Re-evaluating American Health Policy: A Catholic Democrat's Perspective (Part I)

Health care reform has been at the forefront of the American political discourse in the past few months. One of the most difficult tasks in this debate is to discern an authentically Catholic approach to reform efforts. The Catholic Church takes no official position as to how a health care system ought to be structured, but rather presents enduring moral principles that must be present in public policy.

Adhering to the richness of Catholic social teaching, the ultimate goal for Catholics must be to establish a system that is capable of universal access and coverage for all American citizens, one way or another. Any number of schemes might achieve universal health insurance and preferences will differ based on political philosophy, but the end result seems to be a Catholic moral obligation. In this sense, no Catholic ought to oppose universal health care, if it means achieving coverage for all Americans citizens either through market schemes, government assistance, “third sector” non-profit organizations, co-operatives efforts (co-ops), or some combination of these depending on the social need, the ethical principles at stake, and the resources each solution offers.

Catholic social teaching treats health care as a profound social interest and essential for the common good. Health care, because of this, ought not to be viewed as a mere commodity. The poor and vulnerable, by default, are immediately disadvantaged as health care costs increase. The United States, we are told, has the most technologically advanced and best quality medical care. But, one must inquire: at what cost? Other consumer “goods” are not essential safeguards to the indispensable good of human life in the same way as medical care.

Health care markets that are laissez-faire, an inherently utilitarian mechanism, do not necessarily yield nor are they ordered toward natural justice. Natural law theory is alien to such a mechanism— it is not intrinsic to it, neither is solidarity or preferential option for the poor, though these things are not necessarily excluded by it.

It is self-evident that different spheres of society appropriately employ different standards of distribution. College professors assign grades based on merits of achievement; athletic competition employs the same principle. Parents might distribute slices of cake at a birthday party to strict equality. In the same way, numerical equality governs votes in a democratic society. Food, clothing, shelter, electronic goods, clothing, automobiles, jewelry, etc, receive unequal distribution by market mechanisms—sometimes justly, sometimes not.

Need is one of those principles of distribution (and one of those things often argued about) recognized in some spheres, but not others. Need is terrible for distributing grades, but the proper principle for distributing emergency food supplies. Need, arguably, is a proper principle for the distribution of health care. Health is necessary for a community’s proper functioning. Justice, in terms of health care, will require a redeveloped way of distributing health care based on personal responsibility, collective interest, and legitimate need—the weakest and most vulnerable among us first and foremost.

Many important areas of life must resist “commodification,” at least in the same sense as dispensable goods. This could not be more evident than by the fact that people are becoming commodities to other people. Children are the prime example of this, from abortion to assisted reproduction. Fundamentally, justice demands that we re-examine our consumerism for it is the heart of the issue and I believe, the life-source of the “Culture of Death.”

The American Medical System

The majority of Americans can list a litany of grievances relating to the failings of our health care system. The highest estimates indicate that around 47 million Americans are uninsured. Americans spend $2.2 trillion a year on health care, more than any other industrialized nation, and health care costs have risen about 2.4 percentage points faster than the economy every year since 1970. This trend unless reversed is fatal to the American economy. Figures such as these and forecasts of economic doom are made all the time and it is understood that they point to problems in our health care system. The question of how these relate to the structure of our system and what solutions these demand is less clear. Indeed, the search for villains has distracted the American people and our elected officials from addressing the fundamental causes from this national crisis.

In one sense, there is no American health care system. One can discuss the British National Health Service, the German multi-payer universal insurance system, or the Canadian national health plan. But when the conversation shifts to the U.S., there is no one system that can be discussed. Medicare is different from Medicaid, which is different from the VHA, which is different from private insurance, which is different from no insurance. The U.S. health care system as it currently exists is a hybrid private/public system. Government-funded health insurance such as Medicare, Medicaid, and SCHIP provide coverage to less than a third of the population. The majority of Americans (about two-thirds) have private health insurance, typically through their employer.

This private/public system has, more or less, run this way: first, at the top of the system are the wealthy and well-insured, particularly those with indemnity, fee-for-service health insurance. In this case, the United States has the highest quality, most technically advanced medicine in the world; second from the top is the private, employer-based insurance usually with some features of “managed care” and some restrictions on what the insurance company will cover; the third layer consists of insurance for lower-income workers in the form of tightly managed health maintenance organizations (HMOs), substantial out-of-pocket payments and moderate restrictions on the doctors that can be seen and treatments covered; the fourth layer is Medicaid, Medicare, and the State Children’s Health Insurance Program (SCHIP), which are grossly underfunded systems of federal and state insurance for the lowest of middle class families, the poor, for children, the disabled, and the elderly. This group faces severe restrictions on doctors that can be seen and on treatments covered; fifth and last is “charity care” and emergency room care, which is available to those who have no medical insurance.

