I have a number of friends from both Canada and Europe who express considerable amazement at how we in the U. S continue to debate the subject of single-payer, comprehensive health care. For them it seems like a slam-dunk argument in favor of such a system. I read and hear that we are just being a selfish nation that doesn't care enough for the poor among us. We have been ruined, some argue, by our crass love of free markets and capitalism. And, I have heard American Christians from the political left argue that Christians who do not support national health care are even more culpable since we should be the very ones who are deeply concerned for our weaker, poorer fellow Americans. Indeed, the Christian left touts this entire issue as one of Christian compassion and love for the weak and marginalized. Who could argue with this point if this is the real case? The problem is that I strongly disagree with both the analysis and the reasons behind it. But it is admittedly not as easy to explain why in simple and compelling ways.

For this reason, among others, I was profoundly grateful for a simple, clear even-handed answer to this question recently written by my friend Dr. Robert Benne. Bob Benne is the director of the Center for Religion and Society at Roanoke College (VA). Bob came to Roanoke College from the Lutheran School of Theology in Chicago in 1982. He is a leading figure in Lutheran ethics and social thought.

A selection of his publications illustrates his wide interests and considerable ability: The Ethic of Democratic Capitalism: A Moral Reassessment; Ordinary Saints: An Introduction to the Christian Life; The Paradoxical Vision: A Public Theology
for the Twenty-first Century
; Seeing is Believing: Vision of Life Through Film.

Bob is currently working on a study of higher education in Lutheran and other Christian denominations and remains a prolific student of the subject of Christian ethics. I have read Bob's work for years and met him about ten years ago. I later invited him to speak for an ACT 3 event about six years ago in suburban Chicago. Here is his answer to the questions he received from his European friends.

Benne "Why in the world can't you Americans achieve a comprehensive national health-care program like the National Health Service we have and prize here in England," asked a dear English friend in her letter accompanying the Christmas card that she sent. "We just don't understand your recalcitrance." 

Now those are good questions. I will try to answer them in this column, and then send the column to her for her perusal and response.

Before I get to that larger question, it is important to distinguish the larger questions she posed from the recent demise of the Obama health care reform proposals, which seemed to plummet to the earth with the astounding election of Scott Brown in Massachusetts.  Many analyses of that debacle have been made, so I will pass on providing another.

Even so, two of the intentions behind those failed efforts are very worthy:  to provide more people—especially the poor, the working poor, and those with pre-existing conditions—with access to affordable health insurance; and to hold down the ever increasing cost of health care in this country.  The latter is a widely shared goal even though the Nobel prize-winning economist Robert Fogel thinks that the rising cost of health care is an accurate signaling of what consumers want: they want expanded and more sophisticated health care, and are willing to pay for it. 

[Now] on to the larger set of questions.  Why don't we have a national, single-payer health care system in this country?  Is it just because the wealthier portion of our society has good access to health care and selfishly doesn't want to provide the resources for those who don't have what they have?  Is it also because the large "special interest" groups make good money by catering to that wealthy portion of the population and serve it by blocking what really needs to be done?

No doubt there is an element of truth in both charges, but it seems to me the reasons are deeper and less self-serving than those accusations imply.

First, the charge that the American system of health care is irretrievably and comprehensively broken is vastly over-stated.   The Left constantly exaggerates the defects of a number of sectors of American life—capitalism, health care, campaign finance, food, etc.—and projects their estimates onto the general American populace.  They call for radical over-hauls of these sectors.  But it turns out that the majority is quite content with its lot in these sectors, and therefore resists radical proposals.  The majority's attitude toward the capitalist economic system is instructive.  Roughly eighty percent are pretty content with their contributions to and rewards from their participation in our market economic system.  They resist the constant efforts of the Left to push the country toward socialism or even European-style social market capitalism. The same dynamic operates with regard to healthcare reform.  The majority favors tinkering and extending rather than transforming.

Though most Americans recognize the need to address its weaknesses and problems with it, it seems that the vast majority—that same 80%–like their health provisions enough not to want to risk them for some new and untried system. I am a member of that majority.  Though it is not a "Cadillac" plan, my health insurance plan is a solid one provided by my college that affords my family and me excellent health care for very manageable out-of-pocket expenses.  What I have to pay for coverage for my family is considerable, but certainly not onerous.  I am happy with my insurance and the health care I can obtain through it. [My own plan is not as good as that offered to the faculty of a school like Dr. Benne's but I am also relatively satisfied with it, though I would love to see some tweaks in the way it works.]

I have lived abroad for five different years—as well as for two other extended times— and would not trade the medical care and my access to it that I enjoy in this country for those socialized systems which I have experienced in the countries in which I have lived—England, Germany, and Slovakia. I would rank the German private/public mix to be the best of the three, with Slovakia coming in a lowly third, mainly because its public sector is impoverished after the collapse of the Soviet-imposed centrally-planned economy. In the middle is the British system, which we have utilized many times over the span of the three years we have lived in Cambridge, a university town with highly-touted medical services.

