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BY: GERALD J. BEYER, PhD

In his book The Healing of America, journalist T.R. Reid relates the tragic story of a 32-year-old woman who died of lupus. According to her physician, she died "because of a lack of access to health care," not because of the disease. Reid contends that had she lived in Japan, Germany, Britain or most other industrialized nations, her treatment would have been guaranteed, and lupus would not have claimed her life prematurely.¹

That story jarred me. I knew a 27-year-old man who died of cancer. He was an industrious and affable person who immigrated to the U.S. in search of a better life. Since he could not afford health insurance, he eschewed early diagnosis and treatment. He consigned himself to death so that his wife and daughter might survive financially.

A SYSTEMIC PROBLEM
Prior to the Patient Protection and Affordable Care Act of 2010 (ACA), more than 20,000 Americans perished yearly from manageable illnesses because they were unable to pay for treatment.² A 2009 study estimated that as many as 44,789 Americans die annually because they lacked health insurance.³ The United States has the worst avoidable mortality rate among industrialized countries.

The U.S. also has the highest infant mortality rate among wealthy nations — more than twice that of countries like Japan and Sweden (which have free prenatal and neonatal care).⁴ Within the U.S., children's chances of survival vary greatly according to socioeconomic status and race. New research suggests that children of wealthy, educated, white women are as likely to celebrate their first birthday as any child in Finland or Austria. In those countries, children of the rich and poor survive to age 1 at similar rates, whereas children of disadvantaged groups in the U.S. have much higher post-neonatal mortality rates.5 Evidence indicates that expansive poverty and economic inequality in the U.S. (vis-à-vis other developed nations) engender poor health. These phenomena stifle access to health care and salubrious goods for many Americans (fitness centers, bike paths, nutritious food, etc.).⁶

Racism exacerbates the class-based disparities in U.S. health care access and outcomes. As bioethicist Peter Clark, SJ, PhD, has documented, "racism is alive and well by some members of the medical profession."⁷ For example, African-Americans and Latinos receive experimental treatments or participate in clinical trials far less frequently than whites. Researchers often overlook minorities for clinical trials because they believe minorities are less capable of following protocols. This discrimination, along with other factors such as disproportionate rates of uninsurance, leads to death rates almost two times higher among blacks than among whites from all cancers, diabetes and heart disease.⁸

Even when minorities are insured and well-educated, societal racism still generates worse health outcomes. Exposure to racial prejudice and stigma elevates levels of stress, leading to high blood pressure and other negative health consequences. This stress may account for black women with university degrees having an infant mortality rate almost three times higher than similarly educated white women.⁹ In short, the evidence of racial disparities in U.S. health care is overwhelming.¹⁰

Reid rightly argues that political, economic and medical decisions shape all health care systems, but providing universal access to health care is primarily "a moral one."¹¹ In the light of Catholic social teaching, a society that allows people to suffer and die needlessly while affording state-of-the art care and longevity to the privileged is a society that lacks solidarity.

SOLIDARITY IN CATHOLIC SOCIAL TEACHING
A relational anthropology that sees human beings as interdependent undergirds the Catholic ethic of solidarity.¹² The insight that we need each other to flourish obliges us to recognize our duties to one another.¹³ It should also dispose us to discover "the reality of the poor" and wounded among us.¹⁴ Reflection on human experience, Scripture and Christian theology evinces human interdependence and our obligations to each other.¹⁵ We belong to "one body" (1 Cor. 12:12-26) and are called to reflect the model of solidarity embodied by the loving and mutual relationships of the Trinitarian God.¹⁶ Jesus tells us to emulate him, the one who washed the feet of his disciples (John 13: 1-17), and to show particular concern for people who are poor and the marginalized (e.g. Luke 10:25-37; Matthew 25).¹⁷

