Health Care Reform and the Catholic Church

I am not Catholic, though I have friends and family who are, many quite devout. I attended a Catholic school as a non-Catholic for three years growing up in Houston. And my older son was born in a Catholic hospital founded by the Daughters of Charity. I’ve also had friends in health care in one capacity or another who worked for the local Catholic hospital system (which also runs our public hospital in a public/private affiliation) as non-Catholics.

I’ve listened to the recent uproar over the new regulations associated with the implementation of the Affordable Care Act (ACA) — specifically requiring coverage for contraception and sterilization procedures — and I’ve read many of the posts and statements about it. I responded to Fr. Christian’s post on the subject last night and overnight I believe a way to put my thoughts and reactions in perspective gelled in my mind. I’m going to attempt to outline those thoughts in this post.

I want to start by looking at health care in the rest of the world, or at least the industrialized world and many nations we would consider somewhere between third world and first world. Basically, every such nation other than the United States already provides a form of universal access to health care for their citizens. Because we do not, we have one of the worst health care systems in the industrialized world by almost every measure — including cost, access, and results. I know many people suffer the delusion that that’s not the case, but the facts speak for themselves. We spend double per capita than the next country on the list. But we get no benefit from that extra expenditure. Indeed, we sit somewhere toward the bottom in virtually every measure of health care results. Moreover, the expenditures per capita are actually skewed since almost a sixth of our population lacks meaningful access to our health care system. And many of the rest of us are one serious accident or illness away from crushing debt and perhaps losing the job and its insurance that allows us access to the health care system. Most of us are in a more precarious and vulnerable position than we are usually willing to admit. We have access to our health care system currently, but we could lose that access in a heartbeat.

So how does the rest of the world do it? By and large, they employ variations of three basic approaches. In some nations, the government runs the health care system directly. Britain’s National Health Service (NHS) is an example of that approach. The government runs the clinics and hospitals and employes the doctors, nurses, and other health care professionals directly. It’s funded through individual and employer taxes. Other nations employ a single payer model. Canada’s system is an example of that approach. Employers and employees again fund the system through taxes, but the government does not directly operate the facilities or employ the health care professionals. Instead, they operate like a single, large insurer and pay the providers for covered care. Finally, some countries, notably the Swiss, combine a tightly regulated national exchange of non-profit private insurers with a mandate for all citizens to purchase insurance and subsidies for those at the lower end of the economic spectrum. And again, both individuals and employers help fund the system, both directly through premiums and indirectly through taxes.

There are many variations of the above systems, but pretty much every other industrialized nation’s health care system employs one of them. Compare that to the United States. We have a segment of our population, veterans, served by a government operated health care system. The VA operates hospitals, employs health care professionals, and provides health care directly to eligible veterans. Then we have another segment of our population, senior citizens, served by a government-provided insurance program similar to that employed by single payer nations. We call that program Medicare. It’s funded by a payroll tax shared by employees and employers and is the mandatory single payer (though other insurance can be used as a secondary payer to supplement it) for its target population. (Medicaid is a safety net government insurer program as well, though it is administered at the state rather than the national level with predictable confusion and mixed results.)

Then we have had two categories that other industrialized nations do not have. The first, and the linchpin of the health care system for most of us, is employer-provided insurance. That’s essentially a hidden tax on employers in the global economy and it’s highly variable and inconsistent. It’s also unreliable when people can lose their job or otherwise have to change jobs. Moreover, as we deregulated insurance companies in the eighties and nineties, the vast majority of insurance companies converted from non-profit to for-profit status. Medical loss (the ratio of premiums collected actually spent on health care) plummeted from 95% to something on the order of 70% and costs to employees and employers skyrocketed. Fortunately, our regulations do still prohibit insurance policies for large companies from excluding pre-existing conditions. And they have to cover all eligible employees in the pool. So those of us fortunate enough to work for large employers, most of whom have continued to pay the hidden tax to provide insurance to their employees as a necessary cost of doing business in the US, have been somewhat shielded from the most predatory aspects of the for-profit health insurance industry we created in the nineties. Still, no other industrialized nation dumps this burden on its largest employers instead of treating it as one that should be shared by the nation as a whole.

The other huge category that does not exist in other industrialized nations is, of course, the uninsured and the under-insured. Those are all the people who do not qualify for Medicare or Medicaid, who are not eligible for care from the VA, and who do not work for a large employer offering subsidized and affordable health insurance. That’s something on the order of 40 million people uninsured and tens of millions more who are under-insured. And frankly, it’s a deplorable and utterly amoral situation.

