Creating a Just and Good Healthcare System

On June 3rd, 2017, I gave a talk to the Maryland chapter of the American Solidarity Party. The original text of my talk is below the video.

If there’s one thing everyone can agree on in American politics in 2017, it’s that our healthcare system does not work as it should. We spend more than any other nation in the world on health care and yet have little to show for it: We’re often ranked lower than other industrialized nations on measures like infant mortality, amputations due to diabetes, or overall mortality. We spend more, but get less for our money. We’re better than the others in cancer mortality, and we sure do employ a lot of people through our healthcare system—but that’s about it.

There are a lot of reasons for this. We pay our subspecialists more by comparison than other nations and we de-emphasize primary care. Our systems for billing are so labyrinthine and opaque that we spend four times as much on paperwork as our Canadian brethren do up north. We trap people with massive deductibles and co-pays that discourage them from going to the doctor until it’s too late. Our safety net programs are a patchwork mess depending on where you live, and we’ll pay hundreds of thousands of dollars a year for someone’s visits to the ER before we’ll even consider putting down a tenth of that to help house someone instead.

Those are all things that could respond to different policies, but there are deeper, more philosophical issues, too. We can’t agree on what healthcare is for, what its goals are, because we don’t think about what health is or what it means. We don’t appreciate our ecosystems of life, the way that we are dependent on one another, the land, and animals—so we abuse the Earth and its creatures in order to eat and move around. We live in a culture where personal autonomy reigns supreme, which means that our highest self-achievement involves fulfilling our own personal whims. We have no sense of obligation to one another, leaving many vulnerable people in the lurch when health crises strike them. We concentrate power in the hands of highly educated and wealthy professionals and then act surprised when patients feel disempowered to take care of their own bodies. We take a very scientifically reductionistic approach to what health is, which means that we reduce indicators of health to things we can measure and then sell a pill for.

Health and Wholeness

Most of the problems I mentioned before flow out of our failure to recognize this, our failure to think of health as wholeness in community beyond any one individual person and their body. “Health” and “whole” even come from the same root word! It is impossible to think about our wholeness as person unless we are also considering health in our bodies, for our flourishing is always embodied. We do not treat our bodies as though they are in any way connected to our souls, to one another, or to the places that we live.

Even people who talk about health care as a “right” and want to make sure everyone has a lot of it fall into this trap. I think they’re a little closer to the right idea than the people like Paul Ryan, who treats tax cuts as the highest possible priority and then turns around and says that he’d like health insurers to have the choice to charge you thousands of dollars more for something you need to stay alive.

But even then, I think it’s very confusing to talk about health care as a right, because health care isn’t just one thing that you have that someone can take away from you, it’s a whole panoply of services and goods. Plus, a lot of these people think that providing health care because it’s a right also want the government to give you the freedom to be as free from obligations to others as possible, although other people are obligated to sell you things regardless of how you feel about it.

And so I think a more helpful framework is one which views health care as a social good which is necessary to secure one’s right to life. Rights are things that the government must protect at any cost, but social goods are things that we value and share and use on the basis of obligations beyond what any person is entitled to. And because we understand as citizens that the physical bodies of our fellow citizens are valuable and have God-imbued dignity, we have to care for them by helping to contribute to the cost of sharing this social good.

If we start from the understanding that healthcare is a social good necessary to secure the right to life, it follows that every person should be able to access this social good such that they do not die an otherwise preventable death. Any health system that does not meet this basic test is unjust, and our current system fails miserably. I don’t think it’s utopian to aim for a system in which everyone has access to the care they need in order to avoid an otherwise preventable death.

Protecting Everyone’s Right to Life

If you are an adult in America who is unable to find work that will give you health insurance and you have a condition requiring expensive medications to let you live, you can easily die while you’re waiting to become poor enough or disabled enough to qualify for treatment. There are a lot of other holes to fall through, but I think this is the biggest one.

Charity might possibly step in here (and it often does for folks who have small needs), but if you’re talking about medications in the range of tens of thousands of dollars, any charity you get isn’t going to last long enough to keep you functional and it certainly isn’t sustainable across a whole population. If anything is utopian, it’s the idea that self-interest and massive power concentrated in the hands of insurance companies and hospitals will somehow keep people healthier and that charity will be there for everyone who needs it when they need it.