Given the vast and ongoing disparities in capacities and well-being among human beings, solidarity requires more than fleeting assistance. We should perform acts of kindness and mercy to alleviate immediate physical, mental or spiritual suffering. However, solidarity entails an enduring commitment to the common good, which requires a conversion of heart and creating social and institutional structures that promote the participation and rights of all.¹⁸ As Pope Francis contends, solidarity seeks to eliminate the "structural causes of poverty." This "preferential option for the poor" requires creating laws, policies, communities and institutions that embody solidarity and prioritize the needs and rights of the poor. Like every human being, individuals who are poor have a right to education, access to health care, jobs with just wages, and other goods needed for "integral development."¹⁹ Solidarity seeks to empower the poor, not create passive beneficiaries, so that they may participate in and contribute to the common good.²⁰

Solidarity strives to mend the broken world, wracked by disease, poverty and violence. Duties of solidarity to others thus exist on the local, national and global levels and in all spheres of life: family, work, education and culture, social welfare, politics and government, and international relations and trade.²¹ Many thinkers (e.g., Karl Marx, Max Weber) have argued solidarity is only possible within groups against common adversaries.²² Conversely, Catholicism posits that while human beings often are self-centered due to original sin, Christ's example and grace can empower humans to embody solidarity across classes, genders, races, religions and nations.²³

People with wealth and power have both the ability and responsibility to realize their freedom in solidarity with others, not to abuse it through overconsumption and hoarding, as Pope John Paul II stated.²⁴ They must renounce the solipsistic pursuit of material advantage, share their goods and "restore to the poor what belongs to them."²⁵ Thus, solidarity rejects inordinate attachment to accruing private property, as God destines all goods for the sake of all humanity. This belief in the "universal destination of all goods" undergirds Catholicism's insistence that citizens pay taxes proportionate to their income for the sake of the common good and in solidarity with the less fortunate.²⁶

Charity will always be necessary, Pope Benedict stated, but Christians also must foster the common good through "the institutional path — we might also call it the political path — of charity, no less excellent and effective than the kind of charity which encounters the neighbor directly." Fostering the common good in solidarity with others must entail utilizing "that complex of institutions that give structure to the life of society, juridically, civilly, politically and culturally, making it the pólis, or 'city.'"²⁷

Dialogue remains a key method of solidarity. However, sometimes solidarity requires nonviolent struggle for the sake of the common good.²⁸ The powerful do not always divest themselves of unjust advantages that preclude solidarity.

SOLIDARITY AND HEALTH CARE
The Catholic ethic of solidarity has clear implications for health care. As Pope Francis recently put it, solidarity necessitates "the creation of a new mindset which thinks in terms of community and the priority of life of all over the appropriation of goods by a few."²⁹ If preserving the lives of all people constitutes the litmus test for solidarity, the health care system in the U.S. largely fails, as the evidence above indicates. Any health care system that seeks to protect all people regardless of age, race or social class requires acknowledging that we must "bear one another's burdens" (Galatians 6:2).30 As a society, we must recognize the duty to protect one another from every affront to human dignity, including unnecessary pain, suffering and death.

In other words, the universal right to health care must be grounded in an ethic of solidarity. As bioethicist Daniel Callahan, PhD, puts it, solidarity represents the "best basis for universal care, better than justice or rights."31 Solidarity includes advocating basic rights, such as the right to health care, but moves beyond individuals asserting their claims to a vision of mutual protection of the rights of others, in particular the weakest members of the human family.

In Europe, the principle of solidarity continues to explicitly bolster the universal health care systems in place, even if rising costs and desire for less taxation present challenges.³² Unlike the United States, Europe has a long, robust tradition of solidarity in political and social discourse, which has translated into more ample social protections.³³ Callahan and others lament that American history and culture lack the "sense of solidarity" necessary for undertaking reform that would truly make quality health care accessible to all.³⁴

The idea of solidarity may not have the lineage here that it does in Europe, and it does not enjoy widespread popularity today. Yet, there have been times in American history, such as the Reconstruction and New Deal eras, where citizens and elected leaders have acted in solidarity for the sake of the common good.³⁵ The rise of neoliberalism in the 1980s and its attendant notion of freedom as license, or freedom from constraint, has all but erased solidarity from the American collective consciousness.³⁶ Nonetheless, columnist E. J. Dionne, Jr., PhD, has argued convincingly that the United States has an individualistic and communitarian heritage. Dionne, a senior fellow at the Brookings Institution and professor of public policy at Georgetown University, insists that "capitalism is part of our narrative, but so are solidarity and the idea that no one ever really goes it alone."³⁷

