Healthcare in America: Diagnosis. Cure?

An overly ambitious title? Ridiculously hopeful? Yes. Of course. We’re talking about healthcare after all – a subject almost as contentious as race or immigration. And twice as complicated. We’re considering a system that accounts for 20% of the entire economy and that touches every person. It is both highly technical and deeply personal. A mix of government (at all levels), of private, for-profit institutions, and of not-for-profit, often faith-based organizations.

There’s little disagreement that healthcare in the United States is broken; yet also little understanding of how and why. And no consensus on a fix or fixes.

Our assignment in this Respectful Conversation is overwhelming (see the Leading Questions) and our allotted space limited. My strategy in this first essay is to take each of the principal questions and very briefly to sketch my answers. I simply want to get some things in front of us (Jeff Hammond, my conversation partner, you the reader, and myself) and then to see where the conversation takes us in the next two postings. That process may explore some ideas or issues in depth; others may languish for another time. And that’s okay. It’s a conversation after all.

Certain fundamental Christian social principles determine my understanding of our broken healthcare system and of how it might be fixed. These appear throughout the sections that follow:

Human dignity – all persons are created in the image and likeness of God and thus bear a fundamental dignity that can never be forfeit and that healthcare must respect and nourish.

Participation – because of that dignity, all persons have the right and the responsibility to participate in decisions and structures that affect their life and human flourishing.

Justice – as a social institutional, healthcare must be structured justly/fairly; that is, the healthcare system must be so organized and operated as to meet everyone’s reasonable need for care within the limits of the resources socially available for health and healing.

Stewardship – as Christians we are responsible to manage and conserve the resources God has given for our well-being. There are limits on our wants and desires. No part of society should be allowed to claw essential resources from other sectors.

Common Good – the principal duty of government is to defend, nourish, and advance the common good of the community for which it is responsible. Because the common good is fundamentally related to human dignity, participation, and justice, government has the duty to protect and advance healthcare justice, dignity, and participation while stewarding the ensemble of spheres of life that constitute society.

I shall not attempt to explain or develop these ideas further at this point but shall be happy to do so as the conversation advances.

A Public Good?

Our first leading question asks: Is healthcare a public good that everyone has a “right” to (and therefore government has a role to play in securing that “right” for everyone) or is healthcare a private good; a “privilege” that is primarily the responsibility of each individual with minimal governmental assistance?

There is no simple answer to these questions, partly because I believe that the language of “common good” is better than “public good” for understanding the role and responsibilities of government, individuals, and civil society. I think it better for Christians to speak about the “common good,” rather than public or private goods. Public versus private is a function of the development of classical economics in the last few centuries, predicated on a highly individualistic view of human persons. The common good, on the other hand, has a long history in Christian theology and ethics grounded upon a communitarian view of human persons more in line with biblical and historical Christianity.

However, even if one accepts the economic constructs of public and private goods, healthcare has features of each. Healthcare in modern societies is essentially communal, contributing both to the human flourishing of individual persons, but also to the health of the body politic. I have developed this argument extensively elsewhere {here;  here; and here}. Suffice it now to say that healthcare has some features of a classic public good. (In economics, a public good is one that is both non-excludable and non-rivalrous in that individuals cannot effectively be excluded from use and where use by one individual does not reduce availability to others. Clean air is one example; national defense is another.) Classic public health measures (vector control, water and sanitation, air quality regulations, infectious disease monitoring and intervention, and anti-smoking campaigns) have all or most of the features of a classic, economic public good. Other public health measures, such as vaccination requirements, are strictly speaking, excludable, but the “herd immunity” created by high vaccination rates is not.

Other features of our healthcare system also suggest a relationship to the whole society and its flourishing; that is, to the common good. An extensive body of research documents the social determinants of health. Poor social health in a community (racism, poverty, economic inequality, high crime rates, addictions, and so forth) produces poor mental and physical health. Communities with low rates of social dysfunction have better health than other communities. The common good of the whole society thus intimately relates to the health of that community. And the reverse is true: healthy citizens are more able to contribute to the flourishing of the entire community; healthy citizens are productive economically and engaged civilly.

Some medical interventions are indeed economically “private” health goods (that is, excludable and perhaps rivalrous. The best oncologist in a community is physically unable to treat every cancer patient in the community.) However, even these “private” health goods contribute to the common good. Healing interventions repair and even restore human dignity. A healing touch is a powerful expression love and a vital builder of community. Making health interventions available to all who need them is an expression of Christian community, solidarity, and belief in the dignity of all persons. Persons who receive healing interventions are more able to participate fully in the life of the community; that is, contribute to the common good, than those who need medical care, but do not receive it.[i]

Finally, some health care goods are common goods; that is, their production and maintenance depend upon mutual effort and cooperation. Medical training requires community – education resources, organizational structures, and funding that no one person or small group of persons possesses. Medical knowledge and technology are webs of connected intelligences, organizations, and institutions.

