A Christian Response to Health Care Injustice

Poverty and ill health travel together in the United States. The poor and near-poor do not get the health care they need. The primary barrier keeping the poor from health care is lack of health insurance, and the number and percentage of uninsured is increasing dramatically. About 42 million people (15.6 percent of the population; about 18 percent of the under-65 population) are without health insurance, often for months at a time. This figure includes 31 percent of persons below the poverty line. Access to the health care system at the appropriate time and place, to the right treatment, and without over-whelming financial burden depends on health insurance. And health insurance is tied to employment for most of the working population.

This system, however, is breaking down. There has been a steady decline in private, employment-based insurance over the last decade. Job growth today is in the private sector, in part-time employment, in self-employment, and in contractual employment. These sectors traditionally do not offer health insurance benefits to the same degree as the manufacturing and blue-collar sector. Moreover, even those employers offering insurance have increased employee cost-sharing, making it more expensive for the worker and, especially, for dependent coverage. Very few workers are uninsured by choice. The vast majority has no employment-based access to health insurance or cannot afford it at their low wages.

Health Care and Public Justice

When the healing and caring arts were largely the possession of families, their relation to the common good was indirect. As the meaning and production of medicine became more social, particularly in the 20th Century, their relation to the common good became more direct, with a corresponding increase in the responsibility of public authority.

What does it mean to say that medicine has become more social? Today, the knowledge of medicine cannot be contained by families or even by well-trained medical professionals. Medicine in the late 20th Century is a social art; that is, its divisions (nursing, obstetrics, psychiatry, surgery, and so forth) are distributed to specialists who (in the best of circumstances) work together for the good of particular patients. Moreover, the advancement of medicine in the form of research and development is also a collective enterprise, often heavily financed by government. Finally, the specialists who hold and advance medical art receive their formation in educational institutions founded and supported by the public through philanthropy, public financing, and (often) public governance.

Therefore, the health care system is both a common good, in the sense that it is a good produced by the common action of society and its representatives, and at the same time a means to the common good, in the sense that it assists individuals to remain members of the community in the face of illness and injury. Because government has a primary responsibility to promote the common good, it has an obligation to develop policies that assist the health care system to fulfill its God-given vocation. But not the sole or final responsibility. The health-care profession itself has responsibilities, as do families, churches, and other associations. Individuals, civil society, and government form a web of responsibility.

If institutions of health care have a social character and if the common good is the focus of public action, then justice in the distribution of health care means distribution primarily according to the need for health care. Different spheres of society appropriately employ different bases of distribution. College professors aim to assign grades on the basis of merit or achievement. The same principle is used for prizes in an athletic competition. Parents distribute slices of cake at a child's birthday party according to strict equality, lest fights break out. Numerical equality governs votes in a democratic society. Cameras, blue jeans, automobiles, pencils, and diamond rings are distributed according to the logic of the market.

Need is the proper principle for distributing health care because health is necessary for a community's proper functioning. Good health facilitates social interaction and economic enterprise. Medical care is one of the principal means to preserve and restore physical, mental, and emotional functioning. Therefore, all societies (except the United States) that value health and that have the financial and technical means to develop modern systems of medical care recognize that health care for all citizens is a matter of public justice.

The prime competitor of need as a distributive principle is the market. Commitment to laissez-faire capital-ism promotes a vision of the market as the single metaphor for life. Yet the market, however appropriate for the distribution of commodities, depends on an individualistic perspective foreign to commitment to the common good. It treats health care as a commodity like cameras, cars, pencils, and blue jeans. Those without financial resources receive inferior care or no care at all. The American tendency to make health care a market commodity produces very high quality technical care, but at the highest cost and worst access in the modern world.

Responsibility Extends Beyond Government

Social responsibility for the provision of health care does not exclude indispensable personal responsibility or a role for civil society. Individuals and the family members closest to them certainly are obligated for their own health care, especially when many of its means are largely under their control (good eating habits, avoidance of smoking and excessive alcohol consumption, sufficient rest, and the like) and for minor health needs. They may even assume responsibility for part of the sophisticated and expensive care given by the medical system (insurance deductions and co-payments), as long as no unacceptable financial bur-dens are imposed.

The language of individual responsibility can be used far too glibly. Many persons with mental or physical handicaps, with addictions, or with damaged social skills are only margin-ally capable of personal responsibility. Moreover, the language of individual responsibility is often an excuse for denying public responsibility to pro-vide adequate medical treatment, counseling, addiction treatment, and housing for the poor. The obligation of meeting needs is a shared responsibility.

Lack of insurance does not generate all of the barriers to the health care system. Even if all persons were guaranteed public or private health insurance coverage, millions of persons would find it difficult to get the care they need. Many Medicaid-eligible persons today, for example, do not take advantage of the insurance offered. Millions of children lack their complete vaccination program, despite the availability of free shots. Governmentally guaranteed insurance is part of the picture; effective work by churches and other non-profit organizations is the other part.

Recommendations on the Policy Front

If health insurance is a vital part of a comprehensive approach to a just society, how should we think about providing for its distribution? Health insurance complements other essential measures: sound wages, access to capital, food stamps, the Earned In-come Tax Credit, and employment conditions. Together these describe a basic minimum set of resources that a modern, prosperous democratic society owes to all citizens through a combination of market forces, civil society, and government programs.

With respect to health care and government policies the following advocacy goals should be part of a Christian public justice ethic:

1. In the long run (but we should push hard for the earliest possible implementation), there should be a health-care and insurance system that guarantees universal access to curative medicine, preventative health care, and effective care for those with chronic conditions. Universal health insurance may be achieved through any one of a variety of schemes, but its enactment is a vital goal for Christian political action.

2. Because comprehensive health-care justice is some years away, short-range, incremental measures are also important.

a. First, expansion of Medicaid and the Children's Health Insurance Program (CHIP) to cover the maxi-mum number of children, the unemployed, and the uninsured, particularly the working poor.

b. Second, aggressive cooperative efforts by local governments and civic organizations (especially churches) to inform people of their eligibility for Medicaid and CHIP.

c. Third, protection of essential "safety net" institutions such as neighborhood clinics, public hospitals, departments of health, and community health centers.

d. Fourth, resistance to legislative proposals such as medical savings accounts that would further fragment the health-care financing and delivery systems.

e. Finally, protection of the Medicare system and expansion of its prescription coverage, especially for the poor and near-poor elderly.