Perhaps it is wishful thinking to propose that American society can hark back to solidarity to promote access to affordable health care for all in this age of "radical individualism."³⁸ Reducing premature mortality and avoidable morbidity require rejecting the "radical individualism" that characterizes health care discourse in the U.S. in favor of solidarity.³⁹ Recognizing our duties to one another also means accepting that access to health care cannot be determined solely by market mechanisms, which in the U.S. prioritize ability to pay and drive health insurance companies to maximize dividends for shareholders.⁴⁰

Americans must renounce their fear of "big government," the primary cause of resistance to the ACA.⁴¹ Universal access does not necessarily mandate a government-run, single-payer system. The health care systems in Germany, Holland, Switzerland and Japan rely on multi-payer health care delivery systems, permitting competition among insurers and providers. However, their governments regulate insurers and providers. Provider fees and insurance rates are capped, and insurance companies (largely nonprofit) cannot deny or terminate coverage of the sick.⁴² Each of these countries provides universal coverage and ranks much better than the U.S. on infant mortality, avoidable mortality, survival rate and healthy life expectancy at age 60 indices.⁴³

The ACA has moved toward solidarity by helping approximately 17 million people gain health coverage. No longer can insurance companies refuse coverage due to pre-existing conditions or benefit caps. But the ACA may leave more than 20 million uncovered. Furthermore, currently more than 31 million are "underinsured" and vulnerable to medical debt.⁴⁴

Solidarity in health care requires sacrifice. The relatively affluent must be willing to incur greater costs. As ethicist David M. Craig, PhD, has elegantly argued, access to health care for all will not happen "without a solidarity supplement from a 'We Party' movement that strikes covenantal chords of everyone's being at the table — both in having covered access to health care and in taking responsibility for paying into and managing the cost of the system. The future direction of health care reform depends on whether Americans can make solidarity a cornerstone value of U.S. health care."⁴⁵

Solidarity in U.S. health care also requires combatting the pernicious effects of racism on the health of minorities. The Catholic principle of solidarity must be institutionalized in a way that combats systemic racism and white privilege wherever it exists.⁴⁶ Given the evidence of racial discrimination in health care and racial disparities in outcomes, the United States Conference of Catholic Bishop's call, in its 1979 pastoral letter Brothers and Sisters to Us, to dismantle racism by undertaking "an equally radical transformation, in our own minds and hearts as well as in the structure of society" remains urgent today.

As health policy specialist and author Deborah Stone, PhD, research professor of government at Dartmouth College in Hanover, New Hampshire, demonstrates, the market-driven U.S. health care system "creates, perpetuates and intensifies racial and ethnic disparities" and "allows racism to continue under cover of economic justifications."⁴⁷ Therefore, in order to better protect the lives of people of color, the principle of solidarity requires acknowledging that health care is one of those human needs Pope John Paul II maintained cannot exclusively be "satisfied by market mechanisms."⁴⁸ Whites also must denounce racism and promote racial solidarity with their sisters and brothers of color. Their health, and the health of the nation as a whole, depend on it.

GERALD J. BEYER is associate professor of Christian ethics in the Department of Theology and Religious Studies at Villanova University, Villanova, Pennsylvania.

