conservative Christian single payer health care: critiques & responses

First Things was gracious enough to publish my brief argument for single-payer health care from a conservative, Christian perspective. There was a lot that had to be cut due to space and a lot that I didn’t write simply because to do so would make a web essay bloated. Honestly, a short book is really about the length that one needs in order to make an argument that anticipates counterarguments, provides space for digressions about particular issues, etc. So I must give that caveat and say that this post will be a little on the overstuffed side to compensate. 

Mark Tooley over at Juicy Ecumenism has responded to my essay, and while some of his criticisms are valid and require a lot more explanation to get at my argument, there are some others that don’t hold water and reflect the anemic state of conservative healthcare policy in America.

First, Tooley notes that:

He almost implies U.S. health care now is a largely free market or charity run operation, with government standing at a distance.  In 2021, government paid for at least 38% of health care in America.  Private health insurance covered 28%.   Ten percent was out of pocket.  Other third-party payers were 14%.  Over 90% have insurance whether government or private.

He takes my statement “The cost of healthcare for the poor is too great a burden to ask [the church] to bear” as indicative of this implication. What I meant by this statement relates to a common argument against government involvement in healthcare: it is often suggested that if taxes were lower or other conservative-libertarian reforms implemented, then more money would be free for churches to pay for the healthcare costs of the poor. This is not a serious argument; there is no state in America where lower taxes have led to more charitable health care being delivered to the poor (although conservatives tend to be more generous than liberals.) Churches, Christians, and missionary societies have been providers of healthcare and critical agents in health systems of one kind of another for as long as there have been followers of Jesus, but putting all of this responsibility for maintaining the health of a population is like asking the Church to arrest and convict criminals in addition to visiting those in prison.

Tooley is right that the government is the largest payer for healthcare in America already, with private insurance following close behind. The healthcare system in America is a bizarre amalgam of different systems: a highly regulated private employment-based insurance system, a publicly administered system (the VA), a single-payer system for people over 65 (Medicare), and the no-man’s-land purely free market for people who are uninsured (or procedures that aren’t covered by insurance). I’ve written before about things that won’t work to fix it. Why is Medicare a “third rail” in American politics that politicians swear to defend? Because everyone loves it! Yes, Americans love a single-payer system… because it delivers a lot of care to people who need it.

Next, Tooley asks why, if I am for the state provision of healthcare and think that the state owes its citizens their basic needs, don’t I say that food, shelter and clothing should also be single-payer systems. This is a bit silly. The government highly regulates and subsidizes housing and food so that both are safe and widely accessible, but it still allows the free market to work because it would be tyrannical and inefficient to control it all. The free market works very well for clothes, so government interference is unnecessary there. Any argument about healthcare has to be both prudential and moral; I’m saying that a single-payer system is more prudential than the current mess but also more moral. I don’t think that single-payer is the exclusively Christian way, though I have in the past made some expansive statements on what I think a just healthcare system requires as well as what I think the Bible teaches us about poverty and justice.

Conservatives love to talk about how the free market that has made peanut butter and big-screen TVs cheaper would make a lot of healthcare better, but this is simply not how healthcare works. Health care markets would be a lot more helpful if we all knew when we would be diagnosed with cancer or get our first heart attack, but that is simply not reality. Some conservatives have used the example of LASIK eye surgery as a procedure that the market has made more affordable and accessible over the years, but when you’re bleeding out in a car accident you can’t choose a cheaper trauma surgeon on the other side of town and when you have cancer you can’t wait a year to see if you can get by with glasses for now. The analogy to markets breaks down when Peter needs to buy a big-screen TV every month to stay alive, Paul’s brand of peanut butter gets re-patented and its price raised a hundredfold every few years, and Mary gets grocery insurance that allows her to buy Jif at one grocery store but requires her to get bread at another.

Tooley outright rejects my assertion that the free market cannot work well in healthcare because of the opaque nature of the healthcare market and the nature of healthcare consumers without any counterargument. To expound upon my point further, it is true that people in general seek their own good. However, the nature of healthcare is such that even the most informed consumers cannot make rational decisions about healthcare spending because it is impossible to know what one’s health needs will be in the next year, much less what they will be in ten years. We know that certain things (a healthy diet, regular exercise, good relationships, etc.) are good for your health no matter what and those things should be encouraged, but there are many woes that can befall even the most diligent and we have all known people who died peacefully in their 80’s after a long life of subjecting their temple of the Holy Spirit to a steady stream of toxins. I sketched out some broader ideas about how a more efficient and “distributist” system might work here.

If a single-payer system were focused on primary care and secondary treatment that which had a solid base of scientific evidence for treatment (as well as catastrophic care for emergencies or expensive and deadly illnesses like cancer), there would still be opportunities for the market to work with many other aspects of care. We know from other countries that a private system almost always grows alongside of a public one, and this is both unavoidable and probably good for everyone in the long run. Richer people, if they want a shorter wait time for their elective procedures or more expensive and experimental treatments, can always purchase supplemental insurance or pay out of pocket. These two little benefits would be available to far fewer people as a result of a single-payer system, but to make the wait shorter by keeping people out of the system is like taking our neighbor’s lamb when we have sheep in abundance.

There are things that the state is good at, and thus within its lawful and prudent field of action. Many other initiatives with specifically defined health objectives have long been managed best by the state: sanitation, disease eradication campaigns, and food regulation, just to name a few examples, belong unambiguously to the purview of the state. We would probably still be treating malaria in America if we depended on private charity and the free market to eliminate it. A narrow view of the state that exclusively punishes evildoers and does not prevent or treat the natural evils of disease is neither fair nor rational.

