Fr. Charles Bouchard, O.P., S.T.D.
The obstacles we face as we promote wider access to health care
It is no secret that federal funding for health programs like Medicaid is in jeopardy. Despite the Affordable Care Act's goal to provide coverage for more people by allowing states to expand Medicaid with mostly federal funds, only 34 states including the District of Columbia have done so. Currently, three other states are considering expansion, and 13 states remain opposed. They want to avoid further government involvement in health care, reduce costs down the line, or both.
Various members of Congress have proposed replacing the current federal Medicaid program funding with block grants that states could use as they want or impose per person funding limits known as "per-capita caps" to limit growth. While these proposals reflect a legitimate concern about rising health care costs, they would not improve health or cover more people. About all they would do is pass costs on to states, beneficiaries and to charity programs like those available in our hospitals.
However, the effort to preserve and improve access to the Medicaid program is not just about politics or finances. It is also an inherently ethical question rooted in a biblical mandate, emphasized in both the Hebrew and Christian scriptures to care for the poor and the vulnerable. This mandate led to the gradual development of Catholic social teaching which favors the poor, protects human dignity and the common good, and consistently speaks of "us" rather than "me." In our culture, this precept is countercultural to say the least.
As ethicists, we spend a lot of time on the specific and sometimes technical clinical cases, what we might call "micro ethics". These are the fun parts (at least from an ethicist's perspective), but we can't stop there. We have to address the big ethical questions, the macro issues that go far beyond clinical settings and into our legislatures, our city halls, and even our streets. We have to build support for continuation and expansion of Medicaid and similar programs. To do that, we must have persuasive answers to serious recurring questions. There are least three challenging issues involved: Questions about health care finance, lack of appreciation of Catholic social teaching, and clarifying the legitimate role of government.
GET TO THE TRUTH ABOUT HEALTH CARE FINANCE.
The economics of health care are enormously complicated and not transparent. This is true on a personal level and on an organizational level. If you Google "understanding my hospital bill," you'll see that virtually every provider and many payers have tutorials for patients who don't have a clue what all those numbers mean. On a policy level, few Americans understand how health care gets paid for in the U.S., or that that we have the highest per capita health care costs in the world. In 2016, we spent $10,348 per person on health care costs, compared to Canada, which spent just $4,752.1Administration costs are one reason for the disparity. In 1999, the administrative costs of health care in the U.S. were $1,059 per capita (31 percent of health care expenditures); in Canada they were $307 per capita (16.7 percent of expenditures). Fifteen years later, computerization and other efficiencies had reduced overhead for both countries, but the U.S. still spent 25 percent of its budget on administrative expenses, while Canada spent only 12 percent.2 Administrative costs for Medicare, on the other hand, are far lower, somewhere between 1.5 and 3 percent, depending on whether you count Medicare Advantage plans.3 We pay far more than residents of any other industrialized country, yet millions of people have no coverage, and in some areas, our outcomes are worse than countries that spend less than we do. So, the argument that universal coverage would be too expensive doesn't hold much water. We spend plenty of money on health care, but we are not spending it wisely.
KEEP TALKING ABOUT CATHOLIC SOCIAL TEACHING.
Someone once said that Catholic social teaching is the church's best kept secret. Especially in its current form, this teaching is the result of centuries of theological reflection which coalesced into a body of teaching in the late 19th century. We have failed in our efforts to catechize Catholics about this tradition. Many are unaware of it entirely and some of those who do know about it often see it as optional, or as a matter of "business decisions" rather than ethical choices. Some Catholic thinkers have even managed to merge free-market theory Catholic social teaching and come up with an approach Ayn Rand would like: heavy on autonomy and subsidiarity, light on solidarity and the common good.4
Michael Gerson, an op-ed columnist for the Washington Post, notes that our social teaching is both a blessing and a lost opportunity. Even though he is an evangelical, he says,
"Modern evangelicalism has an important intellectual piece missing. It lacks a model or idea of political engagement ... Catholics [on the other hand], developed a coherent, comprehensive tradition of social and political reflection. [It] includes a commitment to solidarity, whereby justice in society is measured by the treatment of its weakest and most vulnerable members. It incorporates the principle of subsidiarity, the idea that human needs are best met by small and local institutions.
