This article originally appeared in Public Justice Review, a publication by the Center for Public Justice (CPJ), and is part of the recent "What is Public Justice" series.
Like many issues at the intersection of religion and public life, the health care reform debate suffers from seemingly intractable polarization, and the motives of opposing positions are regularly caricatured and maligned. Our nation is in desperate need of a way forward that honors the best of the impulses that motivate the perspectives on both sides while maintaining the primacy of the claims of public justice: a way that says to the right “your desire to honor human dignity by empowering personal stewardship is good and right” and to the left “your desire to harness the power of government to bring justice to those without access to health care” is also good and right. The debate on health care reform in the U.S. is in need of reframing: a teleological reframing that orients health care policy towards the goal of human flourishing or shalom and structural reorganization that empowers diverse institutions to fulfill their right roles and responsibilities in the area of health care.
Human Flourishing as the Foundation for Health Care Reform
Shalom, in Hebrew--is, according to Cornelius Plantinga “universal flourishing, wholeness and delight - a rich state of affairs in which natural needs are satisfied and natural gifts fruitfully employed, a state of affairs that inspires joyful wonder as its Creator and Savior opens doors and welcomes the creatures in whom he delights. Shalom, in other words, is the way things ought to be.”
Though this vision is fundamentally eschatological, shalom also orients our efforts this side of heaven to participate in God’s ongoing redemption of His created order. While the Israelites were in exile living under the authority of their Babylonian enemies, God, through the prophet Jeremiah, told his people to work for the “peace and prosperity” (shalom) of the city (Jeremiah 29), calling them to participate in the partial fulfillment of the covenant he had made with Abraham and the nation of Israel to bless the whole earth through His people. Because we were created as whole, integrated creatures, body and soul woven together, physical and mental health are an intrinsic part of shalom. Indeed, health was one of the key casualties of the Fall. Our calling as Christians to restore shalom while in exile in the ‘now and not yet” of this season of redemptive history is about making whole what has been broken, physically, spiritually, and communally.
With human flourishing as our goal, key principles emerge that guide the development of health care policies, which are elaborated more fully here.
1. Human flourishing requires access to medical care.
Human flourishing requires expanding health coverage along with expanding access to health care. This will require creative public policies at the local, state and federal level to address significant access barriers such as hospital closures, provider shortages and waitlists for Medicaid patients. Access to health care for lower income Americans will also require federal and state funding mechanisms, either directly through financial support for the costs of health care, including health insurance, or access to free or subsidized care, funded at least in part by federal, state and local governments.
2. Human flourishing requires communal actions and commitments.
Shalom in scripture never refers merely to the flourishing of individuals. God intended for his entire created order to flourish in harmony. The communal nature of health care, and the underlying communal nature of shalom, means that if I want to have my basic health care needs met, I also have a responsibility to contribute to the health care common good. In order to better honor both the personal stewardship and communal responsibilities of human flourishing, we should require or incentivize broad participation in the insurance market in order to more transparently and fairly distribute these costs among us. We should all pay our share, recognizing that we may ourselves be in need of care at any time. Under the ACA (Affordable Care Act), this was accomplished through the individual mandate, the requirement that all Americans either provide evidence of health insurance to the Internal Revenue Service or pay a financial penalty. In practice, the penalties for not carrying insurance turned out to be too low to bring enough young, healthy people into the market to offset the new coverage requirements put in place by the law, and the penalties have since been repealed. But the principle behind the individual mandate is sound: to spread health costs as widely as possible across all demographics in an effort to lower health care premiums for everyone.
However, it is not just to force (or even incentivize) people to pay beyond their means. Someone who makes a low salary can commute to work just as well in a Honda Civic as a Mercedes. But cancer can strike anyone, and the treatment regimen costs the same regardless of how much money you earn. As we contemplate reform, we must develop a consensus around the relative percentage of income we expect people to pay for health care and health insurance and develop strategies for helping people make up the difference between what they can pay and the costs they incur. As an example, we, as a society, have largely agreed that families should not be spending more than 25-30 percent of their income on housing. The formula that calculates subsidies for lower-income Americans under the ACA assumes that lower income Americans should not be allocating more than 10 percent of their income towards health care. With this bar in view, we can develop a system of subsidies that enable lower income Americans to contribute to health care costs as their income allows.
3. Human flourishing requires incentivizing personal and collective stewardship.
The principle of stewardship is a key component of shalom--indeed it is at the core of the mandate given to humankind in the garden. In the realm of health care, the principle of stewardship includes not only economic stewardship, but also stewardship of creation itself, in this case our bodies, which for Christians are the temple of the Holy Spirit.