Therefore, because health care is a constitutive part of the common good; because it is a common good, and because it contributes to the common good, government has a role and responsibility to regulate the health care system in ways that shape it toward, rather than away from, the common good. To say this is not to deny the legitimate rights and responsibilities of individual persons to promote their own health or, if they are health providers, to pursue their own personal vocations. However, my assignment in this conversation was to highlight the public features of the healthcare system.

Problems in the U.S. Healthcare System

Our second questions asks: What are the problems with the U.S. healthcare system?

Where to begin?

Far from being the “greatest health system in the world” {“greatest”}, our healthcare is badly shattered. It is rife with injustice and violations of the common good. It too often insults rather than upholds human dignity. It costs far too much, draining resources from other sectors of society. Quality of care is often suboptimal. These indictments evoke Christian principles as fully or even more fully than secular principles.

Access. Alone among modern, wealthy, and democratic nations, the United States leaves major swathes of population without adequate access to medical care. The main reason is lack of health insurance. At this writing, approximately 12 percent of the population remains uninsured. Health insurance in a modern, expensive, highly technological medical complex is essential to effective recovery from illness and injury and to reentry into participation in the full life of community. Even when persons have insurance, barriers to care are frequent: the complex, stratified, and fragmented organization/disorganization of the healthcare system itself, lack of income for co-pays and deductibles, inflexible hours, poor education and information, and racial and ethnic prejudice.

It is not simply that access to healthcare is unevenly distributed, which is true in every health system internationally, but that healthcare in the United States is highly unjustly distributed amounting to unjust rationing, excluding millions of persons from full participation in the common good and insulting their dignity.[ii] 

Cost and Quality. The cost of healthcare in the United States is the highest in the world, whether measured in absolute dollars, spending per capita, or percent of GDP (currently about 18% of GDP, with most other similar nations spending around 11%). That cost might be justified if health outcomes were better. However, the U.S. performs no better than other developed nations on most measures of quality of care; exceeds them in a few; and lags on many. The causes of high cost and quality underperformance are too complex and disputed to address here. The clearest causes are higher prices paid in the United States for drugs, equipment, supplies, and salaries of medical professionals; high administrative overhead related to the complexity and fragmentation of the system; and high reliance on technology.

From the Christian perspective, these features if our system violate the principles of stewardship of resources and balancing of sectors of society to advance the common good.

Can We Do Better? What’s the Cure?

Our third question asks: How can the present system be improved? In addition, our fourth question asks: Is there a Christian perspective that can inform improvement? I have tried to weave the Christian perspective into my discussion of health care as a right and into my diagnosis of the problems in the present system. Here I shall briefly apply these principles to sketch a way that we can do better as a nation and as Christian citizens.

Why the Church?

In addition to the obvious reasons why the church should care about healthcare reform (commitment to justice, fairness, personal dignity, participation, and the common good), the church itself is deeply invested in health care. One of the chief healthcare players is the Catholic church through its network of hospitals, clinics, physician practices, and other institutions. Annually Catholic hospitals care for one of every six U.S. hospital patients. And there are Baptist, Methodist, and other Christian hospitals, in addition to many nursing and assisted living facilities associated with churches. Evangelical Christians are active in the community health center space, often under the umbrella of the Christian Community Health Fellowship.

Christians must invest time, talent, and treasure in healthcare reform because our faith, our current practices, and our hope demand our engagement.

Why Government?

Christians and others of goodwill cannot deliver fair, accountable, and dignified healthcare without substantial government involvement. In the first place, as discussed above, since healthcare is deeply related to justice and the common good, government’s role as an arbiter of justice and as custodian of the common good makes its role indispensable. In addition, certain features of healthcare produce what economists call “market failure”; that is, a situation in which the market cannot regulate itself toward fair outcomes. When markets fail, governments must step in to regulate. Features of market failure in health care are: (1) medical care is not a commodity like other commodities (it deeply involves moral principles and public goods in the strict sense); (2) health insurance creates “moral hazard” (the existence of the product creating demand for the service insured against); (3) “adverse selection” that incentivizes insurance companies to exclude or price out of the market those who most need health insurance; (4) asymmetric information between providers and patients; (5) significant barriers (financial and licensure, for example) to entry into the market; and (6) the large presence of non-profit entities in the healthcare market (the Christian organizations described above, among others.)

