Health Care: A Matter of Soul

“We have 900 billing clerks at Duke. I’m not sure we have a nurse per bed, but we have a billing clerk per bed… it’s obscene.”
Health economist Dr. Uwe E. Reinhardt, describing the Duke Medical System

Yesterday was the start of open enrollment for health care insurance under the Affordable Care Act.

This weekend, Physicians for a National Health Program is holding its annual meeting in New Orleans to consider this year’s theme: “Seeking Health Equity: Politics, Racism, and the Fight for Single Payer.”

In Congress, majority leaders are planning major investment of time and money in investigations into every aspect of creation and implementation of the ACA, and looking for ways to vote, once again, on repeal of all or portions of the act.

And last week  the Supreme Court agreed to hear the case of  King v. Burwell, a case challenging the decision of  the Fourth Circuit court to uphold an IRS rule regarding health insurance subsidies.

I confess, I’ve found the animosity toward Obamacare hard to follow, especially as expressed by Christians. Christians have historically been the ones most insistant on helping the sick, often at great cost to themselves. I posted about this several years ago: 

When plague devastated the 3rd century world, Christians cared for the sick, gathered and took into their homes people thrown into the street by family members fearful of becoming infected.

When Romans and others threw their deformed, surplus, unwanted babies on trash piles or into rivers, Christians gathered them up, fed them, cared for them as their own.

John Chrysostom taught, "If you see anyone in affliction, do not be curious to enquire further... [the needy person] is God's, whether he is a heathen or a Jew; since even if he is an unbeliever, still he needs help."

Even now, with the frightening scourge of Ebola, Christians are essential participants in care of the sick. A Sixty Minutes report on the Ebola outbreak in Liberia made no mention of the Christian faith, but showed the local health workers gathering strength and courage during their breaks by singing hymns together. Two doctors flown back to the US for Ebola treatment last summer were missionaries: Dr. Kent Brantley and Nancy Writebol, both serving with Samaritan’s Purse.

The Good Samaritan, William Henry Margetson,
London, ca 1900

Faithful Christians have always taken to heart the challenging parable of sheep and goats in Matthew 25. The sheep and goats aren’t divided by theological position, experiential worship, whether they’ve prayed or said the correct thing, followed the right leader. In Jesus' parable, they’re judged by their care of those in need: the poor, the hungry, those in prison. The sick. 

‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’

“Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink?  When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?’

“The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’ 

Care of the sick is not a political issue, although both parties try to  make it one.

It’s a moral issue, with practical consequences in the lives of those without access to care, and heavy financial implications in a system where the only option for the uninsured sick is to show up in emergency rooms.

Before the Affordable Care Act was passed, there were nearly 50 million uninsured Americans. According to Health and Human Services Secretary Kathleen Sebelius: 

More than eight million Americans signed up through the Marketplace, exceeding expectations and demonstrating brisk demand for quality, affordable coverage. . . In addition, over 4.8 million more people have been covered by states through Medicaid and CHIP programs, around 3 million more Americans under 26 are covered under their parents’ plans, and recent estimates show that an additional 5 million people have purchased coverage outside of the Marketplace in Affordable Care Act-compliant plans. 

That’s more than 20 million people who now have access to health care. To me, that looks like a win.

Unfortunately, some of the people most in need of care are still unable to receive it. An important 

provision of the ACA is expansion of Medicaid eligibility to individuals with incomes at or below 138 percent of poverty ($27,310 for a family of three). The expansion was intended to be national, but the June 2012 Supreme Court ruling opened the door for states to opt out. As a result, 23 states have refused to expand their programs, leaving the  median income limit for parents in 2014 at 50% of the poverty rate, an annual income of $9,893 a year for a family of three, with childless adults completely ineligible. As a result, four million adults fall into a “coverage gap”,  with incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits. The majority of those are the working poor, working minimum wage jobs or trying to get by with part-time employment.

The ACA, Obamacare, was a compromise cobbled together in an attempt to care for the uninsured while keeping the insurance industry happy.