The current “system” structure leads invariably to a distribution of medical care largely along socio-economic lines, which in turn, creates unfortunate disparities in access and quality of care. These things are probably not intentional. The cost of care is really a decisive factor in the results working out the way they do. But, in the end, the system is more like a medical caste system than a medical care system. The problem is beyond this, these things aforementioned are merely symptoms of a larger problem, as are all other bad industry practices—from long lines at the doctor’s office to skyrocketing prices to incredible numbers of preventable deaths to poor customer service and uneven results. These are reasons why reform is necessary.

A Democratic Perspective on Health Care Reform

The problem with health care, as the political left sees it, is a fundamentally flawed reliance on private insurance. This point is half right. The incentive, the argument goes, is set against the American people. After premiums are paid in, the less care paid for, the better the business. The system, in this way, incentives companies to preserve profits not finance the care of the insured.

There is often a debate about care “options” for the American people. Republicans argue that a national health care plan will lack both in efficiency and in freedom. The irony, to the Democratic-minded, is that such efficiency and freedom is already gone, if it ever existed atll. The system is arguably unjust, fails to cover a significant amount of the population, including children, and there really is no alleged freedom. Much is not a matter of “consumer choice,” but rather the discretion of private sector insurance bureaucrats. They regularly choose the doctors that can be seen, qualifications for coverage, what will and will not be covered, how long treatment can be received, and this is only if a potential customer doesn’t have a history of illness, a “pre-existing condition,” or if there is not some technicality that enables them to drop coverage all together.

The center-left position moreover insists that government intervention in response to this is not a violation of the principle of subsidiarity. This, of course, does not apply to every scheme of universal health care. For example, the systems in the United Kingdom and parts of Canada is not just single-payer, it is also single-provider—this is beyond the point of mere regulation, but rather the government administers and provides health care beyond the realm of simply financing it for those who arguably cannot afford to do so. The schemes found in other countries are not identical to these and many drawbacks found in these two places are not totally characteristic of a single-payer system, as they are of a single-provider system—therefore, glossing this all together without distinction is intellectually dishonest; which, of course, is not to say one is obliged to support either scheme. Though, it can be agreed, that a single-provider system does violate the principle of subsidiarity. It is unclear whether a single-payer (which is not a straightforward system; it can be structured in many ways as well, e.g. a single-payer system that acts as a hybrid for all private insurance companies rather than act in their place after eliminating them) or any public-private scheme violates this principle.

The teachings found in contemporary papal social encyclicals seem to indicate that there is a role for government in regard to social and economic matters—and this role is distinct and limited. The principle of subsidiarity requires that social goods be met by the most local and most efficient means. This means, hypothetically speaking, if the government and private sector can both do the same task with equal efficiency in regard to one matter, it is most prudent to allow the private sector to do it and allocate government resources and energy elsewhere. But if the most local medium cannot accomplish this task, then a higher authority is obligated to offer assistance. It is a morally preferable that given the availability of health care in contemporary society, everyone should be able to both afford and receive quality health care. The private sector alone has not been able to meet this task. The cost of caring for the sick (which includes pregnant women) are so much greater than for those who are less sickly that insurance companies have strong incentives to find ways to insure only the healthy—basically, pricing the sick out of the market. As a result, it is arguably valid for the government to seek to carefully de-incentivize this.

Individuals and the family members closest to them are certainly obligated to their own health, first and foremost, particularly when many of its means are largely under their control—good eating habits, avoidance of smoking and excessive alcohol consumption, regular exercise, sufficient rest, etc. Though, this is not always the case, emphasis on individual responsibility can become an excuse for denying public responsibility and an overly libertarian individualism that is not compatible with Catholic teaching. The opposite is true as well.

Many Americans score low in regard to individual responsibility. However, the circumstances of hardscrabble life make it difficult, particularly for poor people, to exercise the four cardinal virtues in terms of decision making for themselves and their children, though we would like them to and must require them to. Addictions interfere with dependability, shifting addressing and at times unreliable transportation and child care arrangements make it difficult to keep appointments, let alone keep doctors. Poor education or limited intellectual and language skills might upset compliance with directions about self-care or medications. Appointments are missed, even at free clinics.

Individual responsibility interacts with barriers to health care structures themselves. Hypothetically, what may seem like irresponsible behavior may be (not always) a lack of intellectual, emotional, or social resources to negotiate one’s way through large, bureaucratic institutions. Linguistic and cultural barriers on both sides can exacerbate non-compliance. Health care for the poor often comes in hospitals staffed by foreign medical graduates, thus creating a double cultural barrier, or by young residents passing through toward a more rewarding practice. Waiting rooms are crowded; appointments difficult to maintain, and even transportation to care facilities are expensive or erratic.