The Affordable Care Act (ACA) does not actually reform or rationalize our overall hodge-podge of a system. Personally, I wish it had. I think we would be much better off if we simply picked one of the approaches and applied it across the board. But politically that’s clearly not possible. We’re an irrational nation with irrational politics. Even the process of passing the legislation was a national lampoon. Basically, the Democrats threw in the towel and agreed to adopt the long-standing (as in decades) Republican proposal for health care reform. The long-standing Democratic proposal had been some variation of Medicare for everyone. They basically gave up and decided any reform, even the Republican proposal, was better than no reform. Instead of claiming victory, though, the GOP went ballistic. (And that was one of the more bizarre turns in this whole process.)

But that’s beside the point now. The ACA is what we have and we appear fortunate to have even it, flaws and all. Our only option at this point is to figure out how to make our hodge-podge of a system work more effectively. The core of the ACA uses something similar to the Swiss approach to establish health insurance exchanges for the large group of Americans in the last category — the self-employed, or those employed by a small business. Unlike Switzerland, these exchanges will be state based instead of national. And the insurers will be for-profit rather than non-profit. Both of those are pretty severe negatives. Since Medicare recipients, veterans eligible for VA care, Medicaid recipients, and those employed by large organizations are excluded from the pools of those insured by the exchanges, the overall pool is already smaller. When you further divide it on a state by state basis, the pool of insured, and thus the shared risk, becomes even smaller. Non-profit insurance companies typically operate at a 95% or greater medical loss ratio. So by adding profit margins to the exchanges, we are simply increasing the costs for no added benefit. However, the ACA does at least begin to reform and regulate that private, for-profit insurance industry. Personally, I think prohibiting denial of insurance for pre-existing conditions, rescission, and mandating 80% medical loss levels are woefully inadequate and minimal measures. But they certainly improve what we currently have in this segment of our population.

That’s the background, and it’s only in that context that we can discuss the regulations implementing the ACA and the reaction to those regulations by the Catholic Church. The first thing I want to note is the structure of the ACA itself. As a political necessity, it leaves the large employer provided health care portion of our framework largely untouched. The only thing it does is try to make sure that all citizens, whichever part of our system covers them, have access to the same basic level of health care. That’s essentially all that this regulation does. If the Catholic Church employed no-one but Catholics, perhaps that would be a reason for an exception. (In fact, I believe the regulation provides for such an exception in those institutions that do meet that criteria.) But that’s not the case and, in fact, some of the Catholic institutions, at least, couldn’t continue to function if they had to operate under such a restriction. The hospitals, in particular, have to be able to hire non-Catholics to function.

The next thing I note is that the Catholic Church is a huge global organization with established institutions, including hospitals and schools, around the world. That’s only one facet of the Church, of course, but it is an important one for this discussion. Many of the nations in which they operate those institutions have some form of universal access health system that includes access to contraception and sterilization procedures. As an employer in those nations, the Catholic Church participates in those systems. (At least, I’ve never heard anything to the contrary.) Basically, that places them one step removed. In those countries they don’t directly provide coverage which insures and provides access to such services, but they pay whatever is required of employers into the system which then does provide such access. Since we chose to leave the large employer-based framework in place, in our system we end up with this regulation.

Frankly, I think the Church is making a rather fine distinction. It’s OK to participate as an employer in a national health care system that provides access to those procedures, but it’s not OK to provide the health insurance policy directly as a large employer in our system under the ACA. That’s basically the way I perceive the position of the Church on this issue. The regulation doesn’t require that the Church provide contraception or conduct sterilization procedures. It simply requires that, as a large employer, it provide its employees access to health insurance that does cover them, leaving use of that part of their coverage to the individual conscience of the employee.

But set that aside. If it’s truly such a matter of conscience for the Church, then it has the option under the ACA to stop providing health insurance to its employees in 2014. They will then purchase health insurance from the state exchanges established by the ACA. And the Church will pay a penalty/tax for those employees who require subsidies. (There are various ways of calculating it.) That will place the Church at the same remove from the coverage as they are in some of the other industrialized nations. As far as I can tell, that would resolve its current moral crisis on the matter. Of course, if the Church chooses to take that step, it could make them less attractive as an employer, which could have a negative impact on its ability to perform the central mission of its various institutions. But if it’s such an important moral stand, I suppose that’s a price they have to be willing to pay. I agree it would be more equitable if we had one uniform system in which all employers and citizens participated, but we aren’t going to get such a system. The ACA is what we have and we were lucky to even get it.

