My Catholic Vision of Health Care

[Mar. 26 2010] My apologies for not posting lately, but my attention has been wrapped up with matters of health in more ways than one—of course I am referring to the passage of the "Obamacare" health care bill Sunday night, but also to some personal health matters that I have been struggling with this week.

These things have led me to reflect upon the current status of health care in our country, my problems with the new bill and my ideas on how health care could conceivably be much better. I call this post "MY Catholic vision of health care" because although I know that the USCCB and the Vatican have made statements on health care over the years, I confess that I have read almost none of them. Therefore, my solutions and ideas proposed here will be only that: my own ideas, formed by my Catholic faith. If anybody can buttress them with Magisterial statements (or perhaps show me if I am in error) I would appreciate it.

 I'm just going to pass over the abortion related aspects of the current bill since we are all familiar with them already. Besides, my opposition to this bill has little to do with abortion; I would be very much opposed to it even if it was certain that not one cent of tax money would ever go to fund abortions, which is far from certain as it stands. No, my opposition to the bill comes from my strong belief that it is unlawful and unconstitutional for the government to force its citizens to buy a good in the public market. You might say, "Yes, but auto insurance!" But nobody is forced to buy auto insurance because nobody is forced to purchase a car. With this health care law, we all universally have to have health coverage with no exceptions. There is no escape. Whether or not we ought to have coverage is beside the point to me; perhaps we should all have insurance, but as soon as the government mandates that I have to it makes me not want to. It's just like how we all know we ought to drink 6 glasses of water a day. But suppose the government passed a law mandating that we all drink 6 glasses of water a day or be fined. That would probably make me want to fast from water every other day just to be defiant against an overly intrusive law.

But apart from this issue, I think a huge problem is that this law could in fact lead to a single payer, "public option" system. Here's how: the current law mandates that everybody after 2014 purchase insurance or be fined. However, the fines for not purchasing insurance are smaller than the free-market cost to just buy insurance (on average). For me, the fine turns out to be $800 per year if I don't get coverage. But even now, through my employer, I contribute at least $1200 per year to insurance; who knows how much more it would be I had to but it completely on my own. The average cost of insurance for someone my age is about $4000 per year if I buy it on my own. Compare that to an $800 fine. If I was uninsured, it would be cheaper for me to pay the fine than to buy the insurance. Now, what is the effect of having the fine by cheaper than the insurance? It's obvious: most people in this dilemma will opt to pay the fine rather than buy the insurance, that is, as long as they are healthy. But once they get ill or need treatment, then they will buy the insurance instead of paying the fine. I even heard a report on the liberal NPR yesterday admitting just this, that the new law will create a situation in which people are incentivized to not purchase insurance until they get ill.

What does this mean? Since insurance companies can no longer deny people based on preexisting conditions, it means they will be forced to cover a glut of people who only come paying for insurance once they are sick. Since they cannot be denied coverage—and since there are no caps allowed on the dollar amount of coverage—insurance companies will have no choice but to cover these people. The insurance business only works on the presupposition that the amount of premiums coming in is less than the company has to pay out in benefits. It can only function if, for example, it takes in $10 million in premiums but only pays out $3 million in benefits, just like any business can only function is revenue meets or exceeds expenditures. Yet here we have a system that encourages the opposite: mandating insurance companies to cover people who will most likely not buy the insurance until they are already sick, since the insurance usually costs more than the fine. And these people will all have to be covered, likely leading to a situation where premiums are equal or less than expenditures. 

No insurance company can stay in business this way, just like automotive companies can't stay in business when it costs more in wages, union benefits, health insurance and pensions to build a car than they make selling it. The practical effect of this health care bill will be to drive private insurance companies out of business, or at least get rid of the smaller ones and concentrate the power in the larger firms. What will citizens do when private insurance companies are going under left and right? That's when the government will be there to step in with the single-payer public option. Since most insurance companies will be out of business, we will have no other option if we want coverage. And by the way, if most insurance companies are out of business, leaving the industry centralized in the hands of a few giants, what do you think will happen to costs then? What about once the government gets involved in cost and quality control?

 But without harping too much more on why I think the health care bill is not only immoral but also bad business, it behooves us to ask ourselves what a truly Catholic vision of health care reform would look like. For me, this has not been a question about how to extend insurance to the most people, which is the way the liberals tend to frame the argument. For me, it is rather about asking the question, "Why is health care so blasted expensive that one needs insurance to pay for it?" The only reason we need insurance is because the health care is so costly that there would be no way an average person could pay for anything without it. This is a form of slavery; ideally, everybody should be able to pay for health care out of pocket. Granted, some procedures will always be more expensive than others, but why does a hospital need to charge $4,000 per night for a bed? Not for any service, just for a bed? Why does it cost $9,000 for my wife to come into the hospital, get her vitals checked, go into labor and have a normal delivery after 12 minutes of pushing with a one day convalescence? Why does it cost $1,200 for my daughter to get two staples in her scalp to close a minor gash—staples the ER doctor admitted to me are essentially "no different" from the industrial staples I put in my staple gun at home and pay $3 per fifty for?