These are not to be construed as excuses, but as reasons as to why this deeply troubling situation has arisen and what must combated in order to fix it. A Catholic solution and a political compromise in the U.S. may be found in “shared responsibility.” What this means surely will be undoubtedly the subject of much debate. The government is not and cannot be the solution to all these problems. Such a notion is simply illusory.

Medical Care and Preferential Option for the Poor

Poverty and ill health travel together. Families working for wages near or below the “poverty line” have significantly higher incidences of acute and chronic illness. Poverty increases health risk and ill health with its attendant medical bills, impairment of working ability, and days lost from work, can and do frequently lead to bankruptcy. Allegedly over 60% of bankruptcies in America are due to medical bills. Surely, no one can deny that there are other factors at work there, such as imprudent management of personal money, etc. But this cannot remove the necessary concern for the large amount of bankruptcies occurring in association with this issue. There is surely something to be said about education and life choices that must be addressed. However, in some sense, the problem is spiraling and self-reinforcing and poses a serious problem to the common good.

The “working poor” and the middle-class who work full-time, or part, do not always have jobs that can provide health benefits, or whose benefits are too expensive. The percentage of workers covered by private employee based insurance has declined in the last twenty years. Indeed, the cost of health care takes a higher proportion of income the lower one’s income.

Health care insurance is tied to employment for most of the working population. This system, however, is breaking down. There has been a dramatic decline in the private, employer-based insurance in recent decades. Job growth in the service-sector, part-time employment, self-employment, and contractual employment has affected the system. These sectors do not offer health insurance benefits to the same degree as the manufacturing and blue-collar sector. Even so, because of health care costs, the employers offering insurance have increased employee cost-sharing making it more expensive for the working, especially for dependant coverage. Roughly two-thirds of uninsured workers’ employers don’t offer insurance coverage; another twenty percent say this cannot afford the premiums on their wages. Presumably, very few persons— though there certainly are some— choose to be uninsured.

There are common responses to this indictment. First, it is argued that vulnerable populations are eligible for publicly financed Medicaid and for a variety of other federal and state programs that pay for health care. Second, such individuals often have access to emergency rooms and public clinics for the uninsured.

While there is truth to these claims, there is also untruth. First, alternatives don’t necessarily cover every essential medical need; nor are they always available when needed. The uninsured are four times more likely than the insured to report an episode of needing and not getting medical care. They are three times more likely to report difficulty paying medical bills. Given the situation, they postpone attention to symptoms because of their inability to pay for doctor visits.

Medicaid covers only about 50 percent of those living below the poverty line and public hospitals and clinics are overcrowded, financially strapped, so that they must limit hours and care. Beyond that, even after getting access to care, insurance makes a world of difference in how one is treated within the health care system itself. Though the uninsured have higher rates of being sick, compared to the insured, they receive fewer diagnostic procedures and leave the hospital sooner.

No matter what the scheme is, any meaningful models must not neglect this vital principle any Catholic social thought.

Cost Control and Potential Effective Measures

Senator Wyden (D-OR) at the early stages of the reform efforts declared, against some of his own colleagues, that we spend enough on health care, but that money is not being spent in the right places. This analysis, I think, is spot on.

One of the reasons costs is difficult to restrain is that with literally countless different private insurers, it is virtually impossible to negotiate consistently lower costs with providers and drug companies. Private insurance companies also waste a colossal amount of money; an alleged $700 billion is wasted on administrative paperwork and health care services that do not heal anyone or prevent future illness. Much can be done here. Additionally, there is nothing unusual for a hospital to have to bill more than 700 different payers and insurers–HMOs, PPOs, MCOs, IPAs, and an alphabet soup of other organizations. Each one has its own set of rules for what services are covered, the level of reimbursement and the kinds of documentation and pre-approval required. Billing, collection, and payment administration represents some 20 percent of that $2.2 trillion we spend on health care.

Moreover much criticism is needed for the current pay-for-procedure structure of our health care system because it incentives hospitals and doctors to perform unnecessary procedures. In other words, we are reimbursing doctors and hospitals for the volume of care, not quality or institutional efficiency. The more procedures, tests, and surgeries performed, the more money hospitals, doctors, and medical equipment vendors make, regardless of whether or not patients get any healthier or if the care was either superfluous or unnecessary. The incentive needs to be flipped to where it is pay-for-performance. Policies that incentivize this end are a subject of debate, but are certainly necessary. Patient decision aides can help guide people through their treatment options for the most careful kinds of decisions on their health that they might make: surgery, chemotherapy, and hospice. Patient decision aides lay out your treatment options and the medical evidence in an unbiased way—which is a lofty goal in our politicized society!

