rights (freedoms from coercion), inseparable from the foundational principles of property ownership. Philosophically, positive rights demand active provision by others, potentially infringing on individual liberties, while negative rights protect against interference — a tension central to debates on mandatory service or quotas.
This is the fundamental challenge posed by positive rights. For example, the European Union recognizes a right to education, yet someone must actually provide that education. Similarly, the EU acknowledges a right to healthcare, but someone must deliver that care. Even more critically, these positive rights can come into direct conflict with one another. The EU, for instance, guarantees workers certain work-life balance protections, including a minimum of four weeks of paid vacation per year. Physicians, however, are a scarce and finite resource. What happens when physicians exercise their mandated vacation time and there are not enough doctors available to meet patient demand?
In NYC, in the name of Mamdani’s equity, will the city compel physicians to accept every insurance plan? Should it mandate minimum patient quotas? Should it outlaw tiered care — framed through the lens of oppressor and oppressed — to enforce uniform outcomes?
If a city government can conscript doctors in these ways, what else can it command them to do?