Each of these could be elaborated in later postings if desired. The bottom line, however, to this and the preceding subsection is: both the Christian community and government must be part of the reform of the U.S. healthcare system. Christians enter the healthcare policy space with an intent to build a more just, personal, participatory, and communal health care system.

Orienting Principles

I have already suggested the key principles that should guide reform. These morph into more specific policy principles: universal access; equitable access; affordability; quality; and choice. (Here is a Catholic version {Bouchard} and a “secular” version {Gostin}.)

Universal and equitable access can be described in terms of rights; however, my preference is the language of justice, with deep roots in Christian faith. Fairness or justice in healthcare requires that each person receives the treatment he/she needs without resort to begging. “No healthcare beggars” seems a pretty good Christian slogan. Moreover, the governing principle is need for care, not one’s economic resources to pay for care (thus, no queue jumping). Justice also entails that physicians, nurses, dentists, therapists, and other medical persons receive a fair return on their investments of time and resources. There is pretty good evidence that in the U.S. most of these receive a premium above their investment.

Affordability is both social and individual. Effective government ensures that health care remains in balance with other social goods (the common good is the criterion); individuals accept limits on their health care desires and on what is possible for meeting even their needs. The value of participation means that patients also take responsibility by being accountable for their own health to degree which it is within their power. Providers take responsibility for limiting their own demands for income and for the latest and greatest equipment; they accept limits on their capacity for cure. As former Colorado Governor Richard Lamm put it: no citizen can expect all the healthcare possible; no nation can give a blank check to the Hippocratic Oath; and no physician can expect to be an unrestrained advocate for his/her patients.

Within the limits established by these first two principles, we want a system that provides the highest quality of care possible and the most patient choice possible among hospitals, physicians, and other providers of care.

Sketch of an approach

Here I can only chart a way that may be refined in later posts. The current systems of Medicare, Medicaid, Veterans Affairs, and Military Health should be retained and reformed according to their particular strengths and weaknesses. These programs are specific to parts of the population, based on age, income, status as a veteran, and so forth.

The rest of the population receives coverage under employment-based insurance, the individual insurance market, and a fragile “safety net” of hospitals and clinics for the uninsured. The Affordable Care Act (ACA) of 2010 intended to reform and strengthen this triad (as well as reform Medicare and Medicaid). Even if it had been successfully implemented by the Obama administration and if it had not been gutted by the Trump administration, it would have been marginally successful in fulfilling the principles of healthcare reform. As long as it is the only game in town, however, I believe that Christians should support it and resist attempts to hobble it.

But….  Is there something better than the ACA? Neither the typical Republican or Democratic approaches hold promise. Returning to a more unregulated and fragmented insurance and delivery market (Republicans) would decrease access to care and worsen affordability. Replacing employment-based and individual insurance (and possibly Medicare and Medicaid) with a “single-payer” or “Medicare for All” system (many Democrats) would, I believe, too radically disrupt 18% of the economy. {Aaron}

 My own approach would be to require all employers to cover all employees (full- and part-time) with an insurance package of defined benefits covering most health and medical needs. Payments for covering part-time employees would be pro-rated among each employer of these persons. All employees would be charged a modest premium and would be required to purchase the insurance or to pay a tax penalty. Both employers and employees would be eligible for income- or payroll-based public subsidies. Individuals 55 and over could choose to enroll early in Medicare (and pay an adjusted premium), and low-income individuals could choose to enroll in Medicaid (at a small premium). Finally, a highly regulated and subsidized individual insurance market (plus Medicaid for low-income persons) would be available to all persons not currently employed. These requirements would cover all persons in the United States (other than visitors), both citizens and non-citizen immigrants.

Concluding Thoughts

I have undoubtedly covered too much in this initial post and have tried your patience. I can only plead that the assignment given by our moderator demanded it! I shall, however, confine my attention is subsequent posts to the issues and ideas raised by my interlocutor and by reader comments, which I gladly invite.

[i]. See, for example, Rourke O’Brien, “Medicaid and Intergenerational Economic Mobility,” Focus, v. 33, no. 2 (Spring/Summer 2017): 34-35. {https://www.irp.wisc.edu/publications/focus/pdfs/foc332f3.pdf; accessed 4/24/18}

[ii]. See my discussion, “The Affordable Care Act and Rationing,” Health Progress, v. 97, no. 6 (November-December 2016): 13-19 {https://www.chausa.org/publications/health-progress/article/november-december-2016/the-affordable-care-act-and-rationing; accessed 4/24/18}, and the entire June 2017 issue of Health Affairs (“Pursuing Health Equity”) {https://www.healthaffairs.org/toc/hlthaff/36/6; accessed 4/24/18}