It is an interesting historical question to ponder how things got this way. Think back to the doctors of a century ago, men who made house calls and were frequently paid in chickens, bushels of wheat, or whatever a farmer could scrap together. They were not wealthy men, and medical care was not expensive. Now doctors are wealthy (albeit debt-ridden) men and health care expenses are out of control. Some of this probably has to do with new technologies, but not all of it. Granted, the CT machine is probably expensive to build, but is it really so expensive that a CT scan of my chest, like I had last week, must cost upwards of $6,000? Is there any market reason why turning the machine on for 45 seconds must cost $6,000? I have a hard time believing that this exorbitant price is due solely to technological innovation.

The price of becoming a doctor has skyrocketed. In the old days, doctors learned their trade the same way carpenters or masons did—by spending a lot of time as an apprentice. There were some instructor fees, but nothing like what modern medical school costs, where newly graduated doctors start their practice burdened by a student loan debt of $125 to $200K before they even start their internships/residencies. Couple this with outrageous insurance that doctors themselves need to pay and you start to see why the costs are so inflated.

The essential problem is that health care is a business. Doctors, hospitals, drug companies and everyone along the chain is there to make a profit. In premodern times, medical care was a charity. If you got ill in 1450 and had to go get medical care, who would likely take care of you? The homes for the sick were staffed by nuns, all of whom had vows of poverty. Doctors and medicine women always charged fees, but they were vastly more proportionate to what the average person could afford. Treating illness was seen as a charity but also as a chance to advance the medical discipline. Profit was not a real motivating factor; in fact, unless you were fortunate enough to become physician to a king or member of the nobility, most doctors were not well off persons. People used to warn their sons not to become doctors if they wanted to make a decent living, just like most parents would react today if their kids told them they wanted a degree in philosophy. We can see a similar trend in Catholic schooling: what happened to the price of Catholic education once the nuns left and lay "professionals" took their place?

Does it need to be this way? What would happen if our medical system were to be infused with cadres of sisters and brothers, all with vows of poverty, who had received medical training along with their religious training? What if the motivating ideal behind health care was that it was a charitable endeavor done for the good of souls? Granted, I am not insinuating that all doctors now are simply out to make a buck; I've had wonderful experiences with caring doctors most of my life. But since many factors involved are often beyond their control, doctors are faced with so much overhead from insurance, loan repayment, etc. that they have little choice but to pass the cost on to the consumer. Of course there would always be costs, but what would those costs be if all our doctors and nurses had vows of poverty? What if they learned by apprenticeship under the hands of other doctors and did not come to the profession burdened with debt (instead of the current system, in which a residency comes only after the completion of years and years of costly schooling)? What if, because of this, more persons could pay for their care out of pocket and doctors did not have to keep massive staffs for the sole purpose of billing and working with insurance? How would all these factors affect cost?

I admit my plan is a bit utopian, fantasizing about replacing our entire population of doctors with monks and nuns, or at least by lay persons working from charitable motives without such vast overhead. But following the principle of subsidiarity, maybe it would be best to make a trial run of such a system on a more limited basis before proposing any sweeping, industry-wide changes. Already independent clinics staffed by Catholic doctors who see their work as a vocation are popping up all over the country; in my own area there are two Catholic clinics that a person can go to that charge rates easily affordable to most persons, even without insurance. As of now, these clinics are only able to provide primary care; perhaps the next step is the foundation of a larger facility capable of handling emergency care and surgical procedures based on the same principles. For American Catholics, an example to look to would be Padre Pio's Casa Sollievo della Sofferenza (House for the Relief of Suffering) in San Giovanni Rotundo. I'm not sure how this hospital is managed now, but I know that when it was founded it was part of St. Pio's vision that it be a place where the poor could receive medical attention at reasonable costs by Catholic doctors working within a Christian worldview.

And maybe I am tremendously naïve. I admit that I know very little about health care, but I do know it is outrageously expensive. Like housing and higher education, it is way more expensive than it ought to be. So what do you all think? What Catholic principles of morality, and economics can we put to work here to bring these costs down and lessen people's dependence on insurance, thus ensuring that everybody can enjoy more health and freedom?