There is often a lot of cynicism about changing the health care system because it is so massive and thus there is nothing that we can do. The system in general certainly discourages holistic thinking and makes this task harder. But there is a lot that we can do regardless of our political realities—which, quite frankly, could change in any direction in the near future—and a lot that we have to do even if we woke up and had a single-payer system tomorrow.

Single payer solves this problem and a lot of other problems. It also creates other problems and it doesn’t solve some of the biggest problems I’ve mentioned, but it does meet the very basic test of justice I’ve outlined above. Other reforms that would meet this requirement would be things like pushing the ACA further to subsidize or insure everyone, or a more aggressive version of the Cassidy-Collins bill that automatically enrolls everyone in a plan that covers catastrophic care and then lets them figure out what else they want for themselves. People would use HSAs so that they have a lot more choice and there’s still a healthcare market. (I will note that in a single-payer system, there’s still plenty of choice because people can take their business anywhere they choose!) But I think some version of Cassidy-Collins would work and is probably the most appealing to conservatives while meeting the basic test of justice.

What if the system gets worse?

But what if none of that happens and our system keeps limping along as it is—or gets worse when Paul Ryan gives you more “choice”? One of the things I love about the American Solidarity Party is that while we are convinced that policy affects every aspect of human life, we are equally certain that we can’t hope in the government to do the good work of human flourishing that our intermediary institutions do.

The government marks off the boundaries of how we interact with each other, but it doesn’t make us flourish or fail. People in Washington can make it easier or harder for us to love our neighbors, but regardless of what Paul Ryan does, there are decisions we can make in hospitals, clinics, churches, and families that will help us to care for one another and honor the bodies that God has given us.

Health is Stewardship

So how do we do that? I want to start with the idea that health is stewardship. We have the resources to take care of ourselves, we just have to distribute them wisely. I would argue that the best way to heal our ailing body politic is to redistribute power so that people can make better choices.

Right now, the power in health care is concentrated in payers like the government and health insurance companies. The decision-making power is concentrated among hospitals and doctors. These big entities then spend a lot of time and money trying to convince patients to behave themselves, eat right, exercise, and take their medications to keep from getting sick.

All of those other institutions and other things that keep you healthy—your friends, your community, your workplace, your relationships—are just taken for granted. In turn, your friends and your church take your health for granted, because that’s the doctor’s job. And a lot of people take their own health for granted, letting themselves be passive consumers of health care instead of being stewards of their own bodies.

It’s even harder in poorer communities where there are often more structural challenges to being healthy—lack of access to fresh food, no safe places for kids to play, and a glut of tobacco, alcohol, drugs, and unhealthy foods available. When you’re stressed, anxious, or depressed from a life of poverty, it’s that much harder to resist the urge to misuse these things. In that situation, it’s easier to give in to a sense of nihilism about your body, to passively surrender yourself to the medical system. And all of the liberal solutions to these problems are wealth transfers on behalf of poor people to rich people: Section 8 money goes to landlords, Medicaid money goes to hospitals, and food stamp money goes to big supermarkets. The power bypasses the people.

Redistributing power, then, I think should start by shifting the power from the bigger, more imprecise institutions—the places we need to call upon for more expensive or difficult diseases—to all of the smaller institutions that know you and love you. A lot of primary and preventive care, the sort that keeps you from getting sick in the first place, doesn’t need a doctor. A community health worker is probably better than a doctor at knowing the people in a community and helping them figure out how to eat healthy, exercise, quit smoking, etc. And quite frankly, they should also be able to order vaccines, colonoscopies, mammograms, and things of that sort. They can probably also treat people’s colds and adjust their blood pressure medication, though at that point you’re really cutting into a doctor’s business and have to start dealing with local and state legislatures to change licensure stuff.

Developing Partnerships to Promote Health

Doctors are rent seekers. It’s true. We want to secure our own incomes. But I didn’t do seven years of medical training to click boxes and harangue people about how to quit smoking — and yet that’s what a primary care doctor ends up spending a lot of his or her day doing. You can do that with a high-school education or less, and if that’s the level of education you have, you might be even more likely to be trusted by the person you’re talking to! All health professionals should spend their day doing the things other people with less training (and lower salaries) could do, and for primary care doctors that means dealing with the medical problems of the most complex patients.

