How should health care in the United States be reformed? The principles of social justice outlined in Catholic social teaching can be considered by all those of good will as guidelines for ethical health care reform. Those principles, are the dignity of the human person, the common good, solidarity, and subsidiarity. These four social justice principles provide a foundation for a virtuous and economically sound improvement in medical resource allocation; a Christian prescription for health care reform.
It is clear that we have a duty to improve access, affordability, and quality of care for all citizens because of their human dignity. Frequently missing from the discussion of health care reform is the role of personal responsibility. Pope Benedict XVI has emphasized the point: “In the name of freedom, there has to be a correlation between rights and duties, by which every person is called to assume responsibility for his or her choices.”
Behavior and responsibility for the consequences of personal health choices need to be linked for significant health care reform. If patients participated more directly, at the point of service, in paying for their care or for their medical insurance, medical resource consumption would diminish. More health care resources could be used for prevention of disease than spent on chronic illness associated with modifiable risk factors. The 38 percent of American deaths caused by the behaviors of smoking, diet, physical inactivity, and alcohol use could be mitigated. Patients with stronger incentives to stay healthy could decrease expenditures associated with smoking, obesity, diet controlled diabetes, atherosclerotic heart and peripheral vessel disease, strokes, alcoholism, and osteoporosis, to name a few. Two-thirds of Americans are overweight, which directly correlates with chronic disease and increased health care spending.
Christ’s teachings on justice did not omit discussion of personal responsibility. “He will repay all according to his conduct” (Matt. 16:27). Contemporary platforms for health care reform can neither neglect nor discount personal behavior and accountability.
Patients’ paying for health care at the point of service are more prudent purchasers of health care than those perceiving health care benefits as an entitlement. They would spend less on health care if they took better care of themselves for modifiable conditions. They seek to be more informed and ask more questions about quality, outcomes, and cost. Furthermore, as consumers, they are more motivated to negotiate regarding costs of elective treatment decisions. Medical inflation would improve. Patients’ directly paying insurance premiums, rather than indirectly through foregone wages or by taxes, would lead to stronger demands and competition for quality of service from insurance companies.
The Medicare Trust Fund is expected to become insolvent by 2019. Medicare patients are going to have to bear more financial responsibility for their health care decisions, particularly for elective procedures. Presently, physicians and hospitals rarely are asked about the cost of care by patients and families when they expect insurance to cover their bills. Definitions of extraordinary care could consider financial expenditure. Medical resources are not unlimited. Less futile end-of-life spending could potentially increase resource availability for more preventative and basic care, while at the same time promoting greater respect for human dignity. This is an area in which the Church’s teaching offers invaluable guidance. Cases of withholding ordinary care have rightly garnered national attention and provoked outrage, but it is also true that the technological extension of life by extraordinary means can absorb significant resources without enhancing the prospects for a dignified and natural death.
The affluent elderly could bear more financial burden for their health care. The established social contract where workers’ taxes provide for medical expenses of those over sixty-five has to be reconsidered given demographic changes as well as advances in expensive technology and specialty care. Fewer workers are paying taxes to support the ever expanding percentage of the population that is retired.
Some argue that medical care demand is inelastic; the quantity of care demanded is not sufficiently influenced by prices, and increasing consumer responsibility for payment will not curb health care spending. However, much of health care is not emergent. Many patients are sophisticated enough to become informed health care consumers, as they are for other goods and services. Primary care physicians can assist their patients and families in cost-conscious decision-making, in addition to encouraging lifestyle and diet changes that can have tremendous impact on preventable or modifiable chronic disease. There is opportunity for a more just allocation of the two trillion dollars spent annually on health care in the United States. Half of the United States population spends very little on health care, while 5 percent of the population spends almost half of the total amount. The RAND Health Insurance Experiment, completed in 1982, identified considerable price elasticity, wherein some personal financial responsibility for health care did not significantly affect quality of care.
What if consumers choose not to purchase or cannot afford health insurance? Should someone be denied care because they cannot pay? It is reasonable to seek to agree on primary care services or basic safety-net coverage that might be provided to all citizens; for example, children’s health, pregnancy care, and emergent and urgent conditions. Market forces would identify fundamentally desired health care service more effectively than committees or bureaucracies. Furthermore, incentives need to be created to encourage patients to avoid emergency rooms for non-urgent conditions. As a society, we cannot turn our backs on the indigent. However, unlimited procedures and treatments are not possible. Patient participation in the cost of their care, even a small percentage, is a more just situation than abdicating total control of payment and what is provided, or denied, to a third party. Human dignity is promoted by reforms respecting both duties to others and personal responsibility.
