Healthcare & Subsidiarity: Two Interpretations

I’ve been thinking a bit about the principle of subsidiarity recently as it relates to health care reform. To provide some context, here is the Catechism on subsidiarity:

1883 Socialization also presents dangers. Excessive intervention by the state can threaten personal freedom and initiative. The teaching of the Church has elaborated the principle of subsidiarity, according to which “a community of a higher order should not interfere in the internal life of a community of a lower order, depriving the latter of its functions, but rather should support it in case of need and help to co- ordinate its activity with the activities of the rest of society, always with a view to the common good.”7

1885 The principle of subsidiarity is opposed to all forms of collectivism. It sets limits for state intervention. It aims at harmonizing the relationships between individuals and societies. It tends toward the establishment of true international order.

Despite the rancor which sometimes surrounds the health care debate in the Catholic blogosphere, it seems to me that the basic issue is different prudential judgments regarding the application of the principle of subsidiarity. I’m a bit torn between two ways to apply subsidiarity in this particular circumstance, and so I thought it might be worthwhile to explore the different positions as I understand them. 

Position 1: The current health care reform bill is a violation of the principle of subsidiarity. While it is true that there is a human right to health care (and a corresponding duty to ensure that all receive it), this is best accomplished by private means, or at the state and local level. Nationalizing health care is a large step towards the type of socialization that the Catechism criticizes, and the increasing expansion of the national government has a crowding-out effect on private institutions, particularly Catholic charities. Moreover, even if one was to support nationalized health care, this particular piece of legislation is a mess. As its honest defenders acknowledge, it will do little to address the most serious structural problems responsible for increasing costs.  The current proposal is a violation of subsidiarity, is fiscally irresponsible, and is harmful to the comon good. 

Position 2: Subsidiarity is one principle among many which must be balanced.  It is clear both that health care is a human right (with a corresponding duty), and that private organizations and local governments have failed to address the problem. Justice delayed is justice denied. Opposing national health care without any prospect for an alternative solution on the horizon is tantamount to denying a fundamental human right. Yes, admittedly, the current legislation is less than ideal, but “anything worth doing is worth doing badly.” We can address the revenue problems in the future; what we can’t address in the future is the people who will be harmed by a refusal to act today. Increasing the GDP is a component of the common good, but it is far from the most important component. A wealthy society should do more to care for its poor.

I’ve deliberately excluded a discussion of abortion from the preceding sketches, primarily because I thought it might help to focus the discussion on subsidiarity. I’d be interested in hearing readers thoughts on the positions staked out above. Which do you find more persuasive and/or how would you phrase your support or objection to health care reform?

15 Responses to Healthcare & Subsidiarity: Two Interpretations

  • If we’re going to have to have some sort of socialized health care, why not offer vouchers to state governments. There the state legislators can deal with socialized medicine better and more effectively than the federal government.

    Granted it’s still the government, but at least each state will have different levels of socialized health care that they wish.

    For example, Massachusetts and Hawaii have something similar to what House Speaker Pelosi want to offer. Why not instead of creating one huge bureaucracy, just offer vouchers for state governments that have some sort of statewide health care system.

  • John Henry,

    Your division of the two positions are well taken and are roughly on the mark. But I think they are a bit oversimplified — or rather, I think the ‘Position 2′ is not as accurate as ‘Position 1′. The former is precisely on point; I hold Position 2 and that is not how I would describe it (or how I think most people who hold that position would describe it).

    Now I’m not saying that Catholics or anyone else must hold my view (and I hope they would extend me the same charity).

    This is how I put it when I discussed it previously:

    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.

    So far from being a rejection of subsidiarity, it is applying it appropriately to the situation. Subsidiarity is a hard principle to reconcile with solidarity and I think at times we end up with one at the expense of the others.

    So the natural question becomes this: what is ‘socialization’ and ‘collectivism’?

    I think the lack of a clear, concrete definition makes this subject to debate — no matter how tempted we are to impose a definition for the Magisterium.

