The Missing Piece: Health Care and the Faith Community
There is a missing piece in the social programs of the faith community. Many active parishioners and church leaders do wonderful work for the victims of domestic violence, child abuse, and poverty. Yet church programs tend to ignore the need for universal access to medical services. It is “the missing piece” because readily available medical care is so critical for many of the people we try to help.
Some parishioners may consider universal health care to be a personal responsibility. They may believe that advocating for universal health care has no place in the social programs or mission of their church. Yet these values of individual responsibility, choice and freedom are regarded in every other country except the United States as requirements for universal access to medical care for the same reasons that they support public education: it promotes people’s capacity to stand on their own feet, to exercise their individual freedoms, and to assume responsibility for themselves. In fact, an illness or disability can more quickly hobble an individual than missing a year of education.
Besides these compelling arguments for treating the ill to get them back on their feet, there is the Biblical call for ensuring medical services for those in need. The call to give one’s first tenth is clear, so that “the sojourner, the fatherless, and the widow who are within your towns, shall come and eat and be filled; that the Lord your God may bless you in all the work of your hands that you do” (Deut 14:28). “Take heed lest there be a base thought in your heart…and your eye be hostile to your poor brother, and you give him nothing, and he cry to the Lord against you, and it be a sin in you” (Deut 15:9). Among industrialized nations, ours takes up this call the least, so far.
Official and explicit discrimination against the sick and those at serious risk is allowed only in the United States. Everywhere else, it is illegal because it is considered immoral. Only America allows insurers to charge more to people because they are older or have a history of illness in the family or work for a smaller employer. Only here is it legal to exclude coverage for the services people need most for their health risks, present illnesses and chronic disorders.
Exclusion clauses for diabetes, obesity, hypertension, mental disorders, cancer, or heart disease which pay for no services are considered “good business practices” in a voluntary competitive system. About 45 million people do not have health insurance, a figure that rose during the booming 1990s as more employers dropped coverage or made its terms unaffordable. About 3,000 more people lose health insurance every day as employers decide they can no longer afford health insurance.
Increasingly, the insoluble weaknesses of voluntary health insurance are also affecting those who have health insurance, through longer waiting periods, higher deductibles, higher co-payments, exclusion clauses and payment or service caps at the back end of their policies. These are all forms of de-insurance or reduced coverage. Then there are more pernicious practices like “policy churning,” when an employer starts a new policy each year so that anyone who has become sick receives no coverage during the new waiting period, which is often 8-12 months. “Claims harassment” is also common: practices that result in delayed payment or no payment at all, such as “losing” a claim or taking weeks to process it, denying that the claim is valid without explanation, or down-coding a claim so the patient is left to pay more of the bill. Private insurance rewards covering the healthy, rather than providing financial security for people when they become ill.
In our current voluntary competitive system, no officer of a voluntary insurance company can carry out a social ethic of covering those who most need care without getting fired. He or she would be replaced by someone who “understands the business”, which is based on risk assessment in order to charge more or cover less for those at higher risk. Such people include those most likely to be old, sick, abused or attacked, that is, those whom the church is trying to help with its social missions.
Our current system also rewards employers for not providing good health insurance. Nearly half of all employers do not offer health insurance; so their employees have to gamble that they will not get sick or injured, or buy a policy on the individual market. But those policies cost much more and cover much less than group policies. Further, they discriminate against people with health risks or illnesses – precisely the people who most need coverage and access to medical services. Miguel, who washes and prepares cars to be rented for a national chain, was struck with ulcerative colitis. His hospitalization and surgery has left him with a $151,000 bill and no way to pay it. All he has left is a small annuity, and he is filing for bankruptcy to protect it from the collection agency the hospital has hired to go after “bad debtors.” Forty percent of all personal bankruptcies in the United States are caused by medical bills so large that people cannot pay them. We are the only wealthy country that oppresses the hired servants and does not provide for them when they become ill (Deut 24:14).
Reduced coverage limits, increased deductibles and increased co-payments are now being experienced by most employees, including church personnel. They are illegal in every other industrialized country because they violate a global belief that everyone should have access to medical care. A more communitarian principle is expressed in Acts 2: 42-47: “And all who believed were together and had all things in common; and they sold their possessions and goods and distributed them to all, as any had need.” The New Testament has many examples of healing, not only out of compassion but also so that the sick can see and walk again.
In his State of the Union speech, President Bush set the goal of “high-quality, affordable health for all Americans." He continued, “[W]e must work toward a system in which all Americans have a good insurance policy, choose their own doctors, and seniors and low-income Americans receive the help they need.” He could have added that this would help economic growth as well as help the victims of racism, poverty and tragedy get back on their feet and become productive again. In fact, all our trading partners have long had universal coverage combined with choice of their own doctors.
