- Friday, November 8, 2013
Health Insurance in America, part 2
By Daniel A. Westberg
Many Americans regard health-care reform as an issue promoted by liberals and progressives, when it should be seen as an issue of the common good transcending politics, much as good universities, an effective transportation network, and solid national defense are too important to be attached to a particular political philosophy or party. My primary criticism of Obamacare is that even if it achieves its aims (which looks increasingly doubtful), around 7 or 8 percent of the population (up to 30 million or so) will still lack medical insurance. We need to press on to truly universal access to health care, in which each citizen has appropriate medical care available and does not have to worry about a heavy financial burden.
My purpose here is to fashion a line of argument for universal access to health care that would meet many conservative objections and be based on widely shared moral principles. We begin with some clear biblical and theological mandates.
Care for the sick. The task of the Church to bring the gospel to all the world has incorporated a secondary mission of physical and mental healing since Jesus commissioned the 70 to preach the kingdom of heaven and to “heal the sick, raise the dead, cleanse lepers, cast out demons” (Matt. 10:7-8). The worldwide mission of the Church in the last two centuries has, along with preaching and forming congregations, invariably brought medical practitioners, the foundation of hospitals, and clinics and programs to train local personnel.
Care for each member. The uniqueness and importance of every person, each individual member of a family, or group, or society as a whole, is a key Christian contribution to civilization (see Oliver O’Donovan’s profound treatment of “Who is a Person?” in Begotten or Made?). In Luke 15, the parables of Jesus progress from the lost sheep (one of a hundred), to the lost coin (one of ten), and then to the lost son (one of two). Restoring the lost individual is vital, even for one person out of a large crowd: each one matters. The health of the larger body depends on the well-being of each member, a key principle articulated many times by St. Paul, as in 1 Corinthians 12:25-26, which urges “that there be no dissension in the body, but the members may have the same care for one another. If one member suffers, all suffer together with it; if one member is honored, all rejoice together with it.”
Care for the helpless. The parable of the Good Samaritan makes it clear that those in need, even if from a different social group, have a claim on our neighborly care. This is especially true for those who have no one else to care for them, such as the disabled, those without families, and victims of serious accidents and disasters. Christians, more so than adherents of other faiths, have put an emphasis on extending concern and care for the weakest members of society, the poor, and vulnerable.
Jean Vanier, founder of the ministry known as L’Arche, is a good example of the Christian focus on the weak, the forgotten, and excluded. As Vanier wrote in Befriending the Stranger: “The vision of God is to go down the social ladder to take the lowest place in order to be with the weak and the broken. Then God rises up with them to build a new humanity which does not forget or exclude anyone.” Many have pointed out that a good measure of the moral quality of any society is the care it devotes to its weakest and most vulnerable members.
The promotion of life. The encyclical Evangelium vitae of John Paul II addressed abortion in the context of a comprehensive “gospel of life,” incorporating people at the end of life, reluctance to resort to capital punishment, and other areas where a Christian view of life needs to transform culture’s compromise with evil and death.
Karl Barth, writing on the doctrine of creation in the third volume of his Church Dogmatics, provides an even more extensive reflection on what “respect for life” should mean for Christians, including responsibility for the standard of living conditions generally. The principle mens sana in corpore sano (a healthy mind in a healthy body) should be understood in the wider sense of a healthy society overall. This means that we must see to it that the benefits of medicine and health are “made available for all, or at least as many as possible.” Barth applies Paul’s teaching to public health: “When one person is ill, the whole of society is really ill in all its members. In the battle against sickness the final human word cannot be isolation but only fellowship.”
I have sketched a line of biblical and theological reasoning about care for victims of illness and suffering that points clearly to the need for Christians to support the provision of a safety net such that every member of our society should have the guarantee of medical care for accident or illness without the additional burden of financial stress. But let us note the ambiguity of Barth’s qualifying “or at least as many as possible,” with respect to the hope for universal coverage. How many are possible in an American context?
We don’t really require sociologists or political philosophers to tell us that societies must organize to satisfy certain needs to support human life: food, clothing, water and sanitation, shelter, and energy for heating and cooking form a basic foundation. It is possible to survive in cramped quarters and on a meager diet, as resilient survivors of disasters and wars show (like our own ancestors a century or two ago). But there is no denying the correlation between the worldwide rise in life expectancy in the last century with wider availability of cheaper food and clothing, water for drinking, irrigation and sanitation, and health care and education. These things are necessary for human beings to flourish.