In practice, this acts as an 'if-then' requirement for Catholics [but] it splendidly complicates their politics. If you want to call yourself pro-life on abortion, then you have to oppose the dehumanization of immigrants. If you criticize the devaluation of life by euthanasia, then you must criticize the devaluation of life by racism. If you want to be regarded as pro-family then you have to support access to health care. And vice versa. [This view] requires a broad, consistent view of justice which ... cuts across the categories and clichés of American politics. Of course, American Catholics routinely ignore Catholic social thought. But at least they have it."5
CAN ANYTHING GOOD COME FROM GOVERNMENT?
Another problem is the general cynicism about government. I recently referred to an article by Atul Gawande6 that was based on his interviews with friends from his home town in southern Ohio. When he asked them whether they considered health care to be a right, he found that they generally approved of Medicare, because everyone paid into it and everyone benefited. They saw this as fair and equitable. Medicaid, however, was another story. His middle-class friends saw it as a giveaway to people who didn't earn it and didn't deserve it. They felt they were subsidizing the health care costs of people who were able to work. Of course, some people game the system and get care they could pay for. But the truth is that the majority of working age, adult Medicaid recipients do work. This is not widely understood. According to recent data from the Kaiser Family Foundation, 60 percent of working age, non-disabled Medicaid recipients work full- or part-time. Eight out of ten adult Medicaid beneficiaries are in working families, and need the services and security of Medicaid to continue to work. Moreover, some adult beneficiaries are unable to work due to disability, illness or caregiving responsibilities.7 It is also important to note that 39 percent of Medicaid beneficiaries are children who are too young to work.
When we argue for Medicaid, we are invoking the principle of justice, but not a cold, mathematical justice where you get what you can afford. Instead, our tradition talks about justice tempered by mercy or perhaps something like the Jewish biblical concept of tzedakah. Sometimes called "social justice," Rabbi Jonathan Sacks says tzedakah is really a combination of justice and charity. It is based on a notion of collective freedom, in which my freedom (or prosperity or health) is not bought at the price of yours. He says flatly, "A society in which a few prosper and the many starve, in which some but not all have access to good education, health care and essential amenities, is not a place of liberty." 8 It is easy to see where Catholic social teaching comes from. In fact, these close connections have sometimes led me to speak of "the Judaeo-Catholic" tradition rather than the "Judaeo-Christian" tradition, because many forms of Christianity, including much of Evangelicalism, reject the assumptions about community underlying this argument in favor of individual freedom and the market.
This brings us to the idea of the state, which has been the object of academic inquiry for centuries. Where did the idea of the state come from? What does it have to do with society and the common good? Is it a creation of society, or vice versa?
Catholic social teaching generally holds that society comes first, as the natural assembly of people who work together to create a place that is hospitable to all,9 a place where citizens can both contribute to the common good and benefit from it. Societies use various forms of government to bring about and ensure that hospitality. Thomas Aquinas in the thirteenth century had a fairly optimistic view of government, or "dominion" as he called it. He asked whether in paradise, before the fall, there would have been dominion. One would assume that in paradise, free of sin, there would be no need for it. But he said that even before the fall — and presumably in the life to come — there is need for authority or dominion in order to distribute all the goods of creation.10 In view of the current state of the common good and politics in general, this is indeed a hard teaching!
Some thinkers have looked at our political life and concluded that government, the state as we know it, cannot be the guardian of the common good. William T. Cavanaugh, for example, says it is more like the telephone company of old, a well-meaning but inept public service that can in no way contain or manage something as sacred as the common good. He says the state's role as guardian of the common good has been compromised first, because of the "symbiosis of state and corporation", which clearly was not possible before the profit economy; and second, because every aspect of our lives has been "colonized by the logic of the market."11 We in North America are conditioned to see everything in light of market justice. We lose sight of the fundamental importance of society, which is not market-driven and which is prior to any form of government. This is important in our day because much of the resistance to Medicaid comes not just from anger at a perceived injustice, but from suspicion of the state, which many people identify with society. Note how many political campaigns attempt to disparage their opponents by saying that they are "Washington insiders," or that they have "gone to Washington," or even that they are part of a "deep state" that is running things behind the scenes, suggesting they have sold out to the bureaucracy. It is crucial to remember that it is not the government or the state that has the responsibility of providing health care, but society, we the people. This means that we have to take our responsibility as members of society very seriously.