Incentives should be built into our system, not only by the government, but also by insurance companies, employers, and local communities, to promote wellness and to encourage and enable personal stewardship of our own health.As individual patients, we should also be wise in stewarding health care dollars—even if they are not coming out of our own pocket.And, though uncomfortable to think about, we must recognize that some kinds of rationing are an inevitable part of health care resource allocation.
Of course, stewardship is a calling of government as well. Medicare and Medicaid must not only be solvent for today, but we should ensure that we are not accruing unsustainable debt that will have to borne by our children and grandchildren.
Sadly, our system is not well structured to promote the kind of stewardship we just talked about. First, the very nature of our third-party payer system, whether that payer is the federal government or a private insurance company, separates patients from the consequences of their health care spending choices. The move to rely more heavily on Health Savings Accounts is a good and important corrective to this for many Americans, but other significant distortions remain.
Secondly, under current law, the premiums paid by an employer for an employee’s health insurance are exempt from federal tax. In many cases, the employee’s share of the premium is tax free as well. This results in the single biggest “tax expenditure” in the tax code—money that the federal government “foregoes” in revenue--a whopping $260 billion in 2017 alone! Compare this to the $10 billion the U.S. government spent in 2017 subsidizing health care for Americans through the ACA.
This single provision has created enormous distortions in our health care markets and many unintended inequities. Among these are a false perception among American patients about the real costs of health care, a failure to curb overuse of the system, and the perverse incentive for workers to remain in bad jobs because they are afraid of losing health insurance. Employer subsidized health care, a historical accident, does not promote human flourishing. Sadly, neither the Affordable Care Act or the Republican alternatives made any meaningful change to this costly exemption.
A third obstacle to personal stewardship in health care results from other, related social and economic injustices. Of course, it makes sense that we should eat healthy foods to promote our health. But healthy foods can be expensive, and low-income Americans who live in food deserts may simply not have access to healthy food. Housing regulations may be needed to ensure that low-income children are not raised in insect-infested homes that directly correlate with increased incidences of asthma. These and other social determinants of health must be addressed in order to enable many low-income Americans to exercise the personal stewardship of their health that God has called them to.
4. Human flourishing requires valuing all human life from conception to death
As the Center for Public Justice’s Guideline on Human Life indicates, government’s most basic responsibility is to protect the life of its citizens, including the most vulnerable. Government should not, in the context of health care reform, incentivize abortion or euthanasia. The framework of human flourishing helps us expand this concern for the unborn to include a concern for women and families in crisis pregnancy circumstances, as I have argued elsewhere. Indeed, some pregnancy centers have noted that increased access to Medicaid is a critical factor in encouraging low income mothers to carry an unplanned pregnancy to term.
As new genetic technologies emerge, and personalized medicine becomes a reality, Christians will need to think carefully about how “health” should be defined. We must resist the cultural pressure to think of children as commodities to be designed to our own specifications. This means advocating against germline genetic engineering and other technological enhancements that can usher in a new phase of eugenics. And we should refuse to participate in the quixotic quest for immortality—the fight against aging that leads us to undervalue and even discriminate against the elderly. Our faith leads us to encounter suffering, including sickness and disease, with redemptive hope rather than desperate fear. Our pro-life witness should accurately reflect our Savior’s concern for all life—even the most vulnerable, the most “useless” and most burdensome to our society—from conception to death.
Cultural Barriers to Human Flourishing in Health Care
Here it is worth pausing for a moment to examine some of the cultural and philosophical assumptions that undergird our current health care system against the Biblical vision of shalom. Yuval Levin, in his book Imagining the Future: Science and American Democracy helpfully explains the ways in which the scientific revolution and the political revolutions that followed have shaped our modern approach to science and politics. Because current approaches to health care are scientific at their core, many of his observations are relevant to our health care discussion as well and help illuminate the cultural and political attitudes that drive our expectations of health care reform.
As Levin notes, the modern scientific project has at its core a naive utopianism, a sense that through science and technology we will master nature, including death itself. This leads to an idolatry of health and youth, which as Christians we must resist so that we can situate health properly among other, sometimes competing goods. In so doing, we can help our culture recover the ability to die well, with dignity and honor. Dying well includes avoiding the temptation to short-circuit, through euthanasia or assisted suicide, the often physically and emotionally painful process of saying goodbye. But dying well also includes an acknowledgement that death is not the greatest evil. These twin principles flow from our assurance that death is a consequence of the Fall that only Christ Himself can conquer. Our attitudes toward death must reflect both humility and hope.
