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

Missing Balance in Healthcare Reform

Michelle Kirtley


August 28, 2009

The focus of the current healthcare insurance debate has been on whether to establish a government-run “public option.” Liberal Democrats insist that a public option is necessary to control healthcare costs and “keep insurance companies honest.” Conservative Democrats and most Republicans suspect that a public option is merely the first step toward a nationalized, single-payer system and are skeptical that the public option will truly rein in costs.

The result is something like guerrilla warfare involving all the bare-knuckle tactics modern politics has to offer. Even the group seeking to craft a bipartisan proposal in the Senate Finance Committee seems to be close to giving up hope for a workable compromise. Commentators on all sides are wondering if there will be enough votes to get any proposal through Congress.

At the extremes, neither side seems willing to give any ground. Liberals, suspicious of the market’s sometimes cutthroat nature, want to divorce the provision of healthcare completely from for-profit ventures, placing it in the hands of government. Conservatives, on the other hand, doubt government’s ability to control costs without rationing care and are wary of an increased government presence in something as personal as one’s health.

Yet blind trust in either the government or the market is insufficient for dealing with a problem as complex as health care. Modern technology has made even basic health care too expensive to allow for a return to the days when doctors provided services in exchange for goods or cash. At the same time, medicine’s relatively new but very real capacity to improve the length and quality of life has made access to healthcare a matter of basic human dignity.

There is broad, bipartisan agreement that there is a role for the federal government in providing increased access to health insurance. The focal point of the debate is whether government should administer the healthcare it subsidizes. The key to answering this question lies in our understanding of human dignity.

While human dignity may require guaranteed access to healthcare, that guarantee is not sufficient. We learned this from welfare reform. It is not enough for government to offer financial assistance to the unemployed. Government programs that unintentionally encourage vicious cycles of dependency and poverty may actually subvert human dignity. The need is for the right kinds of programs that encourage the exercise of human responsibility.

There is no conceivable means of expanding health coverage to those who need it apart from government support. But government support can be used to enable recipients to participate in the same private insurance system that most Americans enjoy.

Both state and federal governments have undertaken promising experiments in partnering with the private sector to provide health insurance. In Medicare, about 20 percent of the beneficiaries are covered by private insurance companies through Medicare Advantage. Similarly, several states are attempting to offer Medicaid recipients either Health Savings Accounts, which they manage themselves, or vouchers for the purchase of private health insurance. These models offer the added hope that a Medicaid patient carrying a Blue Cross insurance card may actually be treated the same as any other privately insured person.

The debate on health care reform need not be reduced to a choice between an expansion of government-run health care and an affirmation of the status quo. Instead, the goal should be a more robust affirmation of human dignity in which the provision of needed assistance also empowers individual and institutional responsibility.

—Michelle C. Kirtley, Ph.D.
   Health Policy Adviser
   Congressman John Fleming, M.D. (R-LA)



September 14, 2009
Reader responses to this commentary:

1. From Bruce Jackson, Chicago, Illinois

There is much debate about the healthcare reforms now being proposed in Congress. I want to emphasize that government involvement in health care has worked.

There have been many claims that government needs to stay out of health care, yet the government is already involved in health care in various capacities, including Medicare and Medicaid. Both programs have successfully provided a way for health care to be extended to those in need. In addition, the government has provided healthcare insurance for children in the CHIPS program, which makes access to health care possible for children in poverty.

Another successful program directed by the Department of Health and Human Services (HHS) is the government-funded Community Health Centers. These federally qualified health centers (FQHC) and FQHC look-a-likes are located across the country. The centers are in areas where there is a shortage of physicians and where people lack financial resources to access health care. The federal government has funded these centers since the 1960s. What makes the FQHC successful is that federal funding goes to locally based organizations whose boards of directors are community based. Physicians who are committed to the community provide quality primary care. The success of the program is founded on the partnership of the federal government through HHS with local community healthcare centers. This partnership, focused on primary health care for people in under-served areas, empowers communities and physicians to provide necessary care in their specific neighborhoods.

This is a partnership that works. It is a successful model on which to build additional programs throughout the country.

Mr. Jackson, formerly the executive director of a community health center, is now working to develop community-based and church-based organizations in impoverished neighborhoods.


2. From James W. Skillen, President, Center for Public Justice

Unfortunately, we Americans have difficulty understanding what a successful relation between government and non-government organizations should be. The healthcare debate shows this clearly. Many who believe in personal freedom and private enterprise see any government involvement in health care as a dangerous step toward socialism. Many who want the government to uphold fairness for all citizens seem to believe that any decision-making authority left in the hands of insurance companies or other for-profit organizations is a threat to fairness for all.

The root of the problem with this false dichotomy is that government is treated as a mere means to the fulfillment of various individual aims, ambitions, and needs. Those who emphasize individual freedom say that all government needs to do is to protect (and stay out of) the market in which free individuals can bargain to get what they want. Those who think of government as the means of meeting certain human needs argue that lack of access to healthcare insurance is unfair and government ought to make sure that those in need are not left out. The arguments back and forth never resolve the question of the proper responsibility of government and never ultimately identify which human needs government should address.

What we need to recognize in order to get out of this false bind is that human life in society consists of more than individual freedom and a helpful or menacing government. There are organizations and institutions that have distinctive identities and responsibilities in their own right, such as families, businesses, schools, and churches. And one of those institutions is the political community, composed of citizens and government, which has its own ends and purposes. Government is not merely a means to private ends but the authority in the political community that is responsible to uphold justice for all. That means that public funding for services such as public infrastructure, education, health insurance, and unemployment compensation are not first of all a means to private purposes or an illegitimate extension of government into private responsibilities. Government is responsible to maintain a healthy and just public community in its own right and many of its programs—such as police forces, court systems, sewage systems, and more—are essential to the justice and peaceful order of that community.

The fact that many non-government responsibilities, such as the services of doctors, teachers, engineers, and insurers, also have their own legitimate purposes means that government’s actions to maintain a just public community demands that it work fairly and equitably with many non-government institutions to achieve interrelated and mutually encouraging purposes. A properly limited government working closely with doctors, hospitals, and insurers in ways that uphold justice for all citizens as well as justice for those non-government service providers does not represent a slide to socialism at all. To the contrary, it represents government fulfilling its responsibility in cooperation with other actors fulfilling theirs.

Developing public policy in keeping with this view of multiple human responsibilities interconnected through a political community is what Congress, the president, and citizens should be concentrating on now.


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Capital Commentary is a weekly current-affairs publication of the Center for Public Justice. Published since 1996, it is written to encourage the pursuit of justice. Commentaries do not necessarily represent an official position of the Center for Public Justice but are intended to help advance discussion. Articles, with attribution, may be republished according to our publishing guidelines.”