The most important cost-control strategy will be payment system reform, which will be discussed separately. The financial incentives in our system are backwards. Under fee-for-service payment, providers make more money by performing more services. If a hospital makes a mistake and the patient has to be treated again, the hospital makes more money. If a provider group figures out economical ways to keep its patients healthy, it goes broke. When doctors’ and hospitals’ incomes are squeezed, they do more procedures. The problem is self-reinforcing.

The Democrats perhaps are correct to suggest that everyone ought to be covered. Prudent economics would be oriented toward universal coverage because this is how one stops the bills of the uninsured being shifted to the insured, in other words, it stops cost-shifting, and hopefully as a result, restrains costs. If we already pay for everyone to get care, the argument goes, wouldn’t we rather pool together and do it sooner rather than later—where our premiums go sky-high and we are taxed to offer grants to hospitals to offset their losses. Republicans, however, have validly asserted that we cannot turn everything over to the government. We cannot have a one-size fits all system or we will freeze innovation. This point is key because it is easy, I think, to get carried away with criticisms and dream up a solution that is worse than the problem.

Common Democratic Solutions To Our Health Care Problems

I have noted previously here on The American Catholic that I am an advocate of a single-payer universal health insurance system; technically, I still am amongst many mainstream solutions. But I do not think one can so simply move to a single-payer without fixing distortions in the health industry and ultimately, I have come down in favor of a, sort of, multi-payer system (I shall discuss this separately).

Nevertheless, the current progressive trend is to support a “public plan” to compete against private insurance plans, which also might include a health insurance mandate requiring everyone to either purchase insurance, with those in need assisted through employer coverage and government assistance. If enacted, the public plan must have some capacity to fix uncompetitive markets. Though, it has yet to be articulated convincingly enough that a public plan has the necessary aggressive cost containment powers, it can make a difference (the extent we do not know) if allowed to compete in areas such as Iowa where 71% of the health care markets is dominated by Blue Cross and Blue Shield. The immediate effect of such dominance is that there is little choice (which we all seem to be in favor of) for American citizens and unfair practices really go unchallenged. Many other states are similarly uncompetitive, which creates several problems. There is no penalty on insurers for raising rates or trimming benefits because patients have nowhere better to go. Since dominant insurers can protect their profits by raising premiums, they do not have to negotiate as intensely over the rates they pay providers. They also do not need to worry about runaway administrative costs, which can consume as much as 30 percent on some plans. Competing against a public plan willing to go the extra mile in regard to service and accommodating people, especially those with “pre-existing conditions” can go a long way in forcing the private sector to alter its practices and earn business based on cost and service, or lose customers. This is a positive, but the drawback still remains in cost containment.

The current push for health care reform may or may not include an insurance mandate. We do not know yet. But let us assume that it does. The pitch goes something like this: If you like your current health plan, you can keep it. If your employer does not provide health insurance and you do not qualify for Medicaid, the government will make you pay for your health insurance out of your own pocket. If you cannot afford the premiums, at tax time every year the government will give you a credit to reimburse you for part of your premiums. It is worthy to note that no one has specified how “poor” you have to be in order to get a government subsidy. The average cost of an individual policy is nearly $5,000 a year and its $12,000 for a family of four. If you’re in the “middle class,” the government tax credits might be too small to make insurance really affordable, or you may have to buy a less expensive high deductible policy in which you have to pay for doctor visits personally, unless you get really sick and need major surgery or an extended hospital stay. It still remains that you will have to fight your insurance company on whether it will cover procedures your doctor thinks are necessary. But, if you try to avoid buying insurance or think you cannot afford it, the government will penalize you.

To be fair, the plan has its good points, e.g. it bans “pre-existing conditions” thus allowing coverage to those who have extreme difficulty, financially or otherwise, it getting it now. But, by and large, a universal insurance mandate (which we do not know will occur yet) is bad public policy.

