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BY: RON HAMEL, Ph.D.

The passage of the 2010 Patient Protection and Affordable Care Act was undoubtedly a historic accomplishment that will bring much good to tens of millions of people. As momentous as it was, however, the legislation achieved less than it could have and perhaps should have achieved. As many have said, it is a very good first step.

To point this out is not to diminish the accomplishment but rather to emphasize that the work is not yet complete.

The obvious work ahead, and the bulk of it, is related to policy. Less evident is the underlying "value-related" unfinished business.

John Glaser, in an article in Health Progress some years ago, observed that "health care today is rooted in deep and abiding attitudes and assumptions of U.S. culture" — attitudes and assumptions that are resistant to reform and that support and promote the status quo.¹ These deep-seated cultural attitudes and assumptions reveal fundamental societal values, which in turn affect policy choices and behavior.

It was rather clear in the last weeks of the debate over the legislation, and in the weeks following passage, that our nation was almost evenly divided. Some of the opposition may have resulted from a genuine conviction that the policy would be detrimental to the good of the country. Too much, however, was clearly politically motivated, and too much was ideologically based. The latter two problems, at least, were likely driven by attitudes and assumptions that are hard to change. And the attitudes and assumptions remain, sure to resurface as opposition as the work goes on.

Still, we can hope for progress and work for progress on some issues and on the underlying attitudes and assumptions, work that is critical to creating a more just, more efficient and more sustainable health care system for the future.

Here is some of the unfinished business that points to where we need to go.

During the more than yearlong debate, health care reform was never seriously framed or viewed as a moral issue — as a matter of justice and solidarity, respect for human dignity, stewardship and concern for the common good that as a society we cannot afford to ignore. It seems far easier to dismiss significant social change when it is framed in non-moral terms. But when health care is viewed for what it is — a moral issue belonging to American society as a whole and to all Americans individually — it becomes more difficult to dismiss entirely or to oppose.

Moral issues don't just sit out there. They demand to be addressed, to be resolved. They pose a certain imperative to the consciences of individuals and the nation. Unfortunately, the deep conviction that our health care system is profoundly morally flawed was missing in much of the debate — the notion that as a society we have a moral responsibility to make it more just.

Another piece of unfinished business, related to the above, is lack of consensus in our society regarding the nature of health care. Is it a commodity, or is it fundamentally a right? In his book The Healing of America, T. R. Reid recounts conversations with the Harvard economist William Hsiao, who speaks about the "first question":

"Before you can set up a health care system for any country," Hsiao told me, "you have to know that country's basic ethical values. The first question is: Do people in your country have a right to health care? If the people believe that medical care is a basic right, you design a system that means anybody who is sick can see a doctor. If a society considers medical care to be an economic commodity, then you set up a system that distributes health care based on the ability to pay."²

Americans have never really carried on an ethical debate about health care as a right — that is, about which inequalities we are willing to tolerate. …

[T]he United States will have to face William Hsiao's "first question." What are our basic ethical values? Do we believe that every American has a right to health care when he needs it? After that question is resolved, we can move on to the task of designing a health care system that works for all Americans.³

The Patient Protection and Affordable Care Act ultimately passed without settling this question, but what was passed reflects the fact that many in our society believe health care is a commodity. This conviction will continue to influence to whom and how our health care is delivered.

Of course, within the Catholic tradition, as well as in other religious traditions, health care is seen as a basic right because it is considered to be essential to human dignity. It is a basic human good, critical to the flourishing of individuals and communities. As the American bishops said in 1981: "Health care is so important for full human dignity and so necessary for the proper development of life that it is a fundamental right of every human being."⁴

Still, even though this is part of the church's social teaching, beginning with John XXIII in his 1963 encyclical Pacem in Terris, one cannot assume every member of the Catholic community holds the conviction that health care is a right.