What Americans are not told is that their counterparts abroad also get more health care for much less cost, because universal health care is the single most powerful tool for holding down rising medical costs. It’s like having one debit card rather than 100 million. Instead of bills mounting up all over with no way to control them, one can budget, plan and manage costs. For example, a careful comparison of German and American patients found that German patients get more specialist visits, more tests, and more days in the hospital (a week when a child is born) for substantially less than what American patients and payers get for their money. Our highly inefficient system means that about 18 percent less of our contributions pay for clinical care and go instead to the middlemen that run our highly inefficient health care system.
Top systems—the best in the world—cost a third less. Thus universal health care would liberate employers from supporting a wasteful, fragmented system that does not cover 1 in 6 Americans, and it would lower their costs so that they could be more competitive. The U.S. ranks 72nd in the world in health gain per million dollars spent, far below all other industrialized countries. If we take the $1.4 trillion spent on health care and multiply it by the 16-20% that could be saved by replacing it with a simplified universal system, we find there is $224-280 billion of waste, plenty to provide universal access to everyone.
This point takes us in a different, pragmatic direction towards the well-known truth among experts in comparative health care systems that universal coverage is the key to managing costs, prices and volume over the long term. Businesses here claim there just are not enough dollars to pay for health care, when actually not having universal coverage is the principal reason why the health care costs of business keep rising faster than in other capitalist societies. And most universal health care systems are based principally on doctors in private practice. Many other countries have a private system within universal rules for equity and social justice. These realities are dismissed here with crude, inaccurate phrases like, “So you’re for socialized medicine...” Visions of gray patients sitting for hours in drab waiting rooms to see underpaid clinical drudges dance in our heads. Effective rhetoric keeps us from seeing reality! There is much more rationing of medical services here than in other well-run systems.
President Bush backed up his goal by proposing “an additional $400 billion over the next decade to reform and strengthen Medicare.” But why just Medicare and why a decade? As he said of tax cuts, if it is “good for Americans three or five or seven years from now, it is even better for Americans today.” Why not achieve his goal now, this year? And which embody Biblical ethics more, tax cuts or access to health care for the sick and needy?
Moreover, stitching patches in the patchwork quilt of a system like a drug benefit for the elderly does not control the drivers of rising costs and increasing overhead. It will only make people more convinced that universal health care is unaffordable. This is the irony of partial reforms: they make the case against universal access seems even more compelling. Churches need to stand up and be counted as advocating for reforms (like universalizing Medicare) that reflect Biblical ethics and also happen to be more efficient and effective in controlling costs.
The call for universal health care has been endorsed by the United Methodist Church, the Episcopal Church, the Evangelical Lutheran Church, the Presbyterian Church, the American Baptist Churches, the Union of American Hebrew Congregations, the United Church of Christ, the Friends Committee on National Legislation, the National Council of the Churches of Christ, and many others. But denominations, churches and individuals also need to get more active and make this missing piece an integral part of their other social programs. They need to discuss what a just health care system would look like. They will find help in Benchmarks of Fairness for Health Care Reform (Oxford University Press 1996). Here are some highlights:
First, a just system should cover everyone for all needed services and require that everyone participate in proportion to their income.
Second, neither contributions nor coverage should be allowed to discriminate by type of illness or ability to pay. These two mean that choice, that cardinal value, is maximized for everyone, not for the healthy at the cost of those with risks and illnesses.
Third, providers should be paid fairly and equitably for their valued services. This also enhances choice.
Fourth, the system should be designed to minimize waste and inefficiency. A system should be chosen that minimizes administrative costs. Clinical waste should be minimized by starting with a well-funded public health base and a strong primary care system, with emphasis on prevention and enabling patients to take care of themselves as much as possible. Good specialty and hospital care rest on these foundations.
Finally, decisions need to be open and democratic, including decisions to choose different benchmarks of fairness than these. Services need to be accountable to patients and citizens. All providers and insurers must report to the public on the costs and quality of their services. But the first step is to realize that advocating for universal access to medical services is the missing piece in the church’s current missions.
Donald Light has written extensively on the ethics and practices of health insurance as a fellow of the Center for Bioethics at the University of Pennsylvania and a professor of health care policy at the University of Medicine & Dentistry of New Jersey. Thanks to Rev. Leslie Smith at Trinity Church and Rev. Mark Orten at Princeton University for inspiring this essay. Thanks also to Linda Walling for editorial help. (References or documentation of statements upon request.)