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BY: FR. CHARLES E. BOUCHARD, OP, S.T.D.

Fr. Bouchard is vice president, theological education, Ascension Health, St. Louis.

I used to think that if proponents of health care reform could properly frame the argument to support their cause, eventually they could persuade the public that the time was right for changes to the system. That may still be true, but dozens of books and articles on the topic — many arguing for transformation on the basis of solidarity, justice and the common good — have tried but apparently failed to make the case.¹ Americans continue to resist significant health care reform, even though they have recognized the inadequacy of the current system for many years. In fact, researcher Lawrence Jacobs wrote that between 1991 and 2007, "about 90 percent of Americans were fairly consistent in agreeing that the U.S. health system should be completely rebuilt or required fundamental changes. About 70 percent of Americans consistently believed the system was in a state of crisis or had major problems."²

This leads me to believe that resistance to health care reform is not rooted in reasoned argument or intellectual conviction. Rather, it is fear, an unarticulated anxiety that weighs in on the side of the status quo. These tacit fears were effectively tapped in the notorious Willie Horton television ads that aired during the 1988 presidential election — the ones about a felon that stirred the public's emotions on race and crime and contributed to George H. W. Bush's victory over Michael Dukakis.³ In the early 1990s, the Harry and Louise ads sponsored by the insurance industry tapped into the same fearful energy to help defeat the Clinton health plan.

Author Scott Bader-Saye, Ph.D., describes how this "culture of fear" shapes decisions as well as character.⁴ He notes that in the 2004 election "each party dressed itself in flag and uniform and portrayed the other party as dangerous.… The moral of the campaign: If you can't woo voters, scare them." As we know, that strategy continues today.

Bader-Saye also notes that fear "leads us to narrow the scope of our vision and assume a posture of self-preservation." This focused attention is a good thing when encountering a large hungry bear at the campsite, but when it is born of generalized anxiety, it creates a world view that "equates the good life with self-limitation and risk aversion." When this happens, "self-preservation trumps other goods and fosters a set of shadow virtues." Justice and public health are at least two of the goods that are trumped. Inhospitality, xenophobia and callousness are some of the "shadow virtues" (which I would actually call "vices") that are fostered.

St. Thomas Aquinas reminds us that "fear is born of love," because fear arises from the prospect of losing something we love. He also wrote that fear is inappropriate if the object of society's fear is slight, or remote, or if we fear the loss of something which we love too much.⁵

If St. Thomas were to apply his analysis to health care reform, he would say the object of the public's fear — the loss of health care — is not slight, because health care is a basic human good. Nor are threats to health care so remote that they should not cause fear. Limited finances, demographics and uneven distribution of health care resources pose real threats to modern health care. The real issue seems to be whether the public's "love" for the current health care system is excessive. Does America's love of "things-as-they-are" and the public's fear of change conflict with obligations to justice and to the common good?

What Are We Afraid Of?
As of last year, an overwhelming majority of Americans said they believe the U.S. health care system needs serious change,⁶ yet we are not moved to bring that change because Americans are clearly afraid of something. Let's examine four specific ways in which fear has immobilized the public on the issue of health care reform.

1) Loss of Autonomy and Choice
People like me, who are relatively healthy with good insurance, have far greater autonomy than those who are sick and uninsured. I am free to travel, study, write, take an occasional bicycle ride and generally enjoy life. People with chronic illness and inadequate health insurance don't have so many freedoms. I may acknowledge problems with the system at a theoretical level, but on a practical level, my coverage greatly enhances my life.

Choice is important, too. Those who have a "medical home" value the relationship they have built with their physician and do not want to lose it. I recently changed jobs and discovered that one of my long-time health care providers is not part of my current employer's network. Fortunately, I can afford the higher deductible and co-payment required for going out of network. Others may not have that choice.

I recently took another look at the Harry and Louise ads from 1993, and recalled how directly their message played to fear about loss of autonomy and choice. In the course of their kitchen-table dialogue — a setting designed to look familiar to certain middle-class voters who were rich enough to have good insurance but not so rich that health care reform didn't worry them — Louise suggested that reform will allow the government to "force us to pick from a few health care plans designed by government bureaucrats" and said repeatedly, "If they [i.e., government bureaucrats] choose, we lose." A voice-over urges listeners to act "for reforms that protect what we have." What people had, of course, was health insurance.

2) Anarchy and Xenophobia
The lack of an adequate immigration policy has created a tangle of anxiety that directly affects health care reform efforts. We have millions of undocumented non-citizens living within U.S. borders. They sneaked into this country and remain illegal because no orderly path to citizenship exists once they arrive.