Significantly, as Levin also notes, because modern medicine is based on an empirical model, our approach to health care is often mechanistic, operating on the assumption that the human body is a machine which can be broken down into its component parts and repaired when necessary. This reductionist approach to health care has been yielded amazing gains in both the quality of life and life expectancy for millions around the globe. Vaccinations now prevent and have even eradicated diseases such as smallpox which used to kill whole populations. The mortality rate due to cancer is on the decline. And yet, Scripture teaches us that we are whole creatures, body and soul and that any human being is more than the sum of its parts. Because of our immersion in this mechanistic model of health care, we have been slow, both in society at large and at the level of policy making, to incorporate holistic approaches into our modern health care system. Eastern and alternative medical interventions like acupuncture or massage are viewed with suspicion, and therapies that allow for a psycho-spiritual aspect of health are still regarded as a ‘add-on’ to traditional biomedical treatment protocols.
Further, this mechanistic approach to medicine, in synergy with the individualism inherent in our culture, emphasizes the patient as an individual, rather than as a member of a family and a community. This hyper-individualism undermines any widespread recognition of the importance of the social determinants of health. More fundamentally, this emphasis on autonomy blinds us to the cooperative nature of the whole health insurance enterprise. With regard to health policy, the absence of a holistic approach to health care (with shalom as the goal) means that, in Kuyperian terms, government has often neglected the role of families, schools, churches and non-profit institutions in promoting healthy communities.
What would it look like for government to uphold the right roles and responsibilities of all of the institutions who have a God-given role to play in promoting health as a part of human flourishing? As a beginning, families should be enabled and encouraged to care for each other whenever possible, and work policies need to accommodate such caregiving, allowing altered work schedules or paid leave where appropriate. Government and non-profit institutions could partner with families and churches to keep elderly patients or special needs children and adults at home and out of nursing homes for as long as possible. Government should support the inclusion of mental health benefits as an integral part of basic health care coverage, should reward innovative civil sector efforts to deliver health care to the underserved, and should partner with churches and non-profits to address social determinants of health. Ongoing efforts to promote care coordination across medical specialties and throughout the social service sector should be strengthened. In all of these partnerships, because health care is an inherently value-laden endeavor, medical and social service providers must remain free to deliver services in a manner consistent with their deeply held religious beliefs.
In practice, some of these diverse spheres are already working together to deliver health care to the underserved. My home state of North Carolina did not expand Medicaid, and like many states, most able-bodied adults—even the poorest of the poor—do not qualify. Over 300,000 NC residents don’t qualify for Medicaid but fail to make enough to qualify for subsidies under the ACA. Thus, unless they get health care through their employer (and most workers in this income bracket do not), they have no affordable health insurance options.
Around the country, free and charitable health clinics are offering patients like these access to quality medical care, including Samaritan Health Center (SHC) in Durham, N.C. At SHC volunteer physicians, along with some paid staff, have the freedom to minister to these patients without the pressures they face in their private practice. Instead of being asked to see a patient every 10 minutes, our doctors can spend 30 minutes with each patient, some of whom have not seen a doctor in years. The staff pray with patients and attend to the emotional, social, psychological and economic needs that may be impacting their health. Instead of going to the emergency room or waiting for weeks and traveling over an hour through a complicated bus system to get care, patients can walk over to our clinic from an apartment complex full of immigrants and refugees, recently resettled by local churches through World Relief. These patients are often seen by providers who can speak their native language or have in-person interpreters that can help translate. This is what human dignity in health care can look like.
SHC is supported by grants from the state government, by individual donations and by churches--who together, along with other non-profits and social service agencies, ranging from World Relief to the local county health department--form an important network, a complex and interconnected safety net that is becoming more cohesive as technology is enabling various social sectors to partner together.
A variety of institutions can play different, overlapping and vital roles: some churches provide volunteers; other churches recruit patients to the clinic. LabCorp and pharmaceutical companies donate lab services and medications. Significantly, the benefits of this interconnected safety net do not only accrue to the patients the clinic serves. Scripture teaches us that each of us, and society as a whole, flourishes when we, in our various roles in various spheres, fulfill our God-given responsibilities. Free and charitable health clinics around the country are forming medical students and residents who are rethinking the nature of their profession from a perspective of human flourishing. In fact, one medical resident volunteer at SHC recently shared that she felt like she was transformed as a physician by her service with SHC. Medical students who have volunteered at free clinics have gone on to pursue residencies that specialize in medical care for the underserved.
With human flourishing as the goal of health care reform, the debate becomes about more than the provision of health insurance. Looking closely at God’s created order for the structure that supports flourishing - structural pluralism and sphere sovereignty - helps us to chart a path out of the tired, worn debate between privatization and single payer health care towards a tapestry of policies that encourage us all to contribute to the health of our neighbors and communities.
-Michelle Kirtley (Phd, MIT) is a Consultant on Bioethics and Public Policy at The Center for Bioethics & Human Dignity.