1. T. R. Reid, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, 2nd edition with a new afterword. (New York: Penguin Press, 2010), 1-2.
2. Reid, 2.
3. Andrew P. Wilper et al., "Health Insurance and Mortality in U.S. Adults," American Journal of Public Health 99, no. 12 (2009): 2289-95. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/.
4. Reid, The Healing of America, 2,32. See also 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 (2014): 1-6.
5. Alice Chen, Emily Oster and Heidi Williams, "Why Is Infant Mortality Higher in the U.S. Than in Europe?" NBER Bulletin on Aging and Health 15 (2015), http://www.nber.org/aginghealth/2015no1/w20525.html. See also the full report: "Why Is Infant Mortality Higher in the U.S. Than in Europe?," NBER Working Paper No. 20525 (National Bureau of Economic Research, 2014).
6. Ichiro Kawachi, "Why the United States is Not Number One in Health" in ed. James A. Morone and Lawrence R. Jacobs, Healthy, Wealthy, and Fair (Oxford: Oxford University Press, 2005), 19-33.
7. Peter A. Clark, "Prejudice and the Medical Profession: A Five-Year Update," The Journal of Law, Medicine & Ethics 37, no. 1 (2009): 119. See also Peter A. Clark and Sam Schadt, "Mercy Health Promoter: A Paradigm for Just Health Care," Medical Science Monitor: International Medical Journal of Experimental and Clinical Research 19 (2013): 815.
8. Clark, "Prejudice and the Medical Profession," 123- 27, and Clark and Schadt, "Mercy Health Promoter," 815.
9. Tim J. Wise, Colorblind : The Rise of Post-Racial Politics and the Retreat from Racial Equity, Open Media Series (San Francisco: City Lights Books, 2010), 114-15.
10. See Clark, "Prejudice and the Medical Profession;" Clark and Schadt, "Mercy Health Promoter: A Paradigm for Just Health Care;" Wise, Colorblind, 114-24; and Deborah Stone, "How Market Ideology Guarantees Racial Inequality," in Healthy, Wealthy and Fair, 65-90.
11. Reid, The Healing of America, 3.
12. I draw here on my fuller discussions of solidarity in Gerald J. Beyer, Recovering Solidarity: Lessons from Poland's Unfinished Revolution (Notre Dame, Ind.: University of Notre Dame Press, 2010); Gerald J. Beyer, "Solidarity by Grace, Nature or Both? The Possibility of Human Solidarity in the Light of Evolutionary Biology and Catholic Moral Theology," Heythrop Journal 55, no. 5 (2013); and Gerald J. Beyer, "The Meaning of Solidarity in Catholic Social Teaching," Political Theology 15, no. 1 (2014), http://dx.doi.org/10.1179/1462317X13Z.00000000059.
13. John Paul II, Sollicitudo Rei Socialis, nos. 38, 39.
14. Jon Sobrino and Juan Hernández Pico, Theology of Christian Solidarity, trans. Philip Berryman (Maryknoll, N.Y.: Orbis Books, 1985), 8, 11.
15. See Beyer, "The Meaning of Solidarity," 8-12.
16. John Paul II, Sollicitudo Rei Socialis, no. 40. See also John N. Sheveland, "Solidarity in Three Sacred Texts: Bhagavad-Gita, Dhammapada, 1 Corinthians," Vidyajyoti Journal of Theological Reflection 74, no. 8 (2010): 601-603.
17. Sobrino and Hernández Pico, Theology of Christian Solidarity, 57-60.
18. See John Paul II, Sollicitudo Rei Socialis , no. 38-39, Francis, Evangelii Gaudium, no. 188 and David Hollenbach, The Common Good and Christian Ethics (Cambridge, UK: Cambridge University, 2002),159-65, 190-93.
19. Francis, Evangelii Gaudium, nos. 188-92. See also John Paul II, Sollicitudo Rei Socialis, nos. 42-43 and Beyer, Recovering Solidarity, 21-24.
20. See Beyer, "The Meaning of Solidarity," 17.
21. See for example John XXIII, Mater et Magistra, nos. 23, 92; John XXIII, Pacem in Terris, no. 80; Paul VI, Populorum Progressio, nos. 17, 62; John Paul II, Redemptor Hominis, no. 16; John Paul II, Sollicitudo Rei Socialis, no. 39; Benedict XVI, Caritas in Veritate, no. 25.
22. Steinar Stjernø, Solidarity in Europe: The History of an Idea (Cambridge: Cambridge University Press, 2005), 74, 85-88.