    One might run into a problem with other guidelines laid out in the Catechism:

    “In the beginning God entrusted the earth and its resources to the common stewardship of mankind to take care of them, master them by labor, and enjoy their fruits. The goods of creation are destined for the whole human race. However, the earth is divided up among men to assure the security of their lives, endangered by poverty and threatened by violence. The appropriation of property is legitimate for guaranteeing the freedom and dignity of persons and for helping each of them to meet his basic needs and the needs of those in his charge. It should allow for a natural solidarity to develop between men,” (2402).

    “Political authority has the right and duty to regulate the legitimate exercise of the right to ownership for the sake of the common good,” (2406).

    My basic point here — and this is not a blanket endorsement of mainstream Democratic proposals to health care, on the contrary — is that solidary and subsidiarity seem to be at war in contemporary political discourse.

    Now if ‘collectivism’ and ‘socialization’ means a movement toward statist socio-economic policies then most certainly the principle of subsidiarity opposes this tendency firmly.

    But…

    I have become weary of appeals to subsidiarity because I find some Catholics’ understanding of the principle to be problematic in that it evolves into a totally libertarian, social Darwinistic perspective. Historically not far removed from the rise of communism and socialism, government intervention (perhaps rightly) is regarded with suspicion.

    The turning point, which I think is not at all Catholic, is when any social interest or collective good that is not totally privatized is suspicious. In some ways (and I cannot go into much detail here), but I find this thinking to be deeply rooted in legal positivist absolutism and social contract theory. In other words, it is the abandonment of ‘ought’ — I have no duties or obligations with my money unless I (as a free and autonomous person) say so. Taxation is hardly legitimate; it is “government theft” — using my money without my permission or explicit sanction from the social contract, which I must agree to.

    This tendency, from this perspective, travels into the question of collective responsibilities and interests (as well as personal ones) in regard to health care.

    I’m not sure if all of this thinking can be reconciled with the Church’s teaching. Certainly an argument can be made by what the mainstream of Democrats proposals being put forth.

    Good post Henry.

  • Tito,

    Yours is a good question. I’ll write the legislation and you go began to lobby other Congressmen to vote with us.

  • I tend toward position 1; however, I think if we are confining this to subsidiarity then the current proposals are in clear violation. Government has a history of and a tendency to ruin the things it states to do. Far too often the results are practically opposite of the stated intentions. Why should we think this would be different?

    Additionally, we already have socialized health care and it is a disaster so how can we think that growing it and centralizing it more will result in anything other than an increase in the magnitude and quantity of the problems.

    Subsidiarity as federalism allows 50 sovereign jurisdictions to compete with one another, copy the positive, and eliminate the negative. One single decision maker leaves nothing with which to compare the benefits and the pitfalls.

    This does not rule out government’s role even at the federal level because it may have to negotiate concerns between the states, provided they cannot work them out themselves.

    For example, Maryland allows abortion in the state provided health plans and mandates that private carriers offer abortion in their plans. Virginia forbids abortion. What is to stop Virginians from crossing the border to procure abortions? If Maryland and Virginia cannot resolve this problem then it would fall to the federal government. Of course, that does not mean that the VA/MD decision should apply to Illinois and Wisconsin. [This can be any other issue, abortion came to mind because John Henry said don't think about pink elephants so all I can think about is pink elephants]

    As for position number two: The fact that medical care is a right because it can acutely address the health of the human person does not mean that ALL medical or ALL health care is a right. Nevertheless, a minimum level should be provided to everyone who CANNOT provide it for themselves. This does not mean that the medical care, health care, medical insurance, etc. of those who CAN provide for themselves should be interfered with. If the free market is at the disposal of those individuals, which will be the majority, is working well, then it must be left alone. General tax revenue, not necessarily income tax, will be adequate for providing the care for the truly indigent who are not cared for by charities. This is reserved for the truly poor (through no fault of their own) and the uninsurable (through no fault of their own). This will be a small minority of the citizenry of the USA.

    It is a far greater mistake to provide care for all at the expense of some because that is unsustainable and eventually no one will have any medical care whatsoever. As for doing something as opposed to doing nothing: Agreed. However, that something should be to remove the restrictions on the truly enterprising medical, health and insurance providers and to stop rewarding the rent-seeking corporations that used the government to impose these restrictions in the first place. Additionally without addressing the monopoly of the Federal Reserve and their perpetual inflation of the money supply as well as the trial lawyers, all other efforts to ‘fix’ health care are irrelevant.

  • I want to add that Tito directly points out an overlooked distinction that I think could have been the real compromise on this issue — in America, there is not just a federal government, there are 50 state governments that are indeed more local.

    We use the term ‘government’ but I sense we’re often alluding to the federal government.

  • Eric,

    I’d be more than happy to work with you on this. Shoot, I’ll even register as a Democrat, so you and I can both be marginalized for our fervent faith together!

  • Tito and Eric,

    Good points. It is equally important to note that we also have county and local governments. The governing authority closest to the indigent that need to be served is going to be more personal and less beaurcratic, therefore more effective.

    Additionally, local charities and charitable individuals would have more opportunity to fill the gap and probably even leave the governments out of it.

    At the federal level government is far more prone to end up serving itself with little to no recourse for the people at large. Centralization tends to oligarchy.

  • American Knight,

    And then states can decide to pass the money down to county governments or issue refunds to their state citizens.

    On another note, AK, time for you to put up a pic. Those modernist-abstract gravatars do you no justice.

  • Isn’t it important to note here the word “cannot”? Not “will not” or “are not,” but “cannot” is important to subsidiarity. Most states offer some sort of insurance to the unemployed / underemployed (I know this…my children are on it…).

    Of course, this question seems to turn on a matter of semantics. If one insists that the issue is “everyone has federal insurance” than ipso facto, no state can possibly meet the demands. On the other hand, many states do insure the needy, and many uninsured could afford their own health care, which seems to meet the demands of subsidiarity nicely.

  • Why stop at the state level? Give the vouchers to the individuals.

  • Jonathan,

    Excellent point. Like my earlier comment, Massachusetts and Hawaii already offer something like this to some degree.

    RestrainedRadical,

    That would be my favorite, send the vouchers directly to the individuals.

  • John/Tito

    Reading a little deeper nay help this discussion.

    The section on Subsidiarity runs from 1881 to 1885 and the COMPENDIUM
    OF THE SOCIAL DOCTRINE OF THE CHURCH, chapter IV section four has a more detailed discussion.

    185. Subsidiarity is among the most constant and characteristic directives of the Church’s social doctrine and has been present since the first great social encyclical. It is impossible to promote the dignity of the person without showing concern for the family, groups, associations, local territorial realities; in short, for that aggregate of economic, social, cultural, sports-oriented, recreational, professional and political expressions to which people spontaneously give life and which make it possible for them to achieve effective social growth.

    Snip

    186. The necessity of defending and promoting the original expressions of social life is emphasized by the Church in the Encyclical Quadragesimo Anno, in which the principle of subsidiarity is indicated as Nb>a most important principle of “social philosophy”.

    Snip

    On the basis of this principle, all societies of a superior order must adopt attitudes of help (“subsidium”) — therefore of support, promotion, development — with respect to lower-order societies.

    Subsidiarity, understood in the positive sense as economic, institutional or juridical assistance offered to lesser social entities, entails a corresponding series of negative implications that require the State to refrain from anything that would de facto restrict the existential space of the smaller essential cells of society. Their initiative, freedom and responsibility must not be supplanted.

    Bold text emphasis is mine.

    I think the principle of subsidiarity says a little more than saying if the lower unit can do it better it should be done at the lower level and the reverse for the higher level. Intermediate social institutions often have the right to their own decision making and operation. The fact that the higher level of society may not agree with the decisions is irrelevant, unless the problems caused rise to the level of harming the common good.

    The principle of subsidiary is rooted in the need to protect human dignity, an institution that is to large, and with out effective intermediate levels makes the individual to an anonymous cog that has no dignity. The larger unit may in an economic sense be more efficient, but if locating a funciton there tends to harm human dignity the less efficient lower level would be preferred. A good example is that while the Pope is the head of the church the bishops have authority in their own right and the Pope should not intervene in the internal operations of their diocese under normal circumstances no matter how much he disagrees. I think we all know of seveal dioceses where the ocal bishops prunential decisions scream of stupidity, but in fact the bishop, was acting in good faith with in the confines of the faith.

    When considering the common good the Churches Social teaching is that the common good protects the individual, even the least individual. Many secular people using the term see it as meaning abanding the least individual for the more efficient operation of society. Thus some secualar persons see abortion as promoting the common good by getting rid of marginal individuals. But their language is often reminiscent of Catholic teaching if one is not listening carefully, though they are often (unknowingly) promoting the opposite.