Personally, I don’t share the Church’s beliefs on contraception or sterilization, but I do try to respect them, especially in the few Catholics I know who actively practice them. (And honestly I know more Catholics who don’t than do.) However, in this case, I think they are making a mountain out of a molehill. And it’s probably because of my two decades of association with American evangelicals, but I tend to get uncomfortable when Christian groups start clamoring about their “rights.” The heart of Christianity seems to me to include sacrifice, love, self-denial, and service in pursuit of union with Christ more than it does individual or organizational rights. I favor individual freedom, of course. We tend to end up in bondage to sin and death, but God offers us true freedom in Christ. Individual civil liberties treat us with something of the same dignity that God does. But Christianity isn’t much about “rights.” Certainly Christ did not assert his rights.

As I wrote on Fr. Christian’s blog, it will ultimately be up to the courts to decide the fate of the regulation. That’s their role. But the way the regulation is shaped, it may well stand up to the strict scrutiny standard required in such situations. It’s hardly a given that it won’t. Besides, if the government didn’t believe they had a good case for the regulation, they wouldn’t have proposed it. It’s not a black and white case and I can’t predict where the courts will land. I don’t think anyone can.

Does anyone have any other thoughts or think I missed anything? I tried to be pretty comprehensive in this post since it’s a complex issue, but it’s so complex that it’s hard to catch every nuance.

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  1. Posted February 3, 2012 at 11:46 am | Permalink

    Thanks again for your thoughtful response Scott. I will need to think about all that you have written before writing a more thorough response. I do appreciate your taking the time to present the issue as it is, rather than simply sticking to the sound byte versions that we seem to be stuck on at the moment.

  2. Posted February 3, 2012 at 2:21 pm | Permalink

    Akismet thought your comment was spam for some reason. Found it and dug it out. I see it as a complex issue.

    Oh, and reading my post, I realized there are reasons the government would have proposed the regulation even if they thought the courts would overturn it. For example, if they felt they needed to appease a significant portion of their base, they might propose the regulation for political reasons even if they ultimately believed it would be reversed. Then, at least, they would have tried. (Cynical, but politics is often a cynical business.)

    Even so, it’s not clear to me that the regulation the way it is crafted fails to meet the legal standard. But then, I’m neither a lawyer nor a judge, so I’m sure I don’t grasp all the ins and outs of legal interpretation on the issue.

  3. Posted February 3, 2012 at 2:40 pm | Permalink

    Yes! Thank you for pointing out that this was what the republicans would allow. A Universal option is so much better. After living in Canada for over 3 years, I am hoping to write a post on the differences between the 2 systems soon.

  4. Posted February 3, 2012 at 3:30 pm | Permalink

    Once it’s fully in effect, the ACA will at least get us closer to universal coverage than we’ve ever been. Personally, I think only allowing non-profit insurance companies into the exchanges and including a government option in the exchanges would improve it a lot, even though we would still have a hodge podge system.

  5. Posted February 3, 2012 at 4:26 pm | Permalink

    Thanks for pulling my comment out of the muck. I had intended to post a much more substantial comment here, but I am worn out from talking about it online since posting Bishop Stika’s letter. Instead I will simply make a few comments.

    First, I agree with you Scott that had our government found a better solution by either regulating the insurance companies, or adopting a more comprehensive overhaul of our system, we would be in better shape. Honesty though, I am not sure they are capable of doing so. My read is that the U.S. Bishops are not in opposition to trying to find ways to provide affordable health care for Americans. We do run hospitals after all.

    There is a disagreement in our country as to what is the baseline of health care and what things ought to be provided and what ought not. I do not believe that the Church will ever choose to recognize things such as sterilization and abortifacients as anything but morally reprehensible and will balk at having to even provide insurance coverage that employees can purchase.

    If the courts uphold this decision my guess would be that the bishops will either refuse to comply, and most likely end up being fined as you have mentioned and as a result we will probably lose employees and/or valuable services to Americans (not just Catholic Americans I might add), or they will close hospitals, schools, etc. (also not a good outcome)

    You can add me to your cynics lists as I would agree that the current administration may have done this exactly as a way of rallying its base as that would happen even if they lose in court.

    Anyway, it is always a pleasure to talk with you here, even when we don’t always agree. But then again, who does?

  6. Posted February 3, 2012 at 9:56 pm | Permalink

    Thanks, I appreciate the opportunity to discuss and think through things without the hyperbole, Fr. Christian.

    I also doubt our government is capable of doing a better job on health care reform. That’s why I’m committed to doing what I can to make the ACA, inadequate as it, work as best it can. Not sure what I can contribute, but this debate has been going on most of my life with no progress as our health care situation has gotten steadily worse every year. Any step forward rather than backward is one I want to support.

    I went back to the actual rule since I had heard and read so much about it I had forgotten what it actually covered. (The actual rule was initially released back in August. The recent addition was the specific scope of the religious exemption.) The actual rule can be somewhