Health Care as a Social Good

Religious Values and American Democracy

David M. Craig

• Publisher: Georgetown University Press
• Year: 2014
• ISBN:
  9781626160989
• Topic: Medicine
• Subtopic: Ethics in Medicine

David M. Craig traveled across the United States to assess health care access, delivery and finance in this country. He interviewed religious hospital administrators and interfaith activists, learning how they balance the values of economic efficiency and community accountability. He met with conservatives, liberals, and moderates, reviewing their ideas for market reform or support for the Affordable Care Act. He discovered that health care in the US is not a private good or a public good. Decades of public policy and philanthropic service have made health care a shared social good.

Health Care as a Social Good: Religious Values and the American Democracy argues that as escalating health costs absorb more and more of family income and government budgets, we need to take stock of the full range of health care values to create a different and more affordable community-based health care system. Transformation of that system is a national priority but Americans have failed to find a way to work together that bypasses our differences. Craig insists that community engagement around the common religious conviction that healing is a shared responsibility can help us achieve this transformation—one that will not only help us realize a new and better system, but one that reflects the ideals of American democracy and the common good.

Part One

The Moral Languages of US Health Care

Chapter 1

Health Care as a Private Benefit or Private Choice

Consumer-driven health care is similar to managed care back in the nineties. You may not have liked managed care, but if you weren’t in it, you weren’t in health care. Consumer-driven health care may be the grammar that structures the conversation in the future.

Director of mission and values, nationwide Catholic hospital system

AMERICANS ARE divided and confused about health care reform. The divisions were on display during the congressional debates and votes over the legislation that became the Patient Protection and Affordable Care Act of 2010. Alone among his fellow Republicans, Anh Cao, a Louisiana representative, voted for the original House bill. He cast the only Republican vote in favor of any of the bills that fed into the federal law. After the Senate voted along straight party lines, Mr. Cao then joined all of his fellow House Republicans and thirty-four House Democrats in voting against the Senate bill that President Barack Obama ultimately signed into law. This partisan divide and the acrimony of the congressional debate raise the question: Can Americans talk to each other about health care, let alone deliberate about how to reform it?

This question must be answered affirmatively, and there is reason for hope because the story of health care reform in the United States has finally changed. The most significant change is not the 2010 passage of the Affordable Care Act or the US Supreme Court’s 2012 ruling in its favor. The decisive change is that liberals and conservatives now both recognize the need for some kind of systemic reform. With US health spending projections predicting a near doubling from $2.2 trillion in 2008 to $4.3 trillion in 2020, the question is no longer whether to reform health care.¹ It is how to reform health care in the face of unsustainable cost inflation.

Although Republicans and Democrats have both recognized this reality, they remain bitterly divided over whether market forces or government mandates should be the principal tool of reform. The policy debates over the right balance between private enterprise and government regulation employ frightening sound bites about a government takeover of health care and the greed of big insurers. Politicians are adept at crafting language that mobilizes their constituencies’ anger and fear. They wave frantically at the tips of icebergs threatening the ship of state, ignoring or minimizing the real dangers that they know are lurking below the surface of the water.

Their rhetorical strategies are effective because they build on Americans’ ways of talking about health care. On the one hand, some Americans hold fast to the ideal of the 1970s television character, Marcus Welby, M.D., the private family physician who is trusted with their personal health care. This iconic figure has been swept up into large group practices and specialty clinics. The result is a US health care system rife with corporate bureaucracies, but conservatives nonetheless zero in on government bureaucrats intruding on the physician-patient relationship as the quintessential threat to people’s health care and personal choice. On the other hand, although Americans tend to look kindly on the private sector for providing many services, there are limits to that tolerance. The large executive salaries and corporate profits in the health insurance industry are an easily quantifiable indicator of the largesse in US health care spending. Because insurance companies provide no care, they lack the physician’s defense of caring about their patients. Physicians put people first, while insurers put profits first, liberals argue, adding that only the government can tame the power of the insurance industry and protect the rights of patients too often denied the services they need.

Although simplistic, these images of unaccountable civil servants and venal insurance executives are remarkably effective. Their power lodges in their ability to tap into the root ideas of the health care languages that Americans speak. The old politics of health care reform could be mapped along a single linguistic divide with conservatives defending private benefits and progressives arguing for public rights to health care. More recently, conservatives have shifted to arguing that health care should be driven by private choices. The moral languages of private benefits, public rights, and private choice all carry with them assumptions about how health care should be provided, paid for, and delivered. How Americans talk about health care reflects their vision of how health care should be distributed.

