A time to choose

Health Progress, Sep/Oct 2001 by Glaser, John W

The Ministry Should Throw Its Resources into Health Care Reform

How does one criticize care of the poor without sounding like a Charles Dickens novel? Very carefully!

The approach of the U.S. Catholic health ministry to care of the poor is generous but shortsighted and too narrowly conceived. The ministry's current practice primarily treats symptoms, even though its social justice tradition points it toward root causes-the systems and structures of health policy. If the ministry were to address root causes, it would find itself plunged into health care reform.

We believe that the relationship between care of the poor and health care reform has received far less recognition-both conceptually and practically-than it deserves. On one hand, most people involved in Catholic health care agree that service to the health care poor is essential to the ministry. For the delivery of that care, the ministry is equipped with a vision, a philosophy, and concepts for understanding. It also possesses a detailed infrastructure with which to implement this care: committees, goals, budgets, and systems of accountability. On the other hand, however, the ministry has nothing similar to help it deal with health care reform.

We believe that care of the poor and health care reform are two dimensions of the same issue. The former has to do with symptoms, the latter with root causes. In fact, long-term, "upstream" service to the health care poor requires reform of the U.S. health care system. If the nation were to reform its unjust system, the need for care of the poor would disappear.

THREE REALMS OF MORALITY

A paradigm from Catholic moral theology can help us explore this thesis. Our theological tradition recognizes three realms of morality, two of them nested within the third:

Societal morality concerns the extent to which human dignity is promoted and protected by society at large.

Institutional morality concerns the extent to which human dignity is promoted and protected by particular institutions.

Individual morality concerns the extent to which human dignity is promoted and protected by individual behavior.

Many relationships exist among these three realms. Important for our discussion here is society's enormous power to shape life at the institutional and personal levels. Because this is true, we believe, the root cause of health care poverty is the health care system itself. To put the case a bit differently, 39.3 million Americans lack access to care because of the unjust way the system (and its subsystems) has developed.

The United States is alone among first-world countries in this unconscionable situation. Germany, for example, recognized more than a century ago that health care was an issue of the highest importance where the well-being of the nation and justice for its citizens were concerned. As a result, the Germans developed an integrated national system for financing and delivering care, one that tied access and basic need tightly together.

The United States created a very different system. Indeed, we did not so much create a system as allow a rabbit warren of subsystems to spread. We did this because we lacked a vision concerning the importance of health care for our nation and its citizens. As a result, health care in this nation tied access not to need, but to a broad array of factors, often bizarre ones. Some of these inconsistent factors are: being rich, being poor, suffering from end-stage kidney failure (but not from cardiac or respiratory failure), having a good job, being over 65, and living in Mississippi rather than Connecticut.

Characteristic of how our nation's fragmented situation developed is the way we instituted the centerpiece of our system-employment-based insurance, which today accounts for 66 percent of insurance coverage. During World War 11, the United States saw a freeze on wage increases but not on benefits. Employers therefore began using health insurance to woo scarce workers. Because this often occurred in unionized workplaces, the simultaneous growth of unionism in those years helped to spread the practice rapidly and to embed it deeply in the ethos of the American workplace.1

Although the practice demonstrated employer ingenuity at the institutional level, it helped to fragment health care at the societal level-thereby generating injustices. Consequently, 20 years later, the United States was forced to develop Medicare and Medicaid to try to fill the gaps created by this shortsighted wartime maneuver. As other inadequacies emerged, the nation created still newer programs to deal with them. But the criteria, funding, and infrastructure of these programs were almost never integrated. Indeed, they often worked at cross-purposes.

Researchers have provided a detailed look at one state's subsystem for attending to health care for children. In 1990 California had 160 child health programs, with 25 different eligibility criteria, situated in seven different departments of state government, administered by 37 different government programs.2 It would be hard to imagine a more child-hostile approach to the problem.