Some of the reasons why such a mandate, which I cannot see how the push for universal coverage could work without, is a bad public policy:

1. I think it is a colossal waste of money. We are spending enough money already; it is just being spent poorly.
2. Universal mandates will punish the “middle class” who make too much for serious government subsidies, but too little afford the cost of health insurance that the government will coerce them into buying. Massachusetts employed a state universal mandate system that has many profound structural problems. A study done by the Greater Boston Interfaith Organization asserted that the minimum plan is unaffordable to those earning between 300-500% of the federal poverty level. It also showed (and these are their estimates) that a couple earning $42,000 a year would have to pay $19,200 a year in premiums, nearly 46 percent of their pre-tax income, for a plan with deductibles of $2,000 per individual and $4,000 per family and out-of-pocket expenses of up $5,000 per year for individuals and $7,500 for families. A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge plus for the private insurance companies to whom the government delivers large numbers of new customers.
3. A universal mandate assumes that most people will continue to be covered by their employers and therefore they won’t have to reach into their pockets to pay the full cost of meeting the government mandate. But employer-based health insurance is a dying dinosaur. Each year fewer employers offer insurance. Between 2000 and 2006, the percentage of employers offering some type of health insurance declined from 64.2 percent to 59.7 percent and it continues to decline. Moreover, as insurance premiums escalate at a far greater rate than inflation or wage increases, more and more employers increase their employee’s share of premiums, raise deductibles and co-pays and reduce benefits. If you lose your job, you lose your insurance. In the larger picture, leaving the burden of health insurance on employers makes American companies less competitive in the world economy. The solution Democrats seem to have is a mandate on employers.  A mandate on employers, particularly at the small business level, will make matters perhaps even worse.
4. A well expected, large number of people opting for lower-cost, high deductible plans will lead to many middle class people avoiding preventive care and necessary treatment until they are already very sick, leading to worse health outcomes and in the long-run resulting in higher costs from waiting to treat preventable diseases until they become serious. If, after paying thousands of dollars a year in premiums, a middle class family has to pay $2,000-$4,000 in deductibles before their insurance kicks in, many won’t go to the doctor until it’s an emergency. Men won’t get their PSA checked, women won’t get pap smears and breast exams, etc., thus leading to cancers not being found at the early treatable stage. In the long run, it will cost more.
5. A common assertion made by Republicans and Democrats alike (for different reasons) is that a Medicare-like public option that would compete with private insurance, given a universal mandate, which means more customers, would inevitably evolve into a single payer system. It assumes that the public plan would be far superior to any private plan because of the raw power of the government behind it. I don’t think this argument takes into account a few considerations. If it is modeled on Medicare, with improvements (obviously), it would be a fairly generous in which you can chose your own doctor, in which most treatments recommended are covered with low deductibles and co-pays.  But even if costs are reduced from slashes in administrative costs and forcing changes onto private insurance, it still would be expensive compared to high deductible plans, which would lead to undesirable effects. Those young and healthy will opt for cheaper plans. The people who buy into the Medicare-like plan will be those who expect their health care costs to exceed their premiums—in other words, the old and the sick. I’m not arguing against any social efforts to offer them assistance, of course, but I’m pointing out that it seems to me that the public plan will not at all involve into a single-payer system. Rather, it will more likely become more and more expensive, making it less affordable, which would incentive people back toward private insurance, whether or not there are vast improvements in this sector or not—and thus, back to the drawing board.

Therefore, we must forego any talk of health care reform that does not take into account deep structural problems of the “system,” namely incentives. Unfortunately, none of the serious reform plans on the table in Washington attack the three core problems that drive health care inflation: a fee-for-service payment system that encourages waste; a medical system so fragmented that real management of costs is almost impossible and administrative overhead is 25-30 percent; and lifestyles that are creating an epidemic of chronic conditions like diabetes and heart disease. And without cost control, universal health insurance will not be sustainable. Health care markets differ radically in different regions, so successful reform models will differ from state to state. Federal action should encourage states to experiment, while not tolerating anything and everything, so we all learn what models are most effective in what types of markets.

Bioethics, Religious Liberty, and Health Care

American health care focuses on developing newer and more advanced technologies—drugs or treatment—to care for illness and injury. Research into the human genetic code promises to unleash new diagnostic and treatment modalities of unprecedented scope. This is amazing and astounding information.

But, we are well aware that technology is not always beneficial nor is it without cost. First, health care research and development has been the largest drivers of cost increases in recent decades, for various reasons. This has pushed a larger and larger percentage of the American economy into medicine and related industries. Not every aspect of this change is evil or bad, but it does have serious implications for the principle of stewardship and a just distribution of resources. Not to mention, medical technology has posed and will continue to pose significant challenges to Catholic moral teaching—assisted reproduction, human cloning, genetic engineering, and new technologies of contraception and abortion. This is relevant to any sort of “universal” system.

Obviously, biotechnology, at once, is both a promise and a peril. Medical “breakthroughs” and “miracles” are celebrated all the time in newscasts. Many advances in fact produce moral retreats—embryonic stem cell research, drugs to enhance athletic performance, cloning, manipulation of the human genome. Of course, Catholic teaching doesn’t oppose every form of assisted reproduction, e.g. natural fertility herbal medicine or every manipulation of the human genome.

