According to the U.S. Census Bureau, nearly 46 million Americans were without health insurance in 2007. Families U.S.A., a health care advocacy group, has estimated that over the course of 2007-8, 54 percent of Americans under age 65 were without health insurance at some point. Unpaid medical bills are a primary reason people file for bankruptcy. At the same time, the cost of health care coverage continues to escalate, with the average cost exceeding $4,000 per year for a single person and $10,000 for a family. Health care expenditures now constitute 17 percent of the gross domestic product. These realities have contributed to a growing consensus that now is the time for us as a nation to address the related health care questions of cost, coverage and quality.
For several reasons, I am cautiously optimistic that substantive legislation will be passed and signed this year. First, health care reform is a clear priority of the new presidential administration, which, consciously avoiding some of the mistakes of the past, is working collaboratively with Congress. Second, congressional leadership in both houses seems committed to overcoming the turf wars that contributed to the demise of the Clinton health care proposals. Third, interest groups whose conflicts helped derail the last reform attempt have been involved in discussion with both the administration and Congress. Various coalitions of these groups have even tried to draft consensus statements to guide future deliberations. Notably, the president of the association that sponsored the infamous “Harry and Louise” ads in the 1990s pledged at a White House summit to be a constructive participant in the reform discussions. Finally, and unfortunately, the growth of joblessness during the current recession has exacerbated and highlighted the problem of lack of coverage.
Still, there are reasons for caution. First, we have been at this conversation for over 64 years; President Harry Truman called for “health security for all” in 1945. The momentum of history does not favor success. Second, when the 110th Congress began, there was near universal consensus that the State Children’s Health Insurance Program would be reauthorized and its coverage expanded. No one was against covering children. In fact, reauthorization did not happen in the 110th. Though it did occur in January, at the beginning of the new Congress, this failure shows how difficult it can be for our federal legislative process to translate aspirations into action. Third, the president is asking Congress to develop policies and programs that will provide coverage for all or nearly all Americans now and also to find a sustainable way of funding a reformed system. While theoretically this approach is preferable, many wonder whether the complexity of doing both will doom the entire effort; some question whether it would be better to take an incremental approach. Fourth, included under coverage, cost and quality are myriad distinct but interrelated issues that require attention and will not be easy to address effectively.
As an observer of political and legislative processes, I think cautious optimism is a reasonable perspective. But what if one changes the frame of analysis from the political to the ecclesial? Such a change radically alters my perspective; I turn from cautious optimism to deep concern. Why?
As a Catholic theologian, I was struck when President Obama recently began speaking of health care reform as a core element of an economic recovery program. While the president has spoken of expanding coverage in terms broader than containment of cost and a healthy economy, his use of an economic rationale for action is not surprising. Since the Reagan era, and most noticeably in the last administration, the public policy language of health care has shifted. Health care has come to be considered a commodity that should be subject to market forces. As an informed consumer, the patient should be entitled to the best product at the lowest cost. Competition will drive innovation and effective delivery. And the role of government is to be involved as little as possible, lest government impede market forces.
While that is a simplification of a complex series of social developments, it is fair to say that at the level of government and of some social theoreticians, the perspective has shifted significantly on the nature and role of health care in our society. That shift is increasingly is at odds with the Catholic social justice tradition.
In Catholic theology, access to health care is a fundamental social good, because health is essential to human flourishing and the preservation of human dignity; as such, health care is an aspect of the common good. Society and the state have a dual obligation to protect the right to health care and to provide the means necessary for its fulfillment.
Clearly this theological perspective is in tension with aspects of the current American ethos. Polling conducted several years ago by the Catholic Health Association of the United States indicated that Americans are uncomfortable speaking of health care as a “right.” Yet respondents did not consider it to be the same as any other “commodity.” For those polled, health care was “special.”
Building on that insight, I proposed in the Brennan Lecture at Georgetown University in April, 1999, that we consider health care an essential building block for a free society, much like the provision of public education or of police and fire protection, which are necessary for the well-being of society. The Catholic Health Association has outlined values and principles that can inform public discourse on the subject. Last year it published Our Vision for U.S. Health Care, which brings the richness of the Catholic tradition into dialogue with the American political and economic heritage.
While our Catholic social justice tradition has an internal coherency and the Catholic health care ministry in this country has a common voice, as a nation we do not have a similar consensus about the nature of health care and the terms of our social responsibility. Absent such consensus, we lack a framework for evaluating any forthcoming legislation. If our country were attacked, there would be overwhelming support for mounting a vigorous defense, even if that meant increasing the national debt, because we agree as a nation that collective security is essential to our well-being. We do not have a similar agreement about access to health care. Many argue that health care reform must be budget-neutral. But how do we know whether that is the best approach?