23. See John Paul II, Redemptor Hominis, nos. 8, 16.
24. See Redemptor Hominis, no. 16 and Sollicitudo Rei Socialis, no. 39.
25. Francis, Evangelii Gaudium, no. 189.
26. See Compendium of the Social Doctrine of the Church, nos. 355, 372; John XXIII, Mater et Magistra, no. 102.
27. Benedict XVI, Caritas in Veritate, no. 7.
28. See John Paul II, Centesimus Annus, no. 14; John Paul II, Laborem Exercens, nos. 19-20; Francis, Evangelii Gaudium, nos. 226-27. On methods of promoting solidarity, see Józef Tischner, The Spirit of Solidarity (San Francisco: Harper & Row, 1984).
29. Francis, Evangelii Gaudium, no. 188.
30. This phrase captures the essence of solidarity. See Tischner, The Spirit of Solidarity, 2.
31. Daniel Callahan, "America's Blind Spot: Healthcare and the Common Good," Commonweal, Oct. 5, 2009, 4, www.commonwealmagazine.org/americas-blind-spot.
32. Daniel Callahan and Angela A. Wasunna, Medicine and the Market: Equity v. Choice (Baltimore: Johns Hopkins University Press, 2006), 87-116. See also Uwe Reinhardt, "The True Cost of Care: The Complicated Relationship between the Market and Government Health Programs," America, Sept. 8, 2008, 2, http://americamagazine.org/issue/666/article/true-cost-care.
33. See Stjernø, Solidarity in Europe:
34. Callahan, "America's Blind Spot: Healthcare and the Common Good." See also Callahan and Wasunna, Medicine and the Market: Equity v. Choice, 113-14; and David Melville Craig, Health Care as a Social Good: Religious Values and American Democracy (Washington, D.C.: Georgetown University Press, 2014), 176-80.
35. See E. J. Dionne, Our Divided Political Heart: The Battle for the American Idea in an Age of Discontent, 1st U.S. ed. (New York: Bloomsbury, 2012), 155-88, 236-37.
36. See Gerald J. Beyer, Recovering Solidarity, 8-9, 44-47, 208-209; and Angus Sibley, The "Poisoned Spring" of Economic Libertarianism (Washington D.C.: Pax Romana, 2011).
37. Dionne, Our Divided Political Heart, 37.
38. Dionne, Our Divided Political Heart, 224-42. Dionne distinguishes between healthy and "radical" individualism.
39. Callahan, "America's Blind Spot."
40. See Cathy Schoen et al., Harnessing Healthcare Markets for the Public Interest: Insights for U.S. Health Reform from the German and Dutch Multiplayer Systems (The Commonwealth Fund, 2009), www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Dec/Harnessing-Health-Care-Markets-for-the-Public-Interest.aspx. See also Reid, The Healing of America, 36-37, 75 and Callahan and Wasunna, Medicine and the Market, 219-22.
41. Pew Research Center Publications, "Abortion Plays Small Role in Health Reform Opposition," Nov. 19, 2009, http://pewresearch.org/pubs/1417/abortion-plays-small-role-in-healthreform-opposition. Only 8 percent chose governmental coverage of abortion as their reason for opposition, whereas 38 percent chose more government involvement in health care delivery. Another 27 percent believe health care reform is "too expensive for the country."
42. Reid, The Healing of America, 66-103, 177-82 and Callahan and Wasunna, Medicine and the Market, 99-104.
43. Reid, The Healing of America, 32-33. See also Kawachi, "Why the United States is Not Number One in Health."
44. Statistics from Reid, 244-51 and S. R. Collins et al., The Problem of Underinsurance and How Rising Deductibles Will Make It Worse (The Commonwealth Fund, 2015), www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance.
45. Craig, Health Care as a Social Good, 189.
46. For an extensive treatment of this point, see Gerald J. Beyer, "The Continuing Relevance of Brothers and Sisters to Us to Confronting Racism and White Privilege," Josephinum Journal of Theology 19, no. 2 (2012). See also Paul VI, Populorum Progressio, no. 62.
47. Stone, "How Market Ideology Guarantees Racial Inequality," 66.
48. John Paul II, Centesimus Annus, no. 40.