Many liberals (including some evangelicals and Catholics) argue that access to health care should be seen as a human right, along with the rights to food, clothing, unemployment or disability insurance, and so on, which are spelled out in the U.N.’s Universal Declaration of Human Rights. Although I strongly support universal health care, I share with many conservatives a skepticism about the language of rights as the best framework for promoting it, for several reasons. First, rights should be based in an ability and responsibility to meet those rights. There is something illogical about asserting abstract rights in a very primitive or disorganized society. Second, rights are not the same as desires. Some couples mistakenly assert their “right to a biological child,” which can then become a claim on society for IVF or artificial reproduction treatments. Third, unqualified rights discourse tends toward the promotion of a culture of entitlement, so that society is thought of as simply obliged to provide people with jobs, schooling, and comfortable living standards.
My argument is more pragmatic. Government involvement will vary according to the type of need, local resources, the extent of free market function, and so on. Clothing, for example, does not need to be replaced often, prices are low, and perfectly adequate used clothing is readily available through charitable organizations. Here no government involvement is needed. Food, however, is needed daily, and the poor, especially those with families, often need help with groceries if unexpected expenses arise; purchasing food cannot be postponed the way some other bills can. Many churches and organizations offer soup kitchens and food banks, but these function as supplements, occasional sources to tide a family over for a few days. Thus volunteer efforts are insufficient, and many people in the United States require government assistance for their food budget. No doubt there is some abuse of these programs, but even if some clever mechanism could eliminate all such cases, people without incomes sufficient to pay for consistent, balanced meals would remain (as would the need for better jobs and better distribution of income).
All developed countries have a system of universal education (at least through age 15), and all such countries, apart from the United States, provide universal access to health care. The analogy between education and health care is helpful for us to consider, both in the similarities and differences. Since World War I, education has been compulsory in America, with major government involvement, at least on the level of local communities. Health care is expensive, but so is education: the average cost per pupil in the United States is around $11,000 per year, and is most often funded by property tax, so that a family with four children could easily be costing taxpayers more than half a million dollars for their K-12 education.
In the early days some Americans made arguments against compulsory universal education similar to the arguments we hear today about health-care reform: there is too much government interference; not all students need to go to school, so should not be compelled; and society should not interfere with private arrangements already in place and working well. But apart from some Amish communities that felt an 18th-century rudimentary education was adequate for them, there has been little complaint about universal compulsory education, mainly because it is self-evident that both the individual and society benefit a great deal from this training. Employers need trained workers, a democratic society needs an informed citizenry, people need skills and training to earn money, and, not least, everybody benefits from facility in language, opening windows to the worlds of math, science, history, and the arts.
Similarly, health is a self-evident good, with clear benefits for both the individual and the whole of society. Indeed, the link between the individual and society is even more direct, in some ways, in the case of health than in the case of education. If people become sick, they may infect the wider society, especially where communicable diseases are a threat. Employees who cannot show up for work because of illness, especially a chronic untreated condition, represent lost productivity. This places the need for access to health care — for preventive medicine and not just for emergency care — close to the foundational level with water, sanitation, nourishment, and the basic sustenance of daily life. Universal health care brings many advantages, including assurance of coverage when moving or changing jobs and when unemployed; coverage for all family members, whatever age or health condition; and prenatal care for expectant mothers.
To be sure, the needs and benefits of education are equally apportioned in that everybody goes to school and at least has the opportunity for schooling. By contrast, in the case of health care, some have conditions extremely expensive to treat, while others are healthy and fortunate enough not to need much medical care. But accidents and fatal conditions can strike any of us at any time. And the Christian call to provide for each member of society in need, especially the most vulnerable and helpless, is inescapable.
Some readers may agree with my line of argument to this point, but draw a line at any further government interference or control. But universal access to health care in America could, like education, remain decentralized and implemented on a local level. And insurance and funding, hospitals and their infrastructure, and doctors and other medical personnel might be public or private. To this extent, I have not made an argument in defense of the particulars of the Affordable Care Act as currently designed, and much of what I have said tilts in the direction of an argument for substantive revisions of the ACA. The United States needs, however — not least in light of our strong Christian tradition — to commit itself to providing universal access to health care. We should not settle for lesser compromises. This will require more careful investigation, thoughtful discussion, and especially sustained moral education, than we have managed to date.
The Rev. Daniel A. Westberg is professor of ethics and moral theology at Nashotah House Theological Seminary and is preparing a book on the moral and practical arguments in favor of universal health care.