My assessment is that Britain has a system that distributes routine medical care pretty well, but does not do well with serious illnesses.  Even in routine care, e.g., treating high blood pressure, it raises the threshold for treatment so high that most Americans would be appalled.  Further, the medical equipment is generally not up-to-date and the buildings are dingy.  Doctors are overburdened by people with small complaints.  Specialists are very hard to reach. I would not want to be treated there for a threatening—but non-urgent—illness if I could go back home to the USA. If one needed emergency care, there would be little choice, though in Slovakia I had handy the telephone number and location of a hospital in Vienna.  There are private—but very expensive—outlets in Britain and Slovakia.  Ominously, Canada forbids such a private medical system.

However, even if we agree that medical insurance and care are adequate for the majority, why do we not adopt a single-payer national system?  Besides the general happiness with the current health care system by the majority, there is a lack of confidence by that majority in very large, governmental organizations.  They are seen to be ponderous, expensive, and inefficient.  They seem to do less for more, much like the public school system in most states and localities.

Still, shouldn't we be willing to put up with some inefficiencies and loss of quality for just distribution, similar to what we do with public education?  Here is where we get into deeper issues, one having to do with the "spirit of America" and the other having to do with different renderings of justice.

The "spirit of America" prizes independence and self-reliance far more than the countries that have socialized systems.  The spirit of independence—just like the spirit of compassion and justice—flows from Christian notions of human nature and obligation.  Humans are free to manage their lives and most Americans believe they ought to cherish, protect, and express that freedom. It is better to be independent and self-reliant in managing their lives than to be dependent.  Not only should they do things for themselves that would otherwise have to be done by others, they are convinced that they flourish best when independent.  It is better for all concerned to rely on one's own resources and capacities as much as possible.  Besides, if one cedes one's independence to other entities, e.g., the government, those entities have great power over one's life individually, and over the life of the country generally.   Americans believe that it is better to manage one's own life rather than cede that power to others.  All this applies to health care: better to take of oneself and one's family than to rely on others, including the government.

However, Americans also believe that when others cannot take care of themselves, there is an obligation to help them.  Thus, we have free medical clinics along with food kitchens, shelters, rescue missions, and a vast array of private agencies to help those who cannot help themselves. Americans cultivate compassionate service for those who are dependent even as they prize their own independence.  They have ambivalence toward those who can help themselves but don't.  Even so, they tend to err on helping rather than judging.

Yet, most admit that this admirable system of private charity cannot cover everyone with medical needs.  Americans believe that the government must step in where private charity cannot do the job.  But they hold that those who need it must prove that they cannot help themselves.  They believe in "qualified" rather than "absolute" positive rights.  Because of their spirit of independence it is better to order justice toward qualified positive rather than absolute positive rights.

A positive right is one in which another is obligated to perform positive actions toward you.  Every person, for example, has the positive right to be treated with respect, not merely or solely as a means. Indeed, such a positive right is absolute—all are due the positive attitude of respect.   But what about services, not just attitudes?  For instance, what actions or services does the government owe citizens?  And does it owe them to everyone?   Or to only those who show need for them?  Are the rights absolute or qualified?

There is at least one absolute positive right to services that the government owes citizens in the American scheme of distributive justice.  The government is required to provide fitting education to every citizen through high school. That is a huge obligation and task which the government takes seriously. Fortunately, however, it does not require that everyone accept those public services.  It allows private schools to educate students whose families are willing to pay for their private education, with the stipulation that those families also pay taxes to support the public system.

Should health care be an absolute positive right?  It seems even more basic than education.  Or should shelter be an absolute positive right? That seems even more basic than health.  Not many governments—save totalitarian ones such as the Soviet Union—take on responsibility for such an array of absolute positive rights.  And those that have done so often use the ensuing dependence of the populace to manipulate and oppress them. No, it seems unwise and perhaps unjust to elaborate too many absolute positive rights.  It makes for an overpowering government and a dependent people.

The American approach views the provision of health care as a qualified positive right.  The government and hospitals are obligated to provide health care for those who cannot afford it or will not provide for themselves. The very poor have access to Medicaid plus charitable offerings.  They also use emergency rooms and hospitals for their health care, which shifts costs dramatically to the hospitals, which pass them on to insurance companies, which in turn leads to higher premiums for individuals and institutions. This arrangement is not very efficient and leaves many people out.  Even those who take advantage of this qualified approach do not receive consistently good medical care.