It is pertinent to keep in mind far-reaching moral issues in regard to health care reform. The general American public shares very little of such ambivalence. America cannot understand Catholic objections to biomedical research using embryos when it could be a potential “medical breakthrough” to treating Parkinson’s or Alzheimer’s nor can Americans comprehend why Catholics condemn in vitro fertilization and “reproductive technologies.” To be sure, Americans may hesitate at first about new developments, e.g. cloning and genetic manipulations, but as history has shown us, has come to the side of “science” once such developments catches the right spin as a “medical breakthrough.”

The last challenge, then, of health care reform we must remember is philosophical. It is a matter for bioethics and a protection of conscientious objection and religious liberty for those involved, one way or another, in the health care industry. Any sort of health care system that lacks “conscience clauses,” or insists on “reproductive health services,” or “physician-assisted suicide” as legitimate medical procedures should be strongly opposed without compromise. All of these challenges and issues—achieving universal coverage, the role of the government, biotechnology— are extraordinarily complex and contentious.

Right-To-Life Concerns

In recent months, discussion in conservative circles about abortion coverage in the health care reform bills currently being drafted in Congress has spiked. The Democrats, of course, have denounced this as false. The evidence, from what I have seen, suggests that the legislation currently being pushed forward would in fact create a federally run insurance program that would pay for elective abortions with tax-payer dollars and just as well subsidize the purchase of private insurance plans that would cover elective abortions. Obstinate refusal to accept amendments that absolutely and unambiguously prohibit abortion coverage in the public options and to use tax-dollars to subsidize the purchase of private insurance to the exclusion of such benefits is telling and further reiterates that the legislation would indeed be a drastic break from federal policy in regard to funding of abortion in government-subsidized programs. So far amendments to expressly prohibit government funding of abortion were opposed by Democratic leadership in the House and was defeated in all three committees that considered such legislation.

President Obama and many Democratic leaders believe that essential women’s health care includes elective abortion. This reality is manifest in the Capps-Waxman Amendment proposed and adopted by the House Energy and Commerce Committee. This amendment to H.R. 3200 authorizes the Secretary of Health and Human Services, currently pro-choice Catholic Kathleen Sebelius, to authorize federal dollars to pay for elective abortions in the “public option,” in other words, at her discretion—and we have no reason to assume she wouldn’t. Moreover, the abortion coverage would not be optional; everyone that enrolls in the public option (and anyone who pays taxes) will contribute to the funding of abortion.

The distinction that abortions will be paid for by “private funds” is a game of intellectual gymnastics. The public plan and government subsidies for private insurance will be managed by the DHHS. The agency that collects premiums from all those who enroll will use that money, which is as much federal and public funds as any direct taxation by the IRS. Abortion providers, under the Capps Amendment, would send their bills to the Department of Health and Human Services drawn from the federal Treasury account. It is inconceivable to imagine that this is not the public funding of elective abortion.

Additionally, the Capps Amendment explicitly authorizes premiums to go to private insurance plans that do cover elective abortions – which are not currently permitted in any of the existing government health programs. This is an indirect funding of abortion, as the funds will flow directly from the government to the insurers—and regardless of how the books are kept, the government paying for the insurance means paying for what the insurance covers. This is no different, in my view, from Title X funding to “clinics” that provide family planning and preventive health services. While Planned Parenthood receives great sums of money through this program, the money is not specifically earmarked for abortion procedures—but the organization that performs them and promotes them receives the funding nonetheless. This is the sort of deceptive thinking behind the Capps Amendment. This is not the status quo; it is a pro-choice victory.

It must also be said that the Hyde Amendment is not a far-reaching federal law, that is, it does not extend to every sphere of the government—it only applies to funds in the annual appropriations bill that go to Department of Health and Human Services. Zero of the funds that would be expended to a public health insurance plan or any federal dollars that would be subsidize private premiums will come through the HHS appropriations bill. Therefore, none of these funds are affected by the Hyde Amendment.

It is clear then that the Democratic leadership has no intentions, to quote the President, “to revoke the existing prohibition on using federal taxpayer dollars for abortions. Nobody is talking about changing that existing provision.” They do not have to do such a thing; it is superfluous. The legislation is crafted so that the funds used for abortion will not come out of federal money governed by the Hyde Amendment.

The non-partisan organization, Factcheck.org, has confirmed that abortion, directly or indirectly, will be subsidized in both the “public plan” and in private plans that offer abortion coverage. This is certainly consequential to the whole discussion of health care reform, if not absolutely fundamental.