This chapter begins an exploration of the moral languages of US health care. I call them moral languages because they each come with a vision of justice, community, and responsibility. Participants in the health care reform debate frequently dismiss their opponents for acting in bad faith and putting their self-interested concerns with money and power first. For example, Republicans are seen as willing to sacrifice the poor on the altar of free enterprise so that their corporate benefactors can make even more money from health care. Democrats are seen as willing to sacrifice medical innovation, personal freedom, and even human life in the interests of big government and their own political power. Such objections are too easy. They neither advance the debate nor contribute to the constructive compromises required to address both the crushing cost of US health care and the reality that one in six Americans lacked health insurance prior to the ACA’s complete rollout in 2014. It is time to take seriously each side’s moral language, assumptions, and arguments. I am not naively hoping that if partisans impute good faith to their opponents the divisions in Americans’ views of health care reform will disappear. Fundamental convictions about the country’s fiscal welfare and political character are at stake. We can, however, lessen the confusion surrounding health care reform by taking stock of the moral commitments embedded in each of the three ways that Americans talk and think about US health care.

DISTRIBUTIVE JUSTICE: FREE EXCHANGE, DESERT, AND NEED

Understanding how the moral languages of US health care relate to distinct visions of justice, community, and responsibility requires the concept of distributive justice. Distributive justice presupposes that there are goods we jointly produce, pay for, and use as a society, such as public education, citizenship, and national security. Distributive justice asks how the burdens of creating these shared goods and the benefits of enjoying them are distributed among people. Not surprisingly, there are sharp disagreements about distributive justice in American political debates. The idea is too large by itself to build much mutual understanding. We can get a better handle on its complexities by moving from the general idea to the actual principles by which people gain access to and possess shared goods.

Political philosopher Michael Walzer helpfully distinguishes three key principles: free exchange, desert, and need.² Free exchange is the principle of the perfect market. In this market all individuals enter with adequate purchasing power and complete information about the goods that interest them. Buyers choose from the many competitive goods available and pay the sellers their asking price. All that matters is the parties’ freedom to accept or reject the deal and their fully informed agreement that they have struck a bargain of equal value to them.

Desert is the principle of recognized worth. This worth may be in the elevated form of distinctive honors awarded to an individual for special merit, or it may be in the general form of a basic dignity that commands equal respect for everyone. Desert is more than impartial, equal treatment of citizens under the law. It is appropriate regard that actively acknowledges a person and his or her inherent value or worthy qualities.

Finally, need is the principle of unmet necessities. Unlike the first two principles, which get specified through social interaction—either two parties agree on the equal value of the goods they are exchanging or one person’s worth is recognized by other people—need can seem like an isolated, individual affair. Yet individuals cannot define what counts as need across their society. Necessity becomes need when it is unmet. The failure to provide may be one’s own fault, others’ fault, or no one’s fault, but the judgment that a need is unmet looks to the standards of some group. Such judgments usually grow more contentious the larger the group becomes.

Separating the principles of free exchange, desert, and need at the outset will help sort out the practical and moral judgments implicit in how people talk about US health care. By listening to the meanings that Americans assign to health care and by examining the interplay of distributive principles in their visions of health care justice, we can penetrate the swirling political passions and the eye-glazing policy abstractions that cloud the public debate and make it hard for either side to see the good reasons behind their opponents’ positions. A search for productive common ground requires a back-and-forth movement between the everyday political stances and economic concerns that people bring to the health care reform debate and the deeper convictions about justice that frequently turn it into little more than a shouting match.

To lower the heat and shed some light, this chapter and the next clarify the languages of private benefit, private choice, and public right as descriptions of US health care and evaluate their normative statements about justice. This chapter begins with health care as a private benefit and the unique history of employer-based health insurance in the United States. I then discuss how market-driven health care reform shifts the focus from private benefits to private choices.