Thus, it would be far better to provide graduated vouchers or tax credits to those below a certain income level to purchase private insurance of the sort roughly equivalent to the kind I currently possess. Such persons could then claim their positive rights within the same healthcare system that the majority of Americans enjoy.  They would not be relegated to a massive, inferior, government-run health care delivery system.

How to contain ever-increasing health care costs?  I doubt if we will ever be able—or even want —to contain them dramatically.  As Fogel argues, we want excellent, sophisticated health care and we are willing to pay for it, for the most part. But offering vouchers or tax credits to a large segment of the population would be expensive.  Further, we would probably need some sort of government subsidized insurance for those with pre-existing conditions.

Some excellent ideas have surfaced. [These include the following:] Allow insurance companies to compete across state lines.  Introduce tort reform to cut down excessive litigation.  Reward health-care providers for keeping people healthy rather than [just] for treating them when they are sick.  Encourage highly efficient, integrated systems that have emerged in a number of cities.  Encourage states to experiment with innovative approaches.  Increase out-of-pocket co-pays so that customers cannot ignore the actual costs of what is provided for them.  No doubt there are many others of which I am unaware. Further, we should look carefully at the mixed private/public systems of countries like Germany to find out how they are financed.

[I would add to Dr. Benne's positive ideas about fixing the U. S. system another. We need to increase the awareness of, and protect the existence of, the Health Savings Account system we already have in America. I use this system and find it incredibly helpful in keeping insurance costs down while it covers many out-of-pocket expenses at the same time.]

These are some of the responses I will offer to my English friend.  It is not irrational to resist the introduction of a massive, untried, government-financed system for one that the majority thinks is pretty good. Most Americans enjoy some of the best healthcare in the world.  But we have a problem with distributing that fine service, as well as paying for it.

Finally, it is not unjust or non-compassionate to prefer an approach that features qualified positive over absolute positive rights as long as we are determined to treat those who qualify for them justly and compassionately.


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  1. Chris Criminger February 24, 2010 at 8:46 am

    Hi John,
    First off, I prefer smaller government than big government so I am not for a comprehensive government health care program (which I believe would be the largest slush fund for government to abuse).
    But after saying that, the current health care situation has gone from bad to worse. As an independent minister who has no great health care network, I see many of my colleagues falling through the cracks. I have never seen so many ministers going without health insurance (especially when you hit sixty where the premiums are outrageous).
    My health insurance has gone up 100 dollars A MONTH for the past four years (which has been a huge financial strain). Medicare is cutting back its benefits and I see a growing number of poor people who either have to wait years before they get some kind of government help to none at all (depending upon the circumstances).
    In the end, leaving the system alone or the government taking over the system seems to be the false either/or of so many of these discussions. I am open to solutions from either side that is cost effective and efficient.
    For those of you who have great health coverage, I think you should be able to keep it. But for those of us who don’t, things as they are is simply becoming unbearable and SOMETHING has to change.

  2. Josh R February 24, 2010 at 10:59 am

    I think we confuse the definition of the term “right”. If you read the “Bill of Rights” every right was a guarantee that the Government would leave you alone.
    Rights under the Bill of Rights model do not require putting a burden on somebody else.
    So if you say that somebody has a “right” to be fed, or housed, or doctored, there is a flip side that somebody has an obligation to feed, house or doctor. Placing that obligation is the antithesis of what a “right” is.
    I think the core issue with health care costs is the fact that nobody pays for their own care. I go to the doctor who works for the insurance company, who works for my employer who picks for me. All of these layers of transactions add layers of irrationality to the system, and twist the market forces into incentivising increased costs. I want the most Care I can get for the huge premiums I have already paid. The Doctor wants to provide every service the insurance company is willing to pay for, and the insurance company Just figures out what the costs are going to be actuarially and passes the cost along to the employers. There is very little incentive for anyone to cut costs. There is an incentive to cut unexpected costs, but that is about all.
    If you where to move to a pay for service prices would drop. Look at Laser eye surgery for example – Rarely covered and prices have always had the opposite trajectory of the covered health care costs. I would bet Abortion prices have also been comparatively flat.

  3. John H. Armstrong February 24, 2010 at 12:15 pm

    Some very helpful insights Josh. My son now gets his various normal medical and dental work done in Costa Rica or Ecuador when he is there for his mission. The quality is superb and the care very good. The best part is the price! Nothing in the U.S. can touch it. If we paid the real cost for medicine then the whole system would be fixed in a week. The layers and layers of problems are real, and systemic for over sixty years now. This could all be fixed but there are too many interests in the game to fix them until the system collapses or someone cares enough to really get it done. Your example of Lasik is a very good one that proves your point. There are a few others that work.
    If you asked physicians they would adopt a much smaller fee and a “pay-as-you-go” approach in a heart beat. If we wanted to then help the poor we could put in place a means for just that and no more.

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