    I think that the principle of subsidiarity requires a substantial level of evidece that, not mearly health care can be run on a national level, and run more economic efficientcy at the national level but than othe levels but that it provides for individuls and their doctors to make good health care decions on the indivudual basis. I find the case lacking.

    It seems to me, that even in the doubtful case that all the claims for National Health care could be met, it would de facto restrict the existential space of the smaller essential cells of society to effectivly provide healt care to individuals.

  • There are several important prudential arguments as to why National Health Care is not a good choice from a Subsidiarity position.

    Economy of scale. Consolidating operations of any type can produce an economy of scale that allows for more efficient and effective operation. But sooner or later you reach a point of diminishing returns where the additional consolidation starts reducing efficiency and effectiveness. It seems to that part of the problem with health care is that the current organizations providing it are long past the point of diminishing returns. Further consolidation would only increase the inefficiency and effectiveness of heath care delivery.

    Predatory pricing. Monopolies engage in predatory pricing unless there something to stop them. This is often because the normal pressures on an organization push the monopoly in that direction, rather than a premeditated sense of greed. Part of the high cost of heath care that parts of the health care system are limited or quasi monopolies. Moving heath care into a monopoly can only increase this effect. Government regulation can often restrict monopolies but when the government is the operator of the monopoly the regulator and the operator are the same and the regulator function loses. No necessarily greed, just the effect of thousands of decisions responding to normal operatons.

    Living wage. The proposal will move about 20% of the economy into the governmental sector. The government gets money by taxes, even if they are called something else. Yes paying taxes is a duty, but those who levy the taxes have duties to insure they are just and do not cause harm, certainly they should not be so high as to reduce wages to the point that they are no longer a living wage. How this is to be prevented does not seem to be a major item of discussion or consideration by supporters. But a shift of this size could easily do this or cause other distortions not consistent with Catholic social teaching.

    Human dignity. R.J. Rummel, Professor Emeritus of the University of Hawaii, is one of the worlds experts on mass murder (not just genocide) by governments. His conclusion of alife time of study is that the single predictor of government committed mass is the unchallenged ability to do it. This has nothing to do with ideology, if the ability is there sooner or later it will happen. A national health care system will give that kind of unchallenged authority to the government. Not that people set out to do that, or the establishment of “death panels,” but dening care, providing poorer care of even providing fatal drugs will be an easy solution to many day to day problems. Any one who could challenge these decisions is appointed by the same people making the decisions and under the same pressures. Even if things to not rise to the level that Dr. Rommel’s theory would predict, decisions contary to the human dignity of the patients will become more and more common.
    See his power Kills website and his book Death by Government

  • Hank, excellent comments. I was especially struck by the last part of your post.

    Earlier this week, I came across this post at Belmont Club. Now, that is a secular (albeit conservative) blog and I have no idea if the author, Richard Fernandez, is a believing Christian or not. And the blog post was about the rise of the BNP in the UK, not healthcare. Nonetheless, I think this comment connects to the points you have made:

    For as long as man imagined himself to be sacred and accountable to the Creator he stood at the center of polity. The state was there to serve him and not the reverse. Today he has lost that central place and is no more or less than a collection of curiously animated chemical substances with a market value of less then fifty dollars which the state has deigned to keep alive until some bureaucratic panel decides it is too expensive to do so. Just as Global Warming can be understood at one level as an attempt to bring nature into the purview of politics, it is impossible to understand the Left’s fixation with abortion except as a sacramental affirmation of the state’s power over man. The strident insistence on abortion on demand goes way beyond any conceivable need to prevent backroom abortions, or even an affirmation of a woman’s right to choose. It is really an absolute display of the power of politics over life. Abortion’s principal utility is as a stake driven through the heart of the notion of human sacredness, which once performed, ought to prevent its revival entirely.

    That is why I wonder about left-leaning Catholics who seem to assume that a large nanny state will happily co-exist with religion. The larger the state gets, the more it will view religious groups not as valuable co-partners, but as threats to the state’s authority. Forget the Bible and the Pope – the government will tell you what is right and wrong.

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