HEALTH CARE AS A PRIVATE BENEFIT: HISTORY AND CHANGE

The first language of US health care is health care as a private benefit. It is a sign of changing times, therefore, to hear the mission director of one of the largest hospital systems in the country say that consumer-directed health care, with its language of private choice, may be the “grammar that structures the conversation in the future.” That future is not yet, however, as the loudest voices in the recent national debate spoke in the language of private benefits.

Consider these memorable words which crystalized the boiling opposition to Democrats’ initial reform proposals during the summer of 2009. At one of many town hall meetings, a South Carolina retiree stood up and warned, “Keep your government hands off my Medicare.”³ Two different lessons can be drawn from these words, one negative and one positive. On the negative side, many Americans appear not to understand how extensive the government’s role is in paying for health care. In 2010, public payers covered 45 percent of US health care costs,⁴ with projected funding rising to 49 percent by 2020.⁵ In the case of this retiree, the failure to recognize how dependent US health care is on public funding might be explained as willful blindness, the result of an ideological bias that distinguishes the deserving elderly who presumably have paid for their public insurance from the undeserving poor who do not.⁶ On the positive side, Americans have firm convictions that health insurance and health care should be provided as private benefits. These convictions are entrenched in the history of US medical practice and a political culture of personal liberty and responsibility. To appreciate the vision of justice behind the private benefits idea, we must focus on the positive lesson, though clearly the primary pride in having earned one’s health benefits is related to the secondary aversion to public entitlements.

Emphasizing the positive in the private benefits idea clarifies two objections to the Affordable Care Act, one from each side of the political spectrum. For Democrats the law’s excise tax on so-called “Cadillac” insurance plans—plans with annual premiums over $10,200 for an individual or $27,500 for a family—unfairly changes the rules on the benefits that unions have won through collective bargaining and wage concessions. Union members are now out lost wages and face a 40 percent surcharge on premiums that exceed the law’s limits, despite the benefits having been contractually earned. One of Republicans’ many objections to the law is that it does not resolve the projected budget shortfalls in Medicare and Medicaid. To help cut future Medicare costs, Rep. Paul Ryan (R-WI) has proposed shifting Medicare toward a private insurance system subsidized by premium support.⁷ Despite its many critics, this policy proposal is a reasonable response if US health care is indeed a private benefit. Pegging the premium support to the Medicare taxes an individual has paid would fit the logic of private benefits even better, but an average cap on government payments calculated on the basis of recipients’ average contributions is a workable equivalent.⁸

These two objections to the Affordable Care Act illustrate what health care as a private benefit means in terms of distributive justice: People deserve their contracted health benefits. Specifically, people deserve the health coverage for which they have either voluntarily contracted with an employer or insurer or politically contracted with the government by paying their Medicare taxes. Both the emphasis on contracts and the type of contracts are essential, as we shall see.

The staying power of the private benefits idea reflects its history. Two policies from the 1940s and 1950s cleared the ground for the idea of health care as a private benefit to take hold and gain moral legitimacy. The first policy was an outgrowth of the federal government’s wage and price controls following World War II. The development of private health benefits received a big boost from a policy exception that allowed companies to add and increase health insurance benefits for their workers even as wages were capped.⁹ This distinction between wages and benefits remains a fixture of Americans’ thinking today. Ask people what their earnings are, and they will likely state the gross income on their payroll stub. Employees pay close attention to this figure, but the total cost of health benefits rarely enters most workers’ understanding, unless they are self-employed people who buy their own coverage or union workers who engage in collective-bargaining sessions. The premium, copay, and other coinsurance costs that American workers have increasingly had to shoulder do factor into people’s income calculations as losses, but the premiums paid by employers remain out of view.¹⁰ They are a “benefit,” perceived as a bonus, almost a gift, from employers to employees.

This overview of the first language of US health care already presupposes several distributive principles. The contractual basis of health benefits points to the importance of free exchange in purchasing health insurance. Although not seen as wages, health benefits are part of the job contract that employees freely enter, which is why these benefits are considered to be private. But health benefits are not contracted in some morally neutral sense. They are felt to be deserved, a matter not simply of protected property rights but of personal recognition for worthy service rendered, as the affronted anger in the retiree’s warning about his Medicare amply demonstrates. Curiously, the lack of attention that many employees pay to the costs of their health benefits and even the term “benefit” itself suggest a third distributive principle, that of need. Employers have a stake in meeting employees’ needs for health care so the employees will remain productive, missing less work due to illness or injury. W...