The health care system in the United States needs rehabilitation. On that, politicians on both sides of the aisle agree. With costs rising rapidly and consuming a growing share of the economy, and with millions of people unable to qualify for or afford the care they need, the current system can’t continue as is, reform advocates say.
But how should it be fixed? For the better part of the past year, Congress has been bitterly debating overhaul options. In November, the House of Representatives passed a bill that would, among other things, set up a government-run insurance plan and bar insurance companies from excluding people with pre-existing conditions. Heading in to the Christmas break, the Senate was still attempting to settle on its version of a reform bill.
For a look at the issue, Biola Magazine sat down with Biola professor Scott Rae, who has served as an ethics consultant for several hospitals over the past two decades, authored several works on bioethics and lectured on the subject on Capitol Hill.
Scott, there are an estimated 46 million people in America who are uninsured. From a Christian perspective, what needs to be done about this?
I think the first response should be to make sure that the number is correct. That’s a number that is widely thrown around, and I think it’s misleading. It assumes that there are 46 million people who want to be insured, can’t afford to be insured and are one major illness away from bankruptcy. I don’t think that’s quite true. Included in that group are people who choose not to buy insurance — such as young people who don’t want to pay for insurance, and probably don’t need to, except for catastrophes. Others are in between jobs, so they are temporarily without insurance. But they have been insured in the past and will be in the future. And then there is a group of people who are eligible for Medicare or Medicaid and have never applied for it. There are several million of those who are eligible and just don’t take advantage of it. From what I’ve heard, the number of people who want insurance and don’t have it because they can’t afford it is somewhere in the neighborhood of 8 million to 10 million — which is a sizeable number still, but it’s not quite as alarming.
For those who want and can’t get insurance, what’s the appropriate Christian response?
Our obligation to those folks from a Christian worldview is to ensure that they get the treatment they need for illness and to ensure that it doesn’t wipe them out to do it. Most people who are uninsured can get treatment for acute things; it’s against the law for emergency rooms to turn people away. But that’s just for acute things. So if I don’t have insurance and I get cancer, I’m stuck. And the only way I can take advantage of Medicaid is to spend down all of my assets first, which basically bankrupts me before the fact, rather than after it. So we probably ought to make some distinction between being uninsured and not having access to treatment. Practically, those can be the same things at times, but those are not necessarily the same things.
How do you think the system should be reformed?
Well, first of all, I’m not in favor of the government taking it over. In my view, that’s a cure that’s worse than the disease. I think that there are some fairly simple things that can be done that can make a big difference. First, there is no reason why insurance companies shouldn’t be allowed to compete across state lines. That would go a ways toward bringing the cost of insurance down. Second, the law should change so that all medical savings accounts roll over year after year — allowing for a long-term savings account rather than an annual account. There are some states where they do allow that, but we need to make that universal across the country. Third, I think we need to reconfigure how we view insurance. I don’t expect my auto insurance to pay for oil changes and tire rotations and alignment. But I do expect my auto insurance to pay for major accidents, acts of God, that kind of thing.
The combination of medical savings accounts that roll over and competition for higher-deductible insurance that would protect people from catastrophes would go a long way toward controlling the costs. Part of the thing that keeps the costs inflated is that somebody else is paying for it. I would do all sorts of things for my car if somebody else was paying for it, but I don’t because I’m paying for it. I think taking the third-party payer out of it to some degree would bring incentives back to individuals to ration care for themselves. The other thing — and this is not a simple thing — but the tort system where people can basically win the lottery through malpractice lawsuits has to be changed. Doctors won’t stop practicing defensive medicine until that’s changed. I would favor some sort of cap on malpractice settlements.
What do you think about the House and Senate bills that have been evolving over the past several months? Are there elements that you’ve been paying special attention to?
Both bills are way too long, unnecessarily cumbersome and inject government into health care decision making far too much. I don’t think the “death squad” language is quite accurate, but if government is running health care, there will be incentives on physicians to cut costs.
More than there are right now?
Much more than there are now. What those exactly will look like is not quite clear. But that’s the part that troubles me: What might happen to the patient-physician relationship? In the system that is emerging in both the House and Senate versions, our health care system is being asked to pursue goals that are simultaneously incompatible. We’re asking the system to provide the highest quality care and innovation with full access to everyone who has need while keeping costs low and providing freedom of choice. You can’t have all of those at the same time. You have to make choices. We’ve chosen — or defaulted — to maintain quality of care and, to some degree, freedom of choice. But our costs are soaring. And access is not universal. Now, you may not like the choices that we’ve defaulted into. But what I’ve been waiting for in the discussion of these bills is for someone to say, “We have to rank these priorities.”
So everyone is just too idealistic?
Everybody is telling us that we can have it all. But neither the House nor the Senate bill is going to control the costs. My suggestion for the government option would be to fix Medicare first before you take on the whole thing. Medicare will probably be bankrupt by the time I retire. To say that we’ll just clean up the waste and the abuse and the fraud — certainly there is room for progress to be made on that. But that part is a drop in the bucket compared to the demographic landslide that is coming, both in terms of the baby boomers aging and the illegal immigrants requiring care. That’s going to swamp the system. We have to make choices. We may decide that we’re going to have universal access and the highest quality care, but we’re going to limit who you can see, how often you can see them and the procedures you can have. But the costs are going to soar with that. To maintain the highest quality and access for everyone is just a very costly proposition. There’s just no other way around that.
There are some who point to Europe as a better model.
In the U.K., they have made a different set of choices. I personally would not endorse their system, but at least they have made their choices a little bit more deliberately. Their costs are down, but they have virtually no freedom of choice. The care is not what it is here, but they have achieved access. The real costs come in terms of time: In England or Canada, you may wait months for an appointment. Let’s say you need a hip replacement. You may wait six months for that. I think that’s part of the reason why — despite what Michael Moore says — people don’t go from the United States into Canada or Cuba to get their health care. People come here when they want the highest quality. It would be tragic if we chose a system that stifled innovation. I don’t know how you stay innovative unless the private sector is the predominant engine that drives you.
Do you see anything that you like in the proposed legislation?
Well, it will be a good thing to standardize and to make more uniform what treatments will yield the best outcomes. If we can make progress on that, that will be great. And I think giving every one who needs care the access to it is clearly a good thing. Not just for a matter of justice, but also for a matter of public health. I mean, that’s the argument for why illegal immigrants ought to be covered. It’s a public health nightmare if they’re not. So, those, I think, are good things. And that will probably prevent a lot of the immigrant communities and other uninsured from getting their health care in probably the most costly, least efficient way, which is through emergency rooms. We couldn’t have designed it any worse than for people to go there. The law is the way that it is for good reason, but the unintended consequence is the large number of people using emergency rooms as their primary care physician, and it’s just terribly inefficient.
Abortion has been an especially controversial component of the reform debate. The House version has language that prevents federal funding from being used for abortions. Are you confident that this will remain the case?
No. But the states already fund it, so preventing federal funding of abortions may be more of a symbolic victory than a substantive one. Uninsured women in California will still get their abortions funded; it just won’t be by the federal government. I mean, there’s probably wisdom in making sure that federal dollars don’t go to that. But I’m not sure that really helps the plight of the unborn all that much.
Scott Rae is chair of the philosophy of religion and ethics department at Biola’s Talbot School of Theology. He holds a Ph.D. in social ethics from the University of Southern California.