If all else fails, it doesn't hurt to remind ourselves that when we think about health care, there is a little self-interest involved. Even if you are prosperous enough to have coverage for health care, (or education or a safe neighborhood) do you really want to live in a sick, illiterate and lawless society? Since we are essentially social creatures, we cannot deny the reality of the community in which we live without a serious dose of self-delusion.
MEDICAID MAKES IT POSSIBLE
These are some of the obstacles we face as we continue to support universal access to health care. We see preserving Medicaid and even expanding it as one step in that direction, but it is not enough. We need to speak more loudly, make important distinctions and help our society understand that justice, the common good and even tzedakah are not political decorations. They are at the heart of who we are as Catholics. They are negotiable, but not dispensable. They are not the domain of one political party, but oblige all Catholics - Republican, Democrat, or independent.
CHA has developed a website, www.chausa.org/Medicaid, that is full of resources to help us make that argument. It contains an interactive map that shows state-by-state Medicaid coverage, statistics (like those we have graphed here), and stories that show that not all Medicaid recipients are the "usual suspects." Medicaid coverage extends much further than most of us realize. It is a safety net, as we often say, but in many ways, it is also a social and economic glue that tries to compensate for the huge disparities in income, wealth, health status and access to health care.
We hope you will join us in raising a national voice for Medicaid to Make It Possible for the nearly 74 million children, the elderly, individuals with disabilities, veterans and working families to have access to high-quality, affordable health care services. As we learn from Catholic social teaching, health care is a basic human right essential to human dignity.
FR. CHARLES BOUCHARD, O.P., S.T.D.
Senior Director, Theology & Sponsorship
Catholic Health Association
St. Louis
[email protected]
ENDNOTES
1 Peterson-Kaiser Health System Tracker, "How does health spending in the U.S. compare to other countries?" by Bradley Sawyer and Cynthia Cox. Kaiser Family Foundation Chart Collections, Health Spending, Posted: February 13, 2018.
2 D.U. Himmelstein et al., "A comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far," Health Affairs (Sept 2014 33[9]: 1586-94.
3 Physicians for a National Health Program, "Setting the Record Straight on Medicare's Overhead Costs," posted on February 20, 2013. http://www.pnhp.org/news/2013/february/setting-the-record-straight-on-medicare%E2%80%99s-overhead-costs. More recently, Senator Jeff Merkley of Oregon said overhead costs were about 3%. Washington Post, September 19, 2017. https://www.washingtonpost.com/news/fact-checker/wp/2017/09/19/medicare-private-insurance-and-administrative-costs-a-democratic-talking-point/?utm_term=.ab3e9281cce6
4 The Acton Institute in Grand Rapids, Michigan, is a good example of this alternate approach. Their web page says the the Institute is "was founded on the basis of ten Core Principles, integrating Judeo-Christian Truths with Free Market Principles."
5 "How Evangelicals Lost Their Way and Got Hooked by Donald Trump," The Atlantic, April 2018.
6 Atul Gawande, "Is Health Care a Right?" The New Yorker
7 "Millions of Medicaid Recipients Already Work," a CNN report based on figures from the Kaiser Family Foundation. https://money.cnn.com/2018/01/10/news/economy/medicaid-work.../index.html
8 Jonathan Sacks, The Dignity of Difference (London and New York, Continuum, 2002) especially Chapter 6, "Compassion: The Idea of Tzedakah", at p. 116.
9 This view is found in Augustine, Aquinas and John Courtney Murray, the esteemed Jesuit theologian of public life.
10 Thomas Aquinas, Summa Theologica, I, q. 96, a. 4, ad 1: "Because man is naturally a social being, and so in the state of innocence he would have led a social life. Now a social life cannot exist among a number of people unless under the presidency of one to look after the common good; for many, as such, seek many things, whereas one attends only to one. Wherefore the Philosopher says, in the beginning of the Politics, that wherever many things are directed to one, we shall always find one at the head directing them."
11 "Killing for the Telephone Company: Why the Nation-State is Not the Keeper of the Common Good," in In Search of the Common Good," Miller and McCann, eds. (New York and London: T &T Clark, 2005) 301-330, at 319 and 320.
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