Resources Versus Rationing
Concern about the increasing share of the G.D.P. consumed by health care is understandable, but how does one determine what is too much? As a nation we seem incapable of having an honest discussion about what Cardinal Joseph Bernardin once spoke of as “the allocation of scarce resources.” Theologically and practically, there are limits to what government or society can or should do; it is a fiction to believe everyone can have access to everything they want or need with regard to health care. Attempts to address scarcity, however, are sidetracked by the way the conversation is framed, not in terms of the allocation of scarce resources but rather in terms of “the rationing” of health care. Because rationing is perceived as un-American, the public conversation ends at that point. But the scarcity of resources persists.
Without a national consensus, we make ad-hoc decisions with serious consequences. The uninsured are denied access to preventive health care, a primary physician or the full range of medical services and instead receive care in emergency rooms; Medicaid patients in one state have access to services not available in another state; providers who care for Medicare or Medicaid patients are not paid for the cost of providing services and so pass those costs on to patients who have insurance. We already ration health care; we just refuse to admit it.
While substantive, all these concerns do not preclude the possibility of good legislation being passed. But these concerns invite us as advocates for change to resist being trapped by the commonly used terminology of commodity and balanced budget. They also invite Catholics to become involved in the discussion of reform and to use the resources developed by the C.H.A. and others to raise the conversation to the level of principle: evaluating all that is proposed in light of social justice, with our first question being what any proposal will do to or for the poor and vulnerable.
The Question of Abortion
There is a second reason for deep concern: Will the issue of abortion block reform? While there were many reasons the Clinton health care proposal failed before it came to a vote, the issue of abortion was very much in play. Pro-choice advocates insisted that if there were to be universal coverage, abortion must be a covered benefit. From a public policy perspective, the U.S. bishops were strongly supportive of universal coverage, but they opposed expanding access to abortion by making it a covered benefit. The bishops also feared that as a condition of participation in the new delivery system, Catholic health care institutions would be required to provide abortions. Finally, the bishops were opposed to Catholic taxpayers supporting government funding of an immoral activity. There were many attempts to work through this impasse. I was present in the White House when a final effort was made. After it failed, the bishops were among those who raised objections to the Clinton legislation.
The current effort might avoid such pitfalls. That being said, it is a matter of fact that the current administration and a majority of the House of Representatives are solidly pro-choice. Will one or the other feel pressure (or commitment to principle) to use health care reform legislation to expand access to abortion? If they do, will they allow “conscience clause” protection for individuals and institutions morally opposed to abortion?
Though the president has demonstrated a commitment to common goals and an appreciation of the importance of religious discourse and values in advancing the well-being of society, it is not clear that his administration appreciates that for Catholics religion is not just a private matter. While our faith informs and guides our personal lives, it also guides us as faithful and responsible citizens. Opposition to abortion is like opposition to murder or slavery. Though at times there is disagreement among Catholics about the best way to advance this commitment in a pluralistic society, it would be a mistake for any policy maker to underestimate the Catholic commitment to the dignity of all human life.
Finally, the Catholic Church as a social institution— through its ministries of education, health care and social service—is an essential element of the public life of this nation. It is difficult to imagine that legislation could pass that would deny conscience protection to these ministries. But no one should doubt that if forced to make the choice, these institutions would leave the public square before they would abandon their commitment to life from conception to natural death.
The Preferred Route
How do we proceed? We should avoid the pitfall of some who seem to refuse to engage in reasoned dialogue. Our position is nuanced and complex. Many Catholics, including Catholics in public office, do not appreciate the threefold distinction: private practice, public voice and social institutional presence. We need to educate and inform our leaders about these and other Catholic principles. We must translate our faith commitments into language that can be understood in the public square. In a society increasingly influenced by 24-hour news cycles and shrill sound bites, we ought to provide a counterpoint of reasoned, respectful dialogue. A commitment to life does not replace the virtue of charity. The moment might come when moral outrage and prophetic witness are necessary. Until then, strength of conviction and participation in a political process that builds coalitions of support for the right cause are the preferred route. This requires that we reach out to others who share our perspective and that we work together as a church—laity, bishops and our Catholic ministries. Perceived internal divisions only diminish our effectiveness.
Cautious optimism and deep concern are reasons for us as a community of faith and as a nation to see these next months as a time of opportunity. The momentum of history is against us. But who says that history must repeat itself?