From every indicator I can see, it’s improved things for many: young adults struggling to find a permanent job with benefits, peoplewith pre-existing conditions who before would have faced bankruptcy, families of the working poor in states that have followed the Medicaid expansion plan.

And it's made it illegal to charge women more for health insurance.

But I’m still puzzled at the strong opposition to single-payer health care. To me, it’s a no-brainer. 

Why should my health care dollars pay the salary of the insurance gatekeeper who decides whether my doctor’s prescription is eligible? 

Why should my doctor spend hours every week answering to non-medical personnel eager to boost profits by denying care?

Why should a financial executive behind a desk in Hartford have more say over who needs a hospital than the doctor in the room with the patient?

A 2006 survey examined the amount of time physicians spend on billing and insurance-related paperwork in the United States and Canada (a single-payer system): 

20.6 hours of nurse time per physician in the United States versus 2.5 hours in Canada; 53.1 hours per week of clerical time in the United States versus 15.9 hours in Canada; and 3.1 hours per week of senior administrators’ time in the United States versus 0.5 hours in Canada. 

Economic analysis has repeatedly shown that a single-payer plan would slash administrative costs, allow greater focus on preventive care, free workers and employers from insurance-related staffing decisions, and save billions in health care dollars. 

I’m thankful for doctors. And for nurses, optometrists, dentists, therapists of every kind.

I’m thankful for those who spend their lives training, serving, looking for ways to bring health to bones, brains, eyes, ears, teeth.

I’m thankful for the Affordable Care Act, and the difference it’s made in lives of people I know, and don’t know.

I'm thankful for those willing to face political heat and accusations of “socialist!” to advocate for more and better care for those who are still without.

I’ll be praying this weekend for the doctors gathering to look for ways to advance the idea of a single-payer system. Their website is a revelation of simple good sense and compassion.

“The issue of universal coverage is not a matter of economics. Little more than 1% of GDP assigned to health could cover all. It is a matter of soul.”  Uwe Reinhardt

As always, your thoughts and comments are welcome. Click on the   __ comments link below to post.

Silent Sentinels

If I had lived a hundred years ago, would I have been one of the silent sentinels, the women who stood outside the White House, day and night, from January 1917 to June 1919, advocating for the right to vote?

Would I have risked public humiliation to march with the suffragettes? Or would I have stayed home, even more silent, waiting for others to win the freedom I wanted?

Rotate the question just a little: if I lived in Damascus, now, would I be actively protesting Assad’s tyranny, or quietly waiting for things to blow over?

If I lived in Cairo, would I be finding my way to Tehrir Square?

We look back with rosy glasses to our own Declaration of Independence without much thought about the crisis of conscience faced by those called on to sign it. Robert Livingston, member of the five-man committee that met to craft its wording, never signed. Other delegates took their time adding their names; at least three refused to sign.

We forget that there were Loyalists, or Tories, maybe as many as one in five colonists, who sided with the status quo. And we forget that there were many who were neutral – hoping the conflict would pass them by, not sure independence was worth the cost.

I approach Independence Day with a sense of uneasiness. In part, I wonder if the holiday celebrates war, and wonder: if Canada, Australia, New Zealand, India, other colonies gained independence without war, would the same have been possible if the American colonists had exercised greater restraint, greater patience, more creative means of persuasion?

But my uneasiness also stems from a sense of unearned privilege: what have I ever done to deserve the freedoms denied to so many? And what have I done to use those freedoms wisely, or to see them extended to those without?

If freedom is a gift, it’s a gift with a cost, and a weight of responsibility.

What happens when too many of us take our freedoms for granted, or exercise our rights without adequate attention?

The Supreme Court decision last week on the Affordable Care Act threw the question into high relief.

Some people I know and respect listened to the news, then turned quickly to others things. “I’m not interested.” “Politics bores me.” These are people who care deeply about the needs of the world, who give time, money, prayer for those in trouble. These friends quickly dismiss the idea that a piece of legislation could be part of caring for human need, or that concern for others should prompt attention to political process. To them, the actions of government are irrelevant.