The next bit is Tooley’s strongest argument and worth quoting in full:

Obviously, the author does not want totalitarianism but a more Christian society. But state-control and Christian are not necessarily compatible. “A healthcare system that acknowledges its limits deserves to be funded by a state that admits it can only be a small part of human flourishing,” the author says.

But how many governments admit to and abide by being “only a small part of human flourishing?” Humans by nature, singularly or corporately, if unhindered and balanced by others, procure privilege and power for themselves at the expense of others. Governments, with their nearly unlimited coercive powers, are not easily restricted once expanded, with often catastrophic consequences for human dignity and liberty.

[…]

A Christian-infused society should be especially aware of the dangers of concentrated powers, even for laudable purposes. Concupiscence and cupidity, intrinsic to human nature, are with us until the end of this age. How do we protect ourselves from overbearing and even tyrannical governance in defense of decency, dignity and liberty?

There is never a full-proof answer. But, generally, limiting government, and answering social challenges with other institutions, allows for better opportunities to safeguard the best of humanity. Totalizing political proposals, even if labeled as “Christian,” usually replace one set of problems with even worse problems.

Yes, it’s true: giving people power over the lives of others will automatically tempt them to reach for more power. Politics is the art of replacing one set of problems with another. The nation-state is not the guarantor of the common good and it’s a foolhardy assumption to think otherwise. (Here’s a link to a PDF of William T. Cavanaugh’s excellent article “Killing for The Telephone Company: Why the Nation State is Not the Keeper of the Common Good”.) However, right-liberals, conservatives, and libertarians are really struggling to come to grips with the fact that private companies like Amazon and Google are becoming Leviathans in and of themselves requiring checks and balances, and there will need to be a rethinking of principles about concentrating power and the state in light of the massive technological advances that have increased the amount of power that is available nowadays.

We also have to accept certain tradeoffs in our political principles. A concrete good of fewer people dying prematurely has to be weighed against a nebulous loss of freedom and dignity by giving more power to the state. We also have to recognize that the same freedom and dignity is being encroached upon by insurance companies and other nebulous healthcare organizations, so it may not be possible to avoid that particular harm. Right-liberal rhetoric about the value of freedom finds itself stumbling into utopianism when it waxes eloquently about the ideal citizen whose autonomy is only infringed upon in the most dire of circumstances. Finally, if we look at Medicare (where the government already exercises this sort of power in a large portion of the population), we can see that most elderly people are quite happy to let the state have that power because of the benefits it provides to their health.

Does paying for necessary healthcare make people lazier or more likely to abuse substances? Conservatives often argue so, but there isn’t definitive empirical evidence for or against this claim. If it were true, one would expect there to be far less poverty or addiction and far more economic vibrancy in places where government benefits are stingier, but this is not the case. There are many places around the world where the state does not give the poor anything, yet somehow drunkenness and sloth still abound there. We have to deal with those problems in other ways besides the state.

Speaking of non-state solutions to problems, Tooley takes issue with my closing paragraph, which is frankly surprising because I figured that talking about the need for a culture of care for the vulnerable was the sort of rhetoric that all conservatives are about. For example, if you ask a Republican politician about any problem that has some kind of social factor exacerbating it, they will very quickly retreat to talking about the need for greater moral values, respect, decency, the integrity of the family, etc. (Rarely do they have a concrete plan for doing any of this, but that is irrelevant to this particular discussion.) The most obvious and absurd example of this is gun violence, where Tooley stridently rejects any sort of gun regulation and exhorts Christians to be “agents of redemption” who preach against an obsession with guns rather than regulating them. Opposing such an obsession is pretty revolutionary these days, sadly.

Tooley elsewhere says that “the church with all the more vigor should proclaim what it knows to be true, which will eventually prevail in the fulness of God’s own time”, which is more or less what I mean by “a conservative revolution” and “a Christian revolution”. Perhaps the particular word “revolution” is what he got hung up on; by “revolution” I simply mean “important change” and I certainly don’t expect that a Christian ethic of care for the vulnerable or a conservative ideology that prioritizes virtue are going to come about as a result of rapid overthrow of social institutions like the Christian Nationalist folks seem to. I am, however, on the record as suspicious about the liberal order and a fan of the postliberal “common good” politics a la Oliver O’Donovan that Tooley seems suspicious of. That may not be an issue that Tooley and I will ever see eye-to-eye on, but I do think that single-payer is possible within either a liberal or postliberal framework.

Canada’s abhorrent Medical Assistance in Dying program is brought up, and the fact that government-assisted healthcare programs incentivize (in the right cultural conditions) evils like euthanasia is another strong objection to single-payer healthcare. The way to prevent these evils is, quite simply, to ban them. A culture that pushes people towards killing the weak and disabled is a menace that cannot be staved off by the free market (which has no inherent regard for human dignity or love for the disabled). We must work on many other fronts to affirm the goodness of mutual dependence and care for the weak, and the political rhetoric of right-liberalism that disregards the health of people who don’t have enough money does us no favors there. It’s also worth noting that euthanasia remains illegal in many places with broader healthcare systems, with Australia’s laws similar to America’s.

Finally, I want to reiterate that conservatives in America have spent over a decade now simply kvetching about Obamacare while offering few meaningful or workable solutions of their own. It is now at the point where the few states that have not expanded Medicaid are watching their rural hospitals shrivel up and die, which does not seem to be at all congruent with a Republican agenda that claims to have the interest of poor, forgotten rural folks at heart. (To be fair, J.D. Vance is on the record as supporting Medicare drug price negotiation, which I think is a good idea, but only one of many steps in fixing things.) Much of my First Things essay could be taken as an argument against economic protectionism in healthcare, which I suppose could adapted to more conservative kinds of reforms. But the desire for single-payer as a simple solution to a vexing problem will likely continue to grow as long as costs keep rising. I don’t think single-payer solves all of our problems, but it would certainly help with many of them.