Steps on the Journey

To no one’s surprise, our conversation about healthcare in America ends inconclusively. The topic is too large for a month’s discussion, even with as engaging partners as Jeff Hammond and Julie Kuhl! I learned much, and I hope contributed some to advancing the conversation. Which is a good thing. A few steps on a long journey beats waiting for a ride that never comes.

The United States is on a long journey of healthcare reform; it may end well; it may not. The end is not in sight. The best I can do is suggest a path forward and some guiding principles. I hope that my first two essays have done that. Here I address some gaps in my account and some nagging issues that could not fit into the first two essays, and I make a closing plea for social justice.

What’s wrong with government anyway?

 Apparently quite a lot! American culture natively distrusts government, especially federal government. Evangelical Christianity, for its own reasons and influenced by American culture, reflects that suspicion. Catholic social doctrine, to which I subscribe, inclines more favorably to government’s essential role for advancing social justice and the common good.

Jeff’s essays exhibit a marked avoidance of government in favor of Church (and other civic action) to meet (most or perhaps all) healthcare needs. Julie’s response to my first essay asked, “Here is my number 1 issue with government sponsored healthcare. Working in healthcare administration the government programs of Medicare and Medicaid take most of administrative and billing time. It’s a MESS to say the least! So WHY would we want to hand over MORE for the government to mess up?” The question is rooted in her experience with government programs, but also her very strong, principled focus on personal responsibility.

My response is to agree…. Partially. Of course, Medicare, Medicaid, the VA, and other government programs are overregulated, complex, and staffed by incompetent people. However, we forget that (a) so are private health insurance companies and (b) that regulations exist because somewhere, at some time, someone in private healthcare delivery either messed up bigtime or stole lots of money. Government reflects the Fall, but so do you and I. I’m not aware of any evidence that government is more fallen than other institutions.

And I don’t believe that government and its elected or appointed officials are more competent than others in healthcare. I believe only that government (especially federal and state governments given our constitutional system) have essential functions related to the common good and to justice. No other institution bears public accountability for the social good.

Besides I do not call for more government in healthcare

Julie’s comments on my second post rightly ask for more “bones” of my model of reform. Fair enough. My proposal is NOT for single-payer healthcare; NOR is it for a “government-run” system. I champion reinforcing the current joint public-private system. Government provides some services directly (VA, military health, and Indian Health Service); finances some services through Medicare and Medicaid and some state-based payments for indigent persons; and regulates most of the system through a complex of federal and state laws. There are some government-owned providers (country hospitals, for example), but most providers (whether hospitals, nursing homes, rehabilitation facilities, or physician practices) operate in the private sector, and many are Christian in origin and orientation. All must follow public health and safety and anti-fraud regulations, but they are private. Private for-profit and non-profit insurers furnish most employment-based insurance.

My proposal keeps all the private parts intact, as well as retaining the main parts of government delivery, financing, and regulation. My principal changes are few, but vital. First, as a matter of justice (I respond below to Jeff’s objection to this formulation.), government must require and guarantee that all persons have health insurance. Second, Medicare becomes open for purchase through individual premiums by persons 55 and older unable to afford private insurance. Medicaid becomes available to younger, low income persons who are temporarily unemployed or who work part-time. Third, the federal government specifies a few standard packages of insurance coverage, thus simplifying the ability of individuals to understand their benefits. Fourth, I am open to reducing government regulation of various parts of the healthcare system. Which procedures and processes government should regulate are prudential matters, rather than matters of principle.

The side benefit of simplifying insurance options is enhancing the ability of individuals and families to do what Julie rightly advocates in her seven points responding to my second essay. Many (expanded hours, time sensitivity, volunteering, personal responsibility for examining invoices) already exist in nascent forms. Having everyone insured in a system that standardizes coverage makes these more possible. It also deals with the very real problem of chargemasters and full-charge invoices to the uninsured that Jeff rightly criticizes.

Delivery and payment system reform

Both Jeff and Julie in different ways and with different specificity argue that the financing and delivery of healthcare are irrationally (dis-)organized. I agree that changes are needed urgently.

Outcome-based payments

Julie accurately says, “Outcome based care models. A physician/hospital gets the same reimbursement from a heart catheterization that was scheduled and routine as it does for an emergent situation where the patient’s life is at risk. The reimbursement is same if the patient lives or dies. Human nature talking here…take the money for the least amount of work. The ICD10 coding structure allows for more parameters that reward a positive outcome which as a consumer, I find to be a plus.” One of the Chief Medical Officers I used to work with called the current model “ring the bell.” Providers by and large receive payment for each procedure (each ring of the bell), so the incentive is to keep ringing. One health reform mantra for the last two decades has been to change the model to one where payment comes from (a) keeping patients well and then (b) helping them get well successfully when (a) fails. However, the route to achieving that goal has been long, arduous, and scattered with the wreckage of unsuccessful experiments (Accountable Care Organizations, upside and downside risk, Health Maintenance Organizations, medical homes, capitation and salary payments, and many, many more). Two lessons: changing incentives is more difficult than anyone can imagine and, second, most of the innovation in this area has been driven by federal government policies – all the way from the Balanced Budget Act of 1997 to the Affordable Care Act of 2010!

That reform must include a major role for government appears also in Jeff’s discussion of chargemasters and how insured customers obtain discounts on these prices and uninsured persons do not. He advocates reforming this system either though either Congressional legislation or judicial application of the “unconscionability” doctrine to exorbitant medical bills. I don’t disagree; indeed, I am grateful for the innovative idea of applying “unconscionability” to medical bills. Note, however, that Jeff here implicitly endorses major, national government action through courts or Congress to remedy an injustice. Yet, he is skeptical of my justice arguments (more on this below). Note also that Congress already in the Affordable Care Act tightened requirements that non-profit health institutions (mainly hospitals and hospital systems) offer steep chargemaster discounts to low-income, uninsured patients. (This is not a solution to the problem, but it is a government-directed step on the journey.)

Back to Christian Principles: Justice Especially

In my final section, I return to the topic with which I began the first essay in this series: fundamental Christian social principles. I will not rehearse them here; instead, I focus on justice (with brief reference to other principles), since it is central to my conversation with Jeff.

Christian principles in public life

Jeff asks a fair question in his second essay, indeed what he calls “the most fundamental question of religion and politics.” He poses it this way, “are there areas of our common politics that are not or should not be governed by religious, or even Christian principles?” Now “governed” is a very strong term, and Jeff also asks about “analyzing” healthcare policy with Christian principles and “areas of legal or political concern that are off-limits to religious influence, analysis, or understanding.” We would have to unpack “governing” very carefully to answer that question. Fortunately, analysis, understanding, and influence are closer to Jeff’s (and my) concern.

The simple answer, I think, is that there are no significant policy arenas that should be off-limits to Christian understanding, analysis, and persuasion, so long as the issues concern all or most citizens, there are moral principles at stake, and Christians approach them with humility, without insistence that our principles and understandings should determine public policy. (I have in mind the humility Julie expresses in her response to Jeff’s second essay.)

There is a major debate in political philosophy that began with John Rawls’s argument (A Theory of Justice, 1971) that only “publicly accessible” reasons should count in liberal, democratic policy discussions (and that religious principle are not so accessible). Numerous Christians philosophers have challenged his argument directly. Equally pertinent is the matter of how Christian and other faith-based principles should appear in public.  I have argued elsewhere that Christian and other religious public actors should fulfill five conditions to take legitimate part in civic discourse.^[i]

•        Employing principles of democratic discourse within their faith communities;
•        Developing politico-theological vocabulary that applies specific religious concepts to the context of democratic political life (Catholic social thought, for example);
•        Avoiding the temptations of civil religion; that is, too close identification with the polity itself;
•        Doing their policy homework (this entire series of “respectful conversations” being a very fine example); and
•        Avoiding hypocrisy (don’t advocate increasing the minimum wage if you are not willing to take the lead in paying church employees a living wage).

