Non-Binary Conversations

It’s a struggle to move beyond binary thinking. Both Jeff and I (and Julie Kuhl in her thoughtful comments) struggle in different ways to find a healthcare language beyond Left and Right, beyond Liberal and Conservative, and beyond Rights versus Responsibilities. How often political and policy conversations degenerate into either/or confrontation! The beauty of Respectful Conversations, like the beauty of some forms of Christian theology, is to entertain three/four/more approaches to a topic.

However, this beauty sometimes minimizes real disagreements that help to move conversations ahead! This unfortunate possibility is higher when there is so much respect between participants that they are afraid to disagree. When Jeff began his first essay with such kind words about my own writing on healthcare and about my former employer, Texas Tech University, I started to worry that we would not have sufficient scope for difference. I do appreciate Jeff’s kind words, but even more I appreciate his deep engagement with the conundrums of the American healthcare system. Fortunately, I discovered key differences that I hope will move the conversation productively.

The Limits of Scripture in Policy Conversation

Jeff rightly points to the “thinness” of Scripture when it comes to healthcare policy prescriptions. He stresses how Jesus’ healing challenges Christians to attend to the suffering (Mt 25). Rightly again, he points to the responsibility of the church and how for millennia it organized care for the sick and dying. Yet, he says, again rightly, “I find nothing, either approving or disapproving, large-scale, top-down provision of health care services to a polity.”

I’ll leave until a bit later the implicit binary idea that government provision of health services must be “large-scale” and “top-down.” Rather, I want to agree with Jeff’s point about the limits of the Bible when it comes to the provision of modern, curative and preventative health care, about which it is understandably silent.

What to do in the face of such silence? Fortunately, some Christian traditions (I am thinking particularly, but not exclusively, about the Kuyperian and Catholic traditions with which I am most familiar) have developed social principles that allow faithful thinking about policy issues in ways that transcend partisan and ideological binaries. The words and actions of Scripture, particularly the prophets and Jesus, tell us much about the value and dignity of each human person, about God’s special care for the poor, the responsibility of rulers for justice, and about Christian responsibility to minister to the sick, the imprisoned, the lonely, and the outcast.

From this biblical foundation, using reason and experience, these Christian traditions fashioned principles of social thought and of prudential reason that apply general values to actual situations. In my essay, I outlined five such themes (human dignity, participation, justice, stewardship, and common good) and recommended healthcare policy reforms that I believe flow from them. This is the direction that Christian approaches to American healthcare and its failings should travel.

On this journey, there will be a place for Christian hospitals, clinics, and nursing homes, as well as a place for individual Christian compassionate care, as well as a place for government. I think that Jeff and I would both agree on this general principle, though not perhaps, on its specific form in the world. This mutual journey may create a kind of institutional mimesis (to which he alludes) in medical practices and financial arrangements, but it is often the case that secular institutions learn compassionate practices from Christian ones.^[i]

Excellent Care for All or “You Get What You Pay For”?

Jeff’s Story

I appreciated Jeff’s stories of the excellent care that he and his family received from the U.S. healthcare system (and its caring, intelligent, and competent practitioners). Given my social science-induced focus on the system and its deficiencies, I sometimes forget to acknowledge the value of what we have. Equally key is his simple, profoundly biblical statement, “What I have had, I want for everyone else.” In short, “Do unto others….!”

And what is that? Jeff again: “The system came through for me…. The health insurance from our various employers has been exceptional, and we’ve had no worries about how we’ll pay our medical bills.” I agree wholeheartedly. Everyone in a modern, wealthy, democratic nation such as ours deserves exactly that as a matter of justice and as an element of the common good. Such an employment-based insurance system, extended universally to all, is precisely what I advocated in my opening essay.

But now I hear Julie Kuhl’s excellent question in her comments on Jeff’s essay: “The old adage of the value of something is what you pay for it. If healthcare is ‘free’ (which we know as taxpayers is not true) does it have value?”

Julie’s Question

Although framed as a question, there is an implicit objection here to Jeff’s aspiration and to my proposal for universal coverage. Objections to “free” access to health care come from two sources – experience (Julie’s basis) and free market ideology. For the first, it is true that many who work in healthcare observe some recipients demanding this or that treatment, after having failed to take responsibility for prescription compliance or dietary changes. It’s frustrating. The provider knows how valuable (in time, money, effort) the care demanded; the patient is oblivious or focused on her/his “right” to the care.

For the second objection, market advocates claim that “skin in the game” is the only way to rationalize healthcare delivery: co-payments, deductibles, markets for insurance and/or treatments, health savings accounts, and other market mechanisms.

Fair enough. There is, I believe, a (limited) place for market mechanisms in healthcare. They should not, however, be exaggerated. “Market failure” is particularly prominent in medicine for a variety of well-known (though not universally accepted) reasons too complex to review here. But, perhaps more to the point, universal coverage/access need not be free. Many nations with national health insurance systems have a variety of premiums and of fees at the point of care. A U.S. reform that guarantees access could also include co-payments, deductibles, and insurance premiums. Indeed, my own proposal for a form of the current employment-based insurance system at its center implicitly includes these features. However, the major problem with fees is inability to pay (leading to delayed care). The United States’ high proportion of poor and low-income workers and our deep economic inequality make these more burdensome than other nations with better income support and greater equality.

Rights, Entitlements, and the Common Good

The Limits of Rights Talk

Jeff and I agree in principle on the limits and dangers of “rights talk.” His excellent description of how sickness disrupts community exemplifies how a communitarian focus touches the human condition and personal dignity more profoundly than rights claims. This point is fully congruent with my essay’s discussion of health and community. Although rights claims have their place, especially in the legal/constitutional realm that Jeff describes, they are too blunt and too binary (my rights limit your freedoms) to work as the primary Christian political principle.