Women, Abortion, and Health Care

Authentic health care reform, in my view, would be a large step toward comprehensive efforts to build a culture of life. Currently, the promotion of abortion is so deeply ingrained into our society and culture that it is frightening— and the victims of this are not just the unborn, but women as well. Women are less likely to have coverage through their employers and more likely to depend on coverage through their spouses. Women are also more likely to have higher out-of-pocket health care expenses than men and use more health care services than men. Consequently, women have a greater need for comprehensive health care.

The cost of having a baby raises the inevitable question just how can those without health insurance reasonably afford to have a baby without incurring financial ruin. Pregnant women lacking health coverage can anticipate a hospital bill ranging anywhere from$5,000 to $10,000, with another $2,000 on top if there is need for a c-section. These figures do not include costs associated with nine months of prenatal visits, ultrasound costs (though these can obtained for free), and other lab costs. If a baby is born premature or with health problems, neonatal costs can range from a few thousand for a short stay to six figure sums if, say, your baby is born significantly early. Many in this situation leave the hospital knowing they have years of payments to the hospital ahead of them, just for a single birth. I think this general situation inevitably feeds the contraceptive mentality (the less children, the better) and if this thinking occurs, as it does, in the context of a consumerist, materialist, utilitarian pragmatist culture that permeates throughout the U.S., one is in for an unbelievable recipe for disaster.

Maternity leave laws are not perfect by any means and time off from work can add to the cost of having a baby. Most doctors will recommend that a new mother stay home for at least six weeks after birth; most licensed childcare facilities will not accept babies until they are at least three months of age. The most pertinent issue is how, given modern circumstances, how a woman might finance her pregnancy, her home, her child, and put food on the table while on maternity leave.

The cost of having a child (cf. here and here) in a variety of areas—health care, child care, and other necessities—can be incredible. Even if one were to cut corners by borrowing old cribs, clothes, receiving donations, etc., the end cost are astounding. How all these realities play into one another and what it means for a consequentialist abortion-minded populace is frightening to imagine.

By the most conservative of estimates, some 40% of private insurance plans or more cover elective abortions. This number, by more liberal estimates, is 80 to 90%—but I think it is because these group also count plans, without distinction, that offer abortion coverage only to “save the life” of the mother. Given that our current health care system is buillt on employer-based coverage, I think there is unseen incentive (and I am not sure it is a conscious one)—employers, since health benefits are part of the budget, might decide to buy into insurance programs that include contraception and elective abortions because (and again, this is probably a subconscious incentive—and maybe not), in terms of accounting, it is cheaper to cover birth control and abortions than to cover the costs associated with pregnancy in addition to the already well-expected maternal leave, which again, costs money. This, to reiterate, is not an-across-the-board phenomenon I am claiming happens per se, but rather a real possibility. If an employer has more women of child-bearing age than men, the arithmetic becomes quite significant and I am afraid this embedded incentive might not favor the sanctity of life.

Until such realities are addressed, it is difficult to imagine that there will be significant inroads into changing mainstream American values, which tend toward consequentialism and pragmatism. These troubling circumstances, combined with a lack of natural law ethics, makes it difficult for these to be pro-life—and this point is most manifest in the “three exceptions” crowd on abortion who would leave it legal in rare circumstances, not that it justifies their position or the moral incoherency of our country.

The Question of “Death Panels”

Factcheck.org on the question of “death panels” does not come down against Democrats quite as much as their analysis does in regard to abortion. The analysis, more or less, tends toward suggesting that the current health care legislation will not create any so-called “death panels.”

From what I understand, the bill will require that insurance companies cover advanced care planning consultations every five years or when health status changes. Nowhere does it read that it is mandatory that the insured receive such counseling, but that it is covered if opted for. This counseling will include living wills, powers of attorney, etc. This does not strike me as having anything to do with euthanasia. Though certainly, as any pro-life Catholic should, there ought to be an explicit ban on euthanasia to make this unambiguous. If any such pressure is put on patients to make immoral end-of-life decisions, I cannot say based on the legislation they are following government orders, but are operating as the private sector has for quite some time.

In fact, the passionate concern about government rationing of care is a point of interest here. Many commentators and critics have painted a picture that would suggest that a sick woman might need a liver transplant and a bureaucratic government-run “death panel” would step in, judge the woman’s quality of life, and may opt not to pay for the surgery. Despite the protests of the women and her family, the cold, impersonal panel holds their ground and the patient dies before the family can arrange for her to receive health care elsewhere or succeed in finally getting the care delivered. This, unfortunately, is not the future of American health care – it is the present! This point is manifest in the story of Nataline Sarkisyan, a 17 year old leukemia patient from Glendale, California who died in December 2007 after her parents battled their insurance company which refused to pay for surgery because their “analysis” showed that the girl was already “too sick” from her leukemia and that the liver transplant would not save her life. “Death panels” already exist.