Rights and Human Dignity

I agree with Jeff that there is no straight line from a rich Christian understanding of human dignity to the legal right to health care. Indeed, I was critical of rights language in my first essay. Instead, I argue that social justice and social responsibility for the common good entail that (in a wealthy and medically advanced society) every member of the community have good access to the healthcare needed for them to flourish as members of the community. Where we disagree is which actors are responsible for guaranteeing that access: Jeff seems to exclude government (perhaps until he sees society evolving sufficiently toward social solidarity) and to include the church. My case is for a partnership of government and private (including church) actors.

Justice

Jeff’s second essay contains a long and helpful discussion of justice, in both its retributive and distributive forms. I agree with him fully that Americans are more comfortable with retributive than distributive justice. We are, he says, and I agree, living “in a society that is as individualistic as Cochran suspects and not nearly as communitarian as Cochran wants.” He understands my position very well, and I appreciate that. Does this agreement, however, doom (as Jeff believes) appeals to distributive or social justice that ground my Christian understanding, analysis, and public advocacy for health care reform? No. And for four reasons.

1. There are areas of life in which Americans are (or at least have been until recently) very communitarian and solidaristic in policy preferences. For example, Americans strongly support comprehensive education for all (even through at least some post-high school years). Social Security and Medicare are highly popular, solidaristic policies. (It is true, I admit, that most Americans use rights rather than justice language to describe public education and support for the elderly. But the result is solidaristic.) Jeff believes that the correct Christian description of the responsibility for providing needed healthcare is a church and individual Christian responsibility. Would he say the same for education and for Social Security and advocate the church taking these over from government? Why or why not?

2. It turns out that Americans do support the general “right” to healthcare for all. Public opinion surveys for the last four decades find broad and deep support for the notion that everyone (at least every citizen) should receive the best possible needed healthcare. We are more communitarian than we sometimes think. Of course, the terminology is not the vocabulary that I advocate for Christian social principles, but the communitarian effects should be acceptable to Christians. It is also true that agreement on the general principle of care for all breaks down when it comes to how that care should be provided, and there is considerable public resistance to solutions that might impair “my” access to “my” current healthcare. An obstacle to justice surely, but not an absolute impediment.

3. Why should reality trump Christian principle? Faced with opposition in principle and in practice to expanding health insurance to all persons, we can throw up our Christian hands in despair, or we can move forward toward justice and human dignity by whatever small steps our action, organizations, and advocacy create. I like to think that my own reform proposals are both realistic enough (they build on what exists) and radical enough (they depend on root Christian principles) to enable another step on the journey.

4. When push comes to shove, Jeff himself employs social justice vocabulary to support public policy changes! I am puzzled by his objection to distributive justice principles in healthcare reform, because he has a lengthy and enlightening discussion the “gross injustice” of the uninsured paying full price for care. This practice is grossly unjust. However, if it’s up to individual Christians and the churches to provide care for those who need it, why is it not up to them to pay the unjust bills of the uninsured? What I want to understand is why Jeff believes that Christians should advocate reform based on distributive justice to change unjust billing practices, but should not advocate changes to the larger system toward greater justice?

So, I am ultimately confused by Jeff’s objections to “social justice” and the “common good” as orienting Christian principles for healthcare reform. If exorbitant medical bills shock the conscience enough to create room for reform, should not the plight of uninsured healthcare beggars equally shock the conscience?

Thank You!

I have learned quite a bit this month, and I have enjoyed the respectful dialogue and civil debate with Jeff Hammond, my primary conversation partner, and with Julie Kuhl whose interventions have been on point, informed by experience, and probing. Thank you both and thank you to Harold Heie for bringing us together.

[i] See, for example, C.E. Cochran, “Introduction,” in M.C. Segers and T.G. Jelen, Wall of Separation? Debating the Public Role of Religion (Lanham, MD: Rowman & Littlefield, 1998).