Yet, I am worried by the individualism that appears in his essay: “America is built on the idea that her people can make of themselves what they want without government’s goodies softening the blow if they fail or have some calamity happen to them.” I understand the claims of Christian faith to be less individualistic and more solidaristic than he.

Entitlements versus Personal Responsibility: A False Binary

In short, my argument that the common good requires a system of national health insurance (which would “entitle” people to coverage for health needs) does not and need not preclude ways in which such a system might encourage personal responsibility. My own experience with good health insurance is like Jeff’s, but I’m guessing that, despite this good health insurance, both he and I try to exercise regularly, eat properly, and take medicines as prescribed.

Julie makes a related objection: “4. I don’t believe we can ‘fix’ healthcare until we fix the vast socioeconomic inequalities of our society. To do that I believe we need to start with education and add a huge dose of compassion without entitlement. There are many medical professionals within churches that could provide Sat. Clinics, administrators that can chart, records can be kept. Etc.”

My answer is “yes” to the need to address vast socioeconomic inequalities, as in my essay’s attention to the social determinants of health. Moreover, Christian and other organizations are part of the web of care and vital parts of the health safety net. It is not, I believe, a matter of either/or. A reformed healthcare system need not resemble a teeter-totter, where guaranteed access being “up” requires personal responsibility to be “down” or government responsibility being “up” demands churches to be “down.” (Or vice versa!)

The Common Good

I shall not repeat here the description of the common good in my original essay. But suspicion of the common good seems to me a too-frequent symptom of American Christianity’s subtle absorption of liberal individualism. I think this infection is not life-threatening in Jeff’s case, but I wonder why he refers to the “guise” of the common good (Section G under “rights talk”).

An Even Larger False Binary: Universal Access does NOT Require “Government-Run” Healthcare

It seems that both Jeff and Julie believe that a system of national health insurance requires a government-run health system. Perhaps I am wrong, but Jeff seems to imply such a claim, while Julie’s comments are rather explicit in their criticism of government-run health systems (both in the U.S. and abroad).

Of course, I am not sure what they or others who refer to “government-run” health systems understand by this term. The ironic incident of Tea Party objectors to “Obamacare” in 2010 shouting, “Keep government out of my Medicare,” comes to mind!

My own recommendations include retention of Medicare and Medicaid and the VA and military health systems (all “government-run,” but in very important different ways). But its center-piece is the private health insurance system. And private hospitals, clinics, nursing homes, and physician and dental practices remain just that – private.

Every national health system (except perhaps the United Kingdom) has significant private components, and there are numerous organizational and payment differences among Canada, France, Germany, Italy, Australia, and other modern nations. None is perfect, and none is a precise model for the U.S., but all provide quality care and universal access at a far lower cost. Many deliver substantial medical care through private organizations (sometimes faith-based).

Excellent Ideas, But Not Sufficient

Better Jobs for All

Jeff correctly observes that health insurance is a substitute for wages and recommends growing the economic pie so that good jobs at good wages and with good benefits are available to all. I certainly have no objection to that idea, though we may not agree on how to grow the economy! We may even agree that there should be a far higher minimum wage. Again, my own proposal for health system reform depends on employer-based insurance. However, there will always be low wage jobs, elderly and disabled persons, workers temporarily unemployed, and adults pursuing higher education. All these will inevitably require either public programs such as Medicare and Medicaid or public subsidies that allow them to afford employment-based insurance.

Prevention

Julie comments, “1. Neither essay had any focus on PREVENTATIVE care and education. Education is the backbone to any economic advancement and healthcare is no exception. Our bodies our temples of the Lord, we are fearfully and wonderfully made! As a Christian to educate myself and children on nutrition, exercise, warning triggers for common diseases, etc. is a low(er) cost option. In short proactive not reactive.”

My agreement is qualified. Of course, prevention is important. I hope that I follow Julie’s recommended practices. These plus recommended screenings (mammogram frequency at certain ages; regular endoscopy if one has Barret’s Esophagus, and so forth) are an essential part of health care. Moreover, evidence-based and medical panel recommended screenings should be included in universal coverage at no or little cost to the patient.

Too often, however, prevention is oversold as a cure for our expensive healthcare system. Yet, prevention in the form of health education is not cost free. In many cases, a very large population must be educated to prevent a relatively small disease incidence. This is not an argument against education; only a caution that a cost-savings analysis might not reveal monetary savings. Moreover, screenings are also not free and may not be cost-effective. Again, not an argument against them. Catching an early cancer is very important. But screenings entail false positives that may encourage postponed attention to symptoms or false negatives that may lead to unneeded and costly interventions.^[ii] Enhanced attention to prevent will not reform the healthcare system.

Left Undone

I am conscious of several issues raised by Jeff and Julie that I have not addressed:

• ·       Issues with Medicare, Medicaid, and other public programs
• ·       Chargemasters, Collection Practices, and Bankruptcies
• ·       Outcome Based Payment Models

I shall consider these in my third essay.

[i] White, K.R.; C.E. Cochran; and U.B. Patel, “Hospital Provision of End-of-Life Services: Who, What, and Where?” Medical Care, 40 (January 2002), 17-23 and Cochran, C.E. and K.R. White, “Catholic Sponsorship Matters?” Health Progress, 83 (January-February 2002), 14-16, 50.

[ii] See, for example, Russell, L.B., ed., Educated Guesses: Making Policy about Screening Tests (Berkeley: University of California Press, 1994).