The notion that health care is primarily a commodity available to those who can afford it, (i.e., those who are insured) highlights another area of unfinished business: stewardship of our health care resources. Our reluctance as individuals and as a society to steward health care resources was abundantly evident during the health care debate. Large numbers of Americans roundly rejected any intimation of limits. Claims of socialized medicine, rationing and death panels ended virtually any and every discussion of more sustainable and cost-effective ways to deliver medical care. As bioethicist Daniel Callahan has observed, we Americans need "… to begin entertaining a simple but obviously threatening idea: that the combination of biomedical research, technological innovation, and market influences must inexorably drive up costs. Put another way, our love of technological progress and our desire to hold down costs without setting some limits cannot be reconciled. …Unless we hold that any good medical technology ought to be available to every patient without limits, with no concern for cost and for even marginal benefits — a wholly unrealistic possibility — then we need to consider limits."⁵

But we refuse to do so. What Americans expect, at least those who are insured, is the very best medicine that money can buy (i.e., what the insurance company will pay for). Unfortunately, "best" does not always, or even usually, mean the most effective. It generally means the latest, the newest, which is often the more expensive and, at least in some cases, offers only marginal benefits over less-new approaches. In so many people's minds, when it comes to health care, more is automatically better. Yet in reality, it is often not. More health care does not necessarily make us healthier; it only escalates health care costs and the percentage of gross domestic product devoted to this one of many societal goods and needs.

What does it mean when people of faith refuse to steward well a societal resource, refuse to accept some limits on their use of health care resources for the good of society and other individuals within society? What status does this give to health? And what does it say about the depth of belief in a life beyond this one when so many health care dollars are expended in the last six months of life, especially when some expenditures are for futile or marginally beneficial treatments?

This raises a fourth area of unfinished business — a lack of concern for the common good. In the words of Callahan: "The common good as a moral value has little purchase in American culture and politics. … The thought that we might have to ration health care in the name of the common good — even to ensure that others get a fair share — is objectionable to most Americans… ."⁶

In the health care debate, individualism and individual self-interest clearly won the day. Just about any policy proposal that attempted to promote the common good was redefined as socialism or government control, and it was rejected. Even after the passage of the Patient Protection and Affordable Care Act, American individualism and lack of concern for the common good rear their ugly heads in ongoing critiques of the legislation and efforts to undermine it. One example is the lawsuits by some states to do away with the requirement to purchase health insurance.

As Callahan points out: "What might be of immense value to us as individuals may not be compatible with an equitable health care system, aiming for a common good, not just the private good."⁷

Much has been accomplished with the passage of health care legislation, but the energy and the efforts must continue. In the words of Callahan again: "[H]ealth care cannot be reformed, or costs controlled, without changing some deeply held underlying values. I put changing those values within health care in the class of a cultural revolution dedicated to finding and implementing a new set of foundational values."⁸

That sounds like a daunting, though critical, undertaking. Perhaps a good first step is to begin with the Catholic community that proudly claims a long tradition of social teaching. Despite that tradition, it's far from clear that the Catholic community rose to the occasion during the health reform debate to offer a different set of values to guide policy debates and decisions. One is left to wonder how deep the commitment is to the tenets of Catholic social teaching. The health reform debate was a prime opportunity for teaching about and implementing this rich tradition. If as much energy had been put into this as was put into concerns over abortion, we might have made some headway in Callahan's "cultural revolution."

So there is much unfinished business — all of it in our own backyard.

RON HAMEL, Ph.D., is senior director, ethics, Catholic Health Association, St. Louis. 

NOTES

1. "Systemic Reform Is Vital to Our Ministry," Health Progress (May-June 2002): 18.
2. T.R.Reid, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (New York: Penguin Press, 2009) 212.
3. Reid, 219, 222.
4. United States Conference of Catholic Bishops, Health and Health Care, Washington, D.C.: USCCB, 1981.
5. Daniel Callahan, "The Technology Trap," Health Progress 83, no. 3 (January-February 2002): 44-45.
6. Daniel Callahan, Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System (Princeton, N.J.: Princeton University Press, 2009).
7. Callahan, 3.
8. Callahan, 5, 7.