The absurdity keeps coming. There isn’t any national data on insurance claim denials, largely because insurance companies are not required to disclose such stats. But it is telling that a House Energy and Commerce Committee report in June found that just three insurance companies kicked at least 20,000 people off their rolls between 2003 and 2007 for such reasons as typos on their application paperwork, a “pre-existing condition” or a family member’s medical history.

Ironically, the private sector is already doing what reform opponents say they are saving us from at the hands of the government. Understand, I am not justifying government rationing, if such a thing were to occur, but pointing out the clear contradiction—mass hysteria about a future possibility, which is legitimately a concern in its own right, but to the neglect of necessary action that is deeply lacking on the “future possibility” that actually is already happening.

This cannot go overlooked, given our self-proclaimed pro-life consistency, that this sort of care-rationing has been going on for quite some time. It is also disconcerting that pro-life legislative efforts have not been made especially because it would win much bipartisan approach—for differing reasons, of course.

If anything, the “death panels” title can just as easily go to the private sector, if it must go to the government. One does not have to research too far before the numerous horror stories began to appear. Women diagnosed with breast cancer are often at war with their insurance and not their illness. I recently read a memorable story about a woman who lost her mother a few short months after being called into a conference room with hospital administrators to inform her that her mother’s insurance policy would only cover 30 days in ICU, which meant she had to “make some decisions.” She had her options presented to her—take her other home, inevitably to die and given the figures of out-of-cost pay were so impossibly expensive there really was no choice to be made.

This issue goes beyond “horror” stories with insurance companies. While we are inclined to think of a select three states at the thought of hospital-killing (Oregon, Washington, and Montana) where physician-assisted suicide is legal, it is too often overlooked that there are two states, in particular, that have very permissive de facto euthanasia laws that were never written into law explicitly authorizing involuntary killing. The worst of the two is Texas and this isn’t “mercy killing”—it is rationing of care, in the form of legitimized euthanasia, by the private sector.

In Texas, a legislative provision signed into law by then-Governor George W. Bush has created a dire situation that places end-of-life decisions ultimately in the hands of bureaucratic hospital “ethics” committees. From the actual health care reform legislation, there is nothing suggestive that the text endorses or would sanction euthanasia. However, the experience of Texas should give us pause. The Texas Advance Directives Act of 1999 became law with support from a broad ideological spectrum, but one of its unintended consequences is beyond belief.

When a patient or family wants to continue health treatment, but the attending physician does not, the Texas law permits the hospital to have the final say under the obscure and broad concept of “medical futility.” Texas law requires the hospital to provide the patient and family a 48-hour notice that the hospital ethics committee will meet to discuss terminating life support. There are few due-process safeguards in the favor of the patient. Once the committee declares that further care is “futile,” the family has 10 days to find another facility that will accept the patient, or the hospital can remove life-sustaining care (including feeding tubes and water), if the statute is followed rigorously, with complete legal immunity—even if the decision to pull life support was incorrect! Virginia law is very similar, but the family has 14 days. Tragically, many legal victims to these laws receive the hospital’s ruling and commence their 10 (or 14 days) on a Friday—which means, given two weekends, they have lost 4 days further delaying any real chance, in a very unlikely circumstance that they can find another facility. In fact, very few facilities are willing to dedicate their life-saving resources to prolonging the life of a dying patient, even when accepting the patient would be highly profitable for them, and consequently very few families have been able to find a willing facility to accept transfer within ten days.

This strikes me as a de facto “death panel,” which in the growing litany of cases has included the euthanizing of a six-month old infant boy diagnosed with a fatal form of congential dwarfism; this is leaps and bounds beyond doctors trying to pressure you in end-of-life counseling to pull the plug as is asserted will occur if “ObamaCare” is enacted , but bureaucrats taking that initiative on the patients’ behalf even if there are clear and explicit wishes, verbal or documented, to the contrary. This should be a real concern that such wording of the health care legislation—which does not strike me at all as pro-euthanasia—could be misinterpreted and implemented incorrectly. It should be concerned that the federal end-of-life provisions will be implemented under 50 different sets of state laws, which could incentivize against patients’ rights and in the favor of the care providers and the “greater interest” of cost efficiency at the expense of human life. This should be the argument and expression of pro-life concerns, not the rampant insistence that the government is out “to kill you.”

Reinventing Health Care: Criticism of Reform Efforts

Part II!