Others I know saw the court’s decision as a victory in the war on women. I understand why they use the term, but it seems to me that once we start thinking in terms of “war,” we are all losers. War breeds violence, hatred, inevitable loss. Are there better ways to carry on the discussion?

Yet others in my circle of friends consider the Affordable Care Act a dangerous move toward socialism, think President Obama is destroying the country, and are focusing great energy on seeing him defeated in November. People who have never invested much time in the political process are energized and angry. The more I listen, the more I wonder: What’s fueling the anger?

From what I can see, the Affordable Care Act is an imperfect attempt to resolve a wide mix of troubling problems: insurance companies that pocket too much profit and drive our health expenses ever higher; individuals with no primary care who use emergency rooms as their sole source of medical attention; a growing list of “existing conditions” that make adequate coverage impossible; families bankrupted when a parent loses both job and insurance and health expenses swallow a lifetime of savings. And yes, a system that costs women more in premiums, and sometimes denies women the legitimate care they need.

M Turner Obamacare

From what I can tell, the ACA is already benefitting many young adults, caught in part-time jobs while they look for full-time work that will offer health benefits and a salary adequate to pay back college loans. It’s benefitting friends who have struggled with existing conditions, and will eventually make preventive care possible for friends who currently postpone appointments and stop taking medications because they can’t afford them.

The issue for me, though, isn’t so much this particular legislation, it’s the conversation surrounding it. Are those who disagree with me on specific points evil monsters, or well-intentioned people who see things differently? Is Barack Obama an evil man? Is he trying to destroy America?

When a leader – on any side – advocates a policy or position I disagree with, am I free to speak of him as the enemy? Am I free to respond with anger? Am I justified in listening to public diatribes that ridicule, disrespect, misrepresent?

I understand those who run from any political dialogue because they’re tired of the angry rhetoric, or bored by the unstoppable harangues.

And I understand those who grab the party platform, endorse the party favorites, and dismiss all opposition.

But as a Christian, a follower of Christ, steward of gifts I’ve been given, including the right to vote, to speak, to investigate, I find myself caught in a troubling conundrum:

I believe I’m to honor and respect those in authority, even when I disagree with them.

I’m also to look for the best in others, to want their good, to rejoice in the truth.

I’m to listen more than I speak, to seek and model wisdom. I’m to advocate for the poor, earnestly desire justice, demonstrate humility.

And I’m called, as all followers of Christ are called, to be a peacemaker. Do I interpret that globally, advocating for an end to war? Nationally, advocating for peace between parties? Personally, looking for points of agreement with individuals whose opinions challenge mine? All three? Is that possible?

Here are a few questions I take seriously, and will be puzzling and praying about as we near the next election:

What is God for? I hear, maybe too often, about what He's against. But spread our priorities out in front of His word: which ones are worth pursuing? Which aren’t?

Should government be concerned with private morality (sexual expression, family composition), or with public morality (issues of equality, just policy, equitable economy)? Both? Neither? Is it possible to separate the two?

Is the best government the smallest? What are the proper roles of government? What happens when those roles are abandoned?

What is my own responsibility? Is it enough to be a good parent, wife, neighbor, here, in my own small part of the world, or am I called to use the privileges I’ve been given to advocate for others less able to advocate for themselves?

Who stands for the common good? Is it okay to pursue policies that benefit me, my own group, my own demographic, or am I called to affirm policies that benefit all of us – not just Americans, not just Christians, but all nations, all creation?

A Chinese proverb warns: "Unless we change direction, we are likely to end up where we are headed."

Or, as a wise friend of mine recently said "Unless something changes, nothing changes."

Are we headed in the right direction? As a country? As individual followers of Christ?

And if not, what do I need to change in my own life, in my own conversations, actions, expectations?

And what will that change cost?

lines for first Tunisian democratic election, October 201

This is the first in a series about faith and politics: What's Your Platform?

Please join the conversation. Your thoughts and experiences in this are welcome. Look for the "__ comments" link below to leave your comments.