Is Health Care a Right or a Privilege? A Christian Ethical Perspective

One of the basic sources of conflict in our society regarding the direction that health care reform should take stems from a deep division among our populace as to whether health care is a basic human or civil right. If health care is a right, then government has an obligation to provide it, regardless of the individual's ability to pay for it. If it is a civil right, then this coverage must be extended to all lawful citizens. If it is a human right, then it must also be extended to criminals, non-resident aliens and illegal immigrants.

If, however, we do not have a right to health care, then there is no obligation for the government to provide health services to individuals within our society. There is no obligation to stem infant mortality, or control the spread of communicable diseases, or develop better treatments for cancer. That is not to say that these are not worthwhile goals; merely, that it is not the government's responsibility to provide these benefits. It is up to the market to provide these services if they are profitable, and to charities to provide them otherwise.

It seems that some of the most verbal opponents of government-supported health services are committed, believing Christians. I find this counter-intuitive. I cannot mount a competent secular ethical argument for a human or civil right to health care. But I can make a case from a Christian ethical perspective. And I invite commentary from readers of other religious traditions regarding the ethical imperatives arising from their traditions with respect to health care.

Christianity as a religion grew from Judaic roots, and is founded upon the belief that an historical human being who lived in Palestine around 2,000 years ago, Jesus of Nazareth, was in fact the incarnation (the "fleshing out") of God. Consequently, the words and actions of Jesus are perhaps the most authoritative reference for Christian life and practice. Jesus was crystal clear about the individual's responsibility for the welfare of his/her neighbor. In Luke 4 he quotes from the Hebrew prophet Isaiah to define his mission:

"The Spirit of the Lord is on me,

because he has anointed me
to preach good news to the poor.
He has sent me to proclaim freedom for the prisoners
and recovery of sight for the blind (emphasis added),
to release the oppressed,
to proclaim the year of the Lord's favor."

In chapter 11 of the same book, Jesus tells the story of the Good Samaritan, the man who spent his own money to bind the wounds of an injured man (providing emergency services) and put him up at an inn for his recuperation (hospitalization). Defining this as "neighborly" behavior, Jesus commanded, "Go and do likewise."

There are many, many more examples, but I'll give just one more: In Matthew 25, Jesus describes the final judgement of the nations (Greek ethnos, which means cultures or peoples, the concept of nation state having not yet developed). Those who are judged righteous and rewarded with eternal life are those who carried out specific behaviors, and those who were judged evil and condemned for eternity failed to perform these same behaviors:

"I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I naked and you clothed me, I was sick and you looked after me (emphasis added), I was in prison and you came to visit me."

Jesus goes on to say that whenever we treat the least of our neighbors (i.e. the marginalized of society) in this way, it is as if we are literally caring for him.

At this point, the Christian who is inclined to disagree with me will quote Jesus (John 18) telling Pilate, "My Kingdom is not of this world," and follow this with quotes from Paul (Romans 13: submit yourself to the governing authority) and I Peter (submit yourselves to the king), to make the case that how we live our faith is a separate issue from how the government orders our society. I counter with the consistent message of the Hebrew prophets, and offer this one example from Isaiah 10:

Woe to those who make unjust laws,

to those who issue oppressive decrees,

to deprive the poor of their rights

and withhold justice

from the oppressed of my people,

making widows their prey

and robbing the fatherless.

What will you do on the day of reckoning,

when disaster comes from afar?

To whom will you run for help?

Where will you leave your riches?

When the New Testament was written, the Roman Empire was not a Christian state. In fact, Christians were persecuted and killed by Rome. On top of that, Christians were convinced that the end of the world was near, and therefore they were not concerned with temporal matters like social justice, nor were they in a position to influence these matters.

Israel, on the other hand, was a theocracy of sorts. The King and the Temple cult were inextricably tied. Temple worship was the "state religion." It was in this context that Isaiah prophesied against the religious and political leadership of Jerusalem. This context is more congruent with current American society, which is still not yet post-Christian. Christians who believe the American myth of a country founded on Judeo-Christian principles (and I'm using myth in the technical sense here, NOT as a synonym for fable) are violating their own integrity when they adopt the economic conservative stance that we have no societal or political obligation to provide at least a basic level of health care for our nation's citizens.

I therefore call on Christians to put their money where their mouth is. If we believe the United Sates is a Christian (or Judeo-Christian) nation, then we need to be intellectually and ethically consistent and support a more socialized model of medical care. OR, we need to be honest about what we really believe about the authority of Scripture (or, in this case, the lack thereof).

HCR, once stuck in the mud, is moving down the tracks again

As I predicted in my last column, the Senate Finance version of health care reform will form the core of whatever ultimately passes both houses of congress. The Republican minority attempted to derail reform, only to reveal to the Democrats that they can pass reform without Republican support. The opposition party comes off looking merely obstructionist, with the exception of Olympia Snowe.

The Public Option, once on life support, is making a remarkable recovery. Still in all, I am not a big fan of the public option because it will artificially depress the market. The reason is that supporters of the public option intend to set initial pricing at current Medicare rates, which are already below market value. Many older primary care physicians, whose patients have aged along with them into the Medicare universe, are retiring early because they can't afford to keep their practices operating at the rates Medicare pays. If the public option is implemented at those same rates, physicians will opt out, either immediately, or after trying to make it work for several months.

