Capital Commentary is the weekly current-affairs publication of CPJ, written to encourage the pursuit of public justice.

Just Health Care Reform

Clarke E. Cochran


September 30, 2011
by Clarke E. Cochran

“Unless we get control of Medicare spending, the country will go bankrupt! Medicare entitlement costs taxpayers $500 billion per year now; soon it will be over a $1 trillion. We can’t go on like this. Medicare is unsustainable. It must be fundamentally reformed.”

“Reduce the deficit, but don’t cut Medicare! Cutting that program will place the life of the elderly in jeopardy. My grandmother’s heart medications are provided by Medicare.”

It’s not difficult to see how this dichotomy is false. Yet it is not far from current political rhetoric.  There is a broad consensus that health care programs are central to the debate over government deficit and debt. There is broad consensus that we are living as a nation beyond our means. There is not, however, consensus about how federal health care programs should change.

How might we think prudentially and in a principled way about what seem to be irreconcilable approaches to health care and the deficit reduction?

First, we must acknowledge that health care spending increases are unsustainable. Total health expenditures reached $2.5 trillion in 2009, which translates to $8,086 per person or 17.6 percent of the nation’s Gross Domestic Product. Government spends about half of this amount, predominantly through the Medicare and Medicaid programs. There can be no solution to the budget crisis without genuine health program reform.

Second, however, we must also acknowledge that Medicare and Medicaid are fundamental to public justice and intergenerational justice. The Center for Public Justice Call for Intergenerational Justice recognizes the necessity of controlling federal spending, but also that “to reduce our federal debt at the expense of our poorest citizens would be a violation of the biblical teaching that God has a special concern for the poor.” Moreover, the common ground on which all citizens may flourish requires effective programs of income and health care support that ensure that all persons have the opportunity to exercise personal responsibility to contribute to individual and social well-being.

Although I don’t have space to defend the following claims, certain proposed solutions are either not just or will not effectively control costs. Conservative proposals for tort reform and market-based incentives do not adeaquately address the reasons for rising health care costs. Malpractice is not a major driver, and free markets do not generally work in the health care economy. Placing more responsibility on patients and families to pay for care has been going on for some time, but has not slowed the growth of health care costs. Such cost sharing reduces unnecessary care, but also necessary care. At the same time, many liberal solutions also fail to control costs, such as more resources for prevention; single-payer care; and government-mandated price controls.

In the short term, the best hope for fair, but effective health care cost control comes in a variety of provisions in the 2010 health reform legislation: Accountable Care Organizations; electronic medical records; payment per episode of care, instead of by number of procedures; bundled payments and shared savings models to encourage hospitals, physicians, and patients to coordinate care more closely; interdisciplinary “medical homes” for persons with chronic conditions.

The justice of these measures will be judged by the extent to which waste is reduced and to the degree to which they improve quality of care. Each aims to move health care from payment for volume of procedures (fee-for-service medicine) toward payment for quality outcomes. Helping people to get and stay well is both better for the patient and less expensive than uncoordinated care of unknown quality.

In the longer run, however, the only effective way to reduce health care spending and the resulting pressure on the federal budget will be for our culture to accept limits on wishes and desires. Health care of the future must employ individual (patient & physician) and social responsibility to limit expensive and often futile demands and expectations for medical care, especially at the end of life.

As Richard Lamm has said, “No citizen can expect all the health care that can be provided. No nation can afford to give the Hippocratic Oath a blank check.” It would be unjust to leave financial burden of a broken health care system to our children and grandchildren.

—Clarke E. Cochran, PhD is the Vice-President of the Mission Integration Covenant Health System in Lubbock, Texas.


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