Many Americans oppose health care reform because they fear that increased access will reward undocumented immigrants, whom they view as troublemaking lawbreakers and public burdens at taxpayers' expense. In fact, a good number of conservative commentators view the combination of lax immigration policy and growing numbers of illegal immigrants as tantamount to anarchy. If a quick web search for the words "immigration" and "anarchy" is any indication, Daniel Sheehy's book Fighting Immigration Anarchy has become a rallying point for those who fear the fact and the cost of immigrants.⁷

This fear is based on an understanding of health care as a commodity that must be purchased with hard work or status. It ignores the medical fact that my health is jeopardized by those around me who are sick as well as the financial fact that lack of basic and preventive care leads to more expensive care down the line. Plus, it ignores the health needs of innocent children who have no choice about their country of residence.

3) Socialized Medicine and Government Control
Even though it is not clear what "small government" would look like in a country the size of the United States, Americans have a well-honed aversion to anything they perceive as "big government." This antipathy becomes shrill when government is invoked in the same sentence as health care. The thought of "government-run" health care or "socialized medicine" is not palatable to many Americans.

Economist Uwe Reinhardt, Ph.D., notes the public's willful confusion and refusal to critically examine any concept that has "social" in it: "The term 'socialized medicine' in particular conveys to some an objectionably 'un-American' form of government. … In the American vernacular, the term 'socialized medicine,' when it is not being confused with 'socialism' outright, often is confused with 'social health insurance.'"⁸

The more popular political version of this conviction runs something like this:

"Families should be in charge of their own health care dollars. Rising health care costs are a problem, and the best way to bring them down is to increase competition among health care providers — to let the free market work. The last thing we need is the government taking over health care and creating a massive bureaucracy … The answer to our health care problems is a freer market, not socialized medicine"⁹ (Editor's note: italics by author for emphasis)

The health systems in Canada and England — although very different from one another — are frequently lumped and invoked as examples of what government involvement and socialized medicine bring: inefficiency, long waits, outdated equipment and too few beds. As one blogger describes Canadian health care: "It is just like the old Soviet system: everything is free, nothing is readily available."¹⁰

4) The "R" Word
Even though the meaning of the "R" word is not clear, it evokes more fear than all the rest. In fact, some advocacy groups don't even want to use the word "rationing" lest it sound an alarm and preempt discussion of reform altogether.

Some years ago, professors Stephen Boren, M.D., and David Boren tried to get at the intended meaning of rationing when it appeared in an article in the New England Journal of Medicine. In a letter to the editor, they asked whether rationing meant:

"that the providers … third-party payers (or both) are not making available the health care that Americans seek? ... [or] that a conscious decision has been made by providers not to give this care because it is too expensive? … [or] that providers are not giving Americans all the services they demand because it has been deemed that some services are not medically necessary? [or] that because third-party payers refuse to reimburse providers, providers refuse to supply them? [or] that the need for health care exceeds the capabilities of our health care system, forcing a triage situation?"¹¹

Rationing may mean any of the things cited in the Borens' letter, but for American consumers it primarily means two things: the inability to buy what you want when you want it and that someone else will make the decision about whether you are able to buy it. As Harry and Louise said, "If they choose, we lose." The fear isn't just that some people can't get what they need; the fear is that I won't get what I have the money to pay for.

People have commodified and consumerized health care to such an extent that most people see it as just another product.¹² They ignore the fact that nobody owns health care because it is the result of cooperation, sacrifice, learning and suffering of countless persons who have gone before us.

Tipping the Balance from Fear to Hope
Alex John London, Ph.D., a professor at Carnegie Mellon University, said that "fear becomes our shared story in the absence of an account of goods and goals." Until now, the public has chosen fear — fear that freedom and choice will be usurped, fear of government, fear of escalating costs, fear of foreigners, and fear of lawlessness. This has led Americans to reject a coherent set of goods and goals and to view the common good not as "the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfillment more fully and more easily"¹³ but as an "entity that exists in its own right with interests distinct from those of its individual members."¹⁴ This, London observes, is a "zero-sum" approach in which the common good and the interests of individuals can be secured only at each others' expense.¹⁵ In other words, if society wins, individual citizens lose.

Jack Glaser, STD, director of the Center for Healthcare Reform for St. Joseph Health System in Orange, Calif., said this unwillingness to adopt a common set of goods has created a "chronic social injustice" that saturates the public's minds and imaginations. Thus far, he said, no "shared vision powerful enough to overcome it" exists, but he is convinced that the multifaceted "public conscience work" can help reshape attitudes and lead to change.¹⁶

Effective "public conscience work" would help Americans reshape attitudes about the common good so that it is not seen as a separate entity that competes with my own good, but as the intersection of my own interests with those of others.

The Catholic Health Association and Ascension Health have developed sets of "principles" or "features" by which health care reform proposals may be assessed. They aim at the common good yet intersect with individual concerns about access, allocation, cost and choice. A summary of CHA's principles¹⁷ suggests that reform must make health care:

• Available and accessible (especially for poor and vulnerable)
• Health and prevention oriented
• Sufficiently and fairly financed
• Transparent and consensus-driven in allocation and organized for cost-effectiveness
• Patient centered
• Safe, effective and high quality

We need to continue developing reasoned arguments for these principles, but must remember that effective health care reform is not an entirely rational matter. We can help shape public conscience by communicating the values that underlie CHA's principles on many levels: intellectually, rationally, emotionally and metaphorically. We must invoke image and story — in language that is probably closer to preaching than marketing — in order to draw public opinion to a "tipping point" where people recognize that apart from the nourishing soil of the common good, personal and private interests wither and die.¹⁸

NOTES

1. Two excellent resources are: Jose Lavastida, Health Care and the Common Good: A Catholic Theory of Justice (Lanham, Md.: University Press of America, 2000) and Daniel Callahan, "Individual Good and Common Good," Perspectives in Biology and Medicine 46, no. 4 (Autumn 2003): 496-507. Also, Health Progress published one article on the common good as a force for change (79, no. 1, pp. 40-42), five articles on the common good in a 1999 special issue (80, no. 3), and one on nursing and the common good in 2006 (87, no. 6, pp. 59-63). In 2006, Catholic Charities USA focused its annual meeting on the common good and the poor.
2. Lawrence R. Jacobs, "1994 All Over Again? Public Opinion and Health Care," New England Journal of Medicine 358 (May 1, 2008): 1881-83.
3. The controversial Willie Horton television ads aired during the 1988 presidential campaign and became a major point of discussion in the media and the general public. The ads, launched by the National Security Political Action Committee, showed a mug shot of Horton, an African-American convict, who attacked two people in Maryland while he was out of prison as part of a Massachusetts prison furlough program overseen by Dukakis, then the state's governor. The intention of the ads was to question whether Dukakis was soft on crime. Critics viewed them as a method to stir racial fears.
4. Scott Bader-Saye, "Thomas Aquinas and the Culture of Fear," Journal of the Society of Christian Ethics 25, no. 2 (2005): 95-108.
5. St. Thomas Aquinas treats fear as an emotion in the Summa Theologica, 1-2, qq. 42-44; and as a vice opposed to courage (Summa Theologica 2-2, qq. 125-26).
6. An August 2008 survey released by The Commonwealth Fund indicated that 82 percent of Americans think the health care system should be "fundamentally changed or completely rebuilt." The survey is available online at www.commonwealthfund.org/newsroom.
7. Daniel Sheehy, Fighting Immigration Anarchy (Bloomington, Ind.: Rooftop Publishing, 2006), 7.
8. Uwe Reinhardt, "The True Cost of Care," America (September 8, 2008): 10.
9. Celinda Lake and Drew Westen, How To Talk About Health Care Reform: Summary of Research on Health Care Messaging (Washington, D.C.: Lake Research Partners and Westen Strategies, May 22, 2008), 5. This hypothetical "conservative message" was drafted by Democratic pollsters Lake and Westen and based on the words of 2008 Republican presidential nominee Sen. John McCain, R-Ariz. The document is available online at www.familiesusa.org.
10. David Gratzer, "Why Isn't Government Health Care the Answer?" http://freemarketcure.com/whynotgovhc.php.
11. Stephen and David Boren, letter to the editor, New England Journal of Medicine, July 15, 1999.
12. Think about this the next time you see a billboard or a television ad for a particular procedure. The message is "buy it here!" as though there is an endless supply and it is just a question of choosing between Walmart and Costco.
13. United States Catholic Conference, Catechism of the Catholic Church (New York: Doubleday, 1994), no. 1906.
14. Alex John London, "Threats to the Common Good: Biochemical Weapons and Human Research," Hastings Center Report 33, no. 5 (September-October 2003): 17-25, 19, 21.
15. London.
16. See the center's website at www.stjoechr.org. Jack Glaser describes public conscience work as "cumulative engagement at all levels of society in communities of respectful structured reflection … that generates integrated understanding and energy of will for change."
17. A complete description is available at www.chausa.org. Ascension Health has developed a similar set of "Guiding Features" of a reformed health care policy: 1) 100 percent access; 2) 100 percent coverage; 3) insurance benefit package equity; 4) attention to mission-critical groups (e.g., the poor); 5) insurance reforms that include a broad insurance pool; and 6) economic viability that requires all stakeholders to share funding.
18. In his book, The Tipping Point: How Little Things Can Make a Big Difference  (Boston: Little, Brown, 2000), author Malcolm Gladstone uses the analogy of an epidemic to show how the tipping point is a moment of critical mass, a threshold or a boiling point. Can we "tip" prevailing attitudes about health care by starting small and building the same kind of political momentum that led to the Civil Rights Act of 1964 or the attitudinal momentum that led to the stigmatization of smoking?