If this is indeed the turn of events, the public option, rather than tempering the rates charged by commercial insurers for individual and small group plans, will simply devolve into an empty shell, much like the Competitive Acquisition Program that CMS attempted to launch several years ago. For most of you, who have never heard of the CAP, it was an attempt to knock physicians out of the drug reselling business, where oncologists, for instance, earned most of their profits. CMS sought to control costs by enticing a handful of drug distributers to bid for the government's business. These few companies, in turn would have in effect an oligopoly (except without the ability to artificially prop up prices, which is the main purpose of oligopolies). These companies would then develop extensive drug delivery and retailing pipelines, with the oncologists serving as consignment shops.

The drug distribution industry saw the hook in the worm and didn't bite. Neither did the oncologists. The CAP never came to be.

Now here is how the public option can - and should - work: First of all, don't implement the public option right away. Instead, save it and use it as a threatening storm on the horizon, triggering its operation only if the commercial insurance market cannot provide affordable plans to individuals and small groups. Second, if the public option is enacted, set the pricing at 110% to 115% of Medicare rates. That's on the low end of what HMOs will pay for health services, but maybe high enough to entice the most efficient and well-run providers into opting in. From there the market should dictate which way the rates go.

Which brings me to a point regarding Medicare that many folks don't know, and I can't believe I'm about to say this because it'll make me sound like Milton Friedman, God rest his soul:

In a free market, supply and demand are inversely proportional, such that when supply is high and demand is low, prices drop, and vice versa. As the Baby Boomers age into Medicare, the demand for services will rise dramatically. At the same time, we are facing an impending shortage of physicians, as well as most other medical professionals. The result, in a free market economy, would be a significant increase in price commanded for health services.

Medicare works the opposite way. It wants to maintain budget neutrality. CMS, or more accurately, Congress, wants to pay only a certain aggregate amount for health services. So when demand goes up, and quantity supplied increases to meet the demand, Congress will reduce the price paid per unit in order to contain health care costs in the aggregate. What will be the effect of this? More physicians will retire early. Fewer college graduates will enter medical school. Nurses will leave hospital inpatient units in droves. The rate of consolidation in the health care sector will increase.

Medicare and Medicaid beneficiaries will be most vulnerable to these changes, because health care providers will simply stop offering services that are utilized disproportionately by these patients.

Here's a specific prediction: if CMS continues to reduce payments for cancer care - for instance chemotherapy treatments - medical oncologists will stop treating patients in their offices, because they'll lose money on the drugs. They'll begin sending government-insured patients to the hospitals for chemotherapy. However, since hospitals will be hit with a disproportionate number of underpaying patients (the physicians keeping the well-insured patients for themselves), the hospitals will simply shutter their chemotherapy infusion suites. Medicare patients will have to go to the few safety-net hospitals to get their treatments, and they'll have to wait in line, because the demand will far exceed supply.

The same chilling effect will be felt in other sectors of health care where the majority of patients are insured by the government.

Unfortunately, I'm not foretelling a future full of doom. These reductions in services are already occurring. In the large metropolitan market where I work, several community hospitals have already either closed or greatly restricted their outpatient infusion services because they can no longer afford to treat the number of uninsured and underinsured patients seeking chemotherapy at their facilities. And by underinsured, I mean to include Medicaid patients and Medicare patients who don't have a MediGap supplemental policy.

Maybe cancer care is an anomaly. Or maybe it's the canary in the mineshaft.

Senate Finance bill will become the centerpiece of reform

The health care reform bill being crafted in the Senate Finance committee, chaired by Sen. Max Baucus, will become the core of whatever bill ultimately passes both houses of Congress. We will all need to read the bill (I haven't started yet) so that we know for ourselves what the bill puts forth, rather than trusting the pundits to explain it for us.

By now everyone should realize that virtually everyone has an axe to grind when it comes to health care reform. You're not going to get a straight presentation from any major information outlet. So read the bill for yourself.

What I have picked up from reading the Wall Street Journal (still, in my mind, the most objective and accurate reporting on health care reform), as well as other news sources, is that the Finance bill has effectively killed the public option. As I have said before, I think that's a good thing, because the public option was going to start at Medicare payment rates. Most physicians aren't very good businessmen, but those who are will undoubtedly have refused to contract with the public option plan. They are already losing money on Medicare patients and can't afford higher volumes of patients at those payment rates.

Hospitals are even less adept at business than physicians, so most of them probably would have signed on with the public option. The hospital where I work is losing money on Medicare patients. For every dollar we spend to care for a Medicare beneficiary, the government is reimbursing us 90 cents. We can't afford more health insurance plans that pay at Medicare's rates.

Nancy Pelosi and other liberal Democrats will raise cain over the Senate's rejection of the public option, but in the end they will not be able to reverse the direction that Congress is moving.

There is a moderate possibility that the public option will be retained as a "trigger" option; that is, the public option will be retained in reserve and will be activated if the market fails to provide an acceptable level of coverage at a reasonable price for lower income individuals. I would support using the public option as a "poison pill" of sorts. Without the threat of austere action, the players in the health care market will not be sufficiently incentivized to produce the necessary reductions in cost (and economic profit) required to bring health care spending in line.

Let me be so bold as to suggest that you write your senators and ask them to support a delayed public option health plan to be activated only upon the failure of the market to generate the necessary reforms.