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BY: FR. CHARLES BOUCHARD, OP, STD

Debates about Medicaid and Medicaid expansion tend to revolve around two main issues: money and politics. But Medicaid, and health care reform in general, also are ethical questions. They are rooted in the Scriptural mandate to seek justice, exercise good stewardship and to care for the poor and vulnerable. This mandate is at the heart of Catholic social teaching, which favors the poor, protects human dignity and the common good. It has a relatively sanguine view of the role of government and consistently speaks of "us" rather than "me."

In the United States, those are countercultural values. As an example, let's look at some aspects of the ethical case for expanding Medicaid.

HEALTH CARE POLICY BY THE NUMBERS
The first step in any ethical analysis is to understand the problem. It is difficult in health care because health care economics 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 will 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 U.S. health care gets paid for, or how our health care expenditures compare to those in other countries.

The Paris-based Organization for Economic Cooperation and Development gathers and analyzes economic data from 36 countries and makes it available to policy organizations. These data show that the U.S. has the highest per capita health care expenditures in the world. In 2016, total health care spending (private and public funds) in the U.S. amounted to $9,892 per person. Canada, which has a similar standard of living, spent just $4,752.¹

Looking at expenditures as a percentage of the gross domestic product of each country yields similar results. The OECD's latest (2017) report shows the average expenditure across all 36 nations that are members of OECD is 9 percent of GDP. In the United States, all health care expenditures account for 17.2 percent of the GDP.²

There are a number of reasons for these disparities. High utilization, duplication of services (for example, tests that have to be repeated because we lack an integrated medical information system in the U.S.) and the high cost of prescription drugs (the U.S. government cannot negotiate or regulate drug prices like most other countries do) are major factors. Higher administrative costs for health care in the U.S. due to the complexity of our payment system are another factor. In 1999, health care administrative costs in the U.S. were $1,059 per capita, or 31 percent of all health care expenditures at that time; in Canada, administrative costs were $307 per capita (16.7 percent of expenditures). Fifteen years later, computerization and other efficiencies had reduced overhead for both countries, but in the U.S., health care administrative expenses still amounted to 25 percent of our total spending, while Canada spent only 12 percent.³

Despite our lavish spending on health care, millions of Americans have no coverage and no access except through the emergency room. By some measures (overall longevity and infant mortality, for example), U.S. outcomes are worse than in countries that spend less than we do.⁴

CATHOLIC SOCIAL TEACHING
Catholic social ethics goes back centuries, but it began to coalesce into a body of teaching with Leo XIII's On the Condition of Labor in 1891, which often is seen as the first "social encyclical." This tradition continues in our own time with Laudato Sí, Pope Francis' encyclical on the environment. Together these documents apply our ethical tradition to a wide range of social issues, from the condition of workers to the allocation of basic goods like health care and education. Unfortunately, efforts to catechize Catholic social teaching have failed, so it is considered by some to be the church's best-kept secret. Many are unaware of it entirely, some see it as optional, and some reject it as too idealistic (or socialist) and opt for more "businesslike" approaches.

Michael Gerson, a nationally syndicated columnist who is an evangelical, notes that Catholic social teaching is both a blessing and a lost opportunity. He writes, "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. And 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, splendidly complicating 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

THE ROLE OF GOVERNMENT
The role of government is at the heart of politics, but it is an ethical issue as well, because it involves balancing individual initiative with care for the common good. Some favor little or no government involvement, others favor more. All positions on the spectrum are based on an understanding of the best balance between individual freedom and government involvement.

In a 2017 opinion piece for Fox News, U.S. Rep. Kevin Yoder (R-Kansas) summarized the libertarian view and outlined common objections to the idea of expanding health care coverage to all. Yoder called such a plan "socialized medicine" that would raise costs, double taxes, expand the size of the federal government and lead to long wait times and a physician shortage. A single-payer system, he said, would force citizens into a "socialized health care system to receive insurance from central planners in Washington." This is unacceptable, he said, because Americans "value choice, competition and access to care. In socialized medicine, those luxuries would be gone."⁶

Yoder's position favors individual freedom and minimal government involvement. Catholic social teaching respects free choice and personal initiative, but it is biased toward the common good, which requires a relatively equitable distribution of basic human goods like health care. This is why we endorse expansion of government-administered health care — like Medicare and Medicaid — to cover all those without insurance. In other words, it is an ethical approach that places more priority emphasis on the group than on the individual.

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, where citizens can both contribute to the common good and benefit from it.⁷ However, societies use various forms of government to help create these conditions. Thomas Aquinas in the 13th 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 Aquinas 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.⁸

IS HEALTH CARE A RIGHT?
A right could be described as a "moral power," or the ability to expect something — freedom, education, respect or health care — from someone else. A right involves a corresponding obligation, and this interplay of rights and obligations is an aspect of justice, which is a fundamental aspect of ethics.

Physician and author Atul Gawande, MD, demonstrated how important the relationship between rights and obligations is when he interviewed friends from his hometown in southern Ohio. He asked them if 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 but chose not to.

The perception of Medicaid as an undeserved subsidy is the basis for several states to call for people to meet work requirements in order to receive Medicaid benefits. The truth is that the majority of working-age, adult Medicaid recipients do work. According to data from the Henry J. Kaiser Family Foundation, 60 percent of working-age, nondisabled Medicaid recipients work full- or part-time (39 percent of Medicaid beneficiaries are children who are too young to work). Eight out of 10 adult Medicaid beneficiaries live in households where at least one person is employed, and some adult beneficiaries are unable to work due to disability, illness or caregiving responsibilities.⁹

CHA's Medicaid Makes It Possible campaign is based on the principle of justice. However, our understanding of justice is not a cold, mathematical justice where you get what you can pay for. Instead, the Catholic social tradition talks about justice tempered by mercy, or perhaps something like the Jewish biblical concept of tzedakah. Sometimes called "social justice," tzedakah is really a combination of justice and charity, according to Rabbi Jonathan Sacks, an internationally known religious leader, author and philosopher. Tzedakah is based on a notion of collective freedom in which my freedom (or prosperity or health) is not bought at the price of yours. Sacks 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."¹⁰

Another way of saying this is that we are all in it together, so 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 essentially are social creatures, we cannot deny the reality of the community in which we live without a serious dose of self-delusion.

THE COMMON GOOD AND THE MARKET
I already have suggested that the Catholic tradition ascribes a relatively important role to the government in assuring the common good. But theologian William T. Cavanaugh, PhD, rightly observes that we need to be careful not to conflate government with society. Today, 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. The market, an elaborate system of exchanges based on financial rights and obligations, is one aspect of the ethical debate about Medicaid. But from the Catholic perspective, "the logic of the market" has led us to lose sight of the fundamental importance of society, which is not market-driven and which is prior to any form of government. This Catholic perspective is important in our day because much of the resistance to Medicaid comes not just from perceived injustice, but from suspicion of a government that many regard as its own closed and self-serving system. 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. We have to take our responsibility as members of society very seriously. The state may help facilitate the common good, but it is not the sole arbiter.

ETHICS AND ADVOCACY
I have tried to suggest a number of ways in which the debate about Medicaid is not just political and economic, but ethical. Not all politicians want to discuss basic human goods in ethical terms, but it is important for us in Catholic health care to do so.

The Catholic Health Association believes that Medicaid expansion is one important step toward greater justice and community solidarity. But it is not enough. We need to speak more loudly, make important distinctions about what we buy and what we have a right to, 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. These values must be negotiated through the political process, but they are not dispensable. They are not the domain of one political party, but oblige all Catholics — Republican, Democrat and independent. We need to reframe the debate from my taxes, my rights and my freedom to our health, our society and our mutual obligations.

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 of state-by-state Medicaid coverage, statistics and stories that show Medicaid coverage extends much further than most of us realize. We often say that it is a safety net, but in many ways, it also is 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 about 73 million children, the elderly, individuals with disabilities, veterans and working families to have access to high-quality, affordable health care services. This is not just a political challenge, but an ethical obligation.

FR. CHARLES BOUCHARD, OP, is senior director, theology and sponsorship, the Catholic Health Association, St. Louis.

NOTES

1. Organization for Economic Cooperation and Development, "Health Expenditure Per Capita," Health at a Glance 2017, OECD Indicators (Paris: OECD Publishing, 2017) 132-33. www.oecd-ilibrary.org/docserver/health_glance-2017-44-en.pdf?expires=1542665212&id=id&accname=guest&checksum=849AE60840892E6F785031F8B4F62C5E.
2. Organization for Economic Cooperation and Development, "Health Expenditure Per Capita."
3. David U. Himmelstein et al., "A Comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far," Health Affairs 33, no. 9 (Sept. 2014): 1586-94.
4. Data from the World Health Organization in 2015 shows that in life expectancy worldwide, the United States is No. 31, at 69 years. Compare this to Japan, Switzerland and Singapore, all of which are above age 80. The U.S. infant mortality rate, at 6.1 per 1,000 births, according to 2010 data, is more than twice as high as that of Finland, Japan, Portugal and Sweden, which have the fewest infant deaths. See Marian F. MacDorman et al., "International Comparisons of Infant Mortality and Related Factors: United States and Europe 2010," National Vital Statistics Reports 63, no. 5 (Sept. 24, 2014). www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05.pdf.
5. Michael Gerson, "The Last Temptation," The Atlantic, April 2018. www.theatlantic.com/magazine/archive/2018/04/the-last-temptation/554066/.
6. Kevin Yoder, "Republican Congresssman: Socialized Medicine Is Knocking on the Door, America," Fox News, June 11, 2017. www.foxnews.com/opinion/republican-congressman-socialized-medicine-is-knocking-on-the-door-america.print.
7. This view is found in Augustine, Thomas Aquinas and John Courtney Murray, the esteemed Jesuit theologian of public life.
8. 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."
9. Tami Luhby, "Millions of Medicaid Recipients Already Work," CNN Money, Jan. 10, 2018. https://money.cnn.com/2018/01/10/news/economy/medicaid-work-requirement/index.html.
10. Jonathan Sacks, The Dignity of Difference: How to Avoid a Clash of Civilizations (London: Continuum, 2003) 113-16.
11. William T. Cavanaugh uses Alasdair MacIntyre's comparison of government to the telephone company, both of which provide useful services. He argues that neither of them can bear the sacred trust of national destiny or the common good. See William T. Cavanaugh, "Killing for the Telephone Company: Why the Nation-State Is Not the Keeper of the Common Good," in In Search of the Common Good," ed. Patrick D. Miller and Dennis McCann (New York and London: T&T Clark, 2005) 301-30, at 319 and 320.