Hospitals and clinics can (and should) fund these community health workers. There’s a few of them in Maryland—not nearly enough—but one of the most exciting programs I’ve seen is the Healthy Community Partnership’s Lay Health Educator Program out of Johns Hopkins Bayview Hospital in Baltimore. They have medical residents, social workers, chaplains, and nurses from the hospital train people from local churches, trusted community members, in basic preventive health skills. You take the power that was concentrated in the hospital and you spread it around the community, giving these folks skills and knowledge that they can use to help others. I don’t think it goes far enough, but it’s what we need a lot more of.

This program is run by Dr. Daniel Hale, who wrote the book on Medical-Religious Partnerships. In that book, he shares a lot of different ideas for ways that religious and medical institutions can work together. A lot of it is similar to the Lay Health Educator Program, where the medical institution has knowledge and the religious institution has closer connections with people and can communicate things to them in a way that is intelligible. But there’s also things like sponsoring health fairs at churches or with other community groups (which does happen already a fair bit) or even trying to use the church’s space to help deliver health services a little closer, in a way that’s a bit more accessible.

There’s also the route taken by Christian Community Health Fellowship, which is an explicitly Christian network of clinics that delivers health services and are intentionally located in communities with the greatest need. One of the biggest is in the Lawndale neighborhood of Chicago; they have built up a big clinic with a fitness center and a cafe because they understand that health is wholeness and it isn’t just about what you can do in the clinic. It’s about stewarding all your resources for the sake of creating healthy people and healthy communities.

Folks can do this on an even smaller level, too: in Japan there are health co-ops through ‘han’ groups that are just groups of people getting together to check their blood pressure, do health education together, and encourage one another. Professionals also help to supervise and participate in these groups, but again the focus is on what people can do for themselves.

Where I saw this happening the best in Sandtown, West Baltimore, where my family and I lived for 6 years was in mental health groups. We tried a lot of different things to help deal with the mental health issues that people in the neighborhood were facing — we brought in counselors, we held events, we applied for grants… but the thing that was most helpful was what we ended up calling the “Women’s Support Group”. A few ladies in the church went through a training called Community Health Evangelism (or CHE); it’s used all over the world for all sorts of different educational and vocational trainings. CHE’s main focus is always on “what can you do for yourself?” and it trains people within the community to solve their own problems.

So in Sandtown, nothing else really worked besides these groups. Every month someone would lead a group about a different topic — stress, depression, trauma, grief, etc. — and they’d sit around and process and talk and deal with stuff that came up. I wasn’t able to get people to go to the counselor, but folks were able to get a whole lot of therapy just from sharing in the group. And it was something folks could do for themselves once they had access to the curriculum and we invested in training leaders.

Conclusion

All of these ideas require that people who have power and knowledge be willing to share them with people that don’t. There are lots of things that need to happen from the top down to have a more just system — something at the federal level to redistribute our wealth in order to make sure that everyone has access to health care, something at the level of medical organizations and state boards so that highly educated professionals aren’t doing things that community health workers or parish nurses can do, something at the level of hospitals and big insurance companies that pushes more of the money and power towards supporting these smaller, more local things.

I’d love to see HSAs function as a means of distributing money and power downward, giving people more freedom. There are things that HSAs can’t do — again, if you need $50,000 a year in prescriptions to keep you from dying, an HSA is not going to cut it — but what if people could use an HSA for anything a doctor says? If you need to get your ducts cleaned because your kid has asthma, or even if everyone in a neighborhood wants to get together and build a park and pool together their HSAs– that’d be great.

And the bottom-up change is just as important. I don’t want us to lose sight of that. Every individual person, each body in our body politic, has a history and a trajectory to their life. They’ll spend a big chunk of their life at the beginning and the end dependent on others, and they will always be interdependent with others. So any healing in our healthcare system will be a matter of these millions of individuals choosing interdependence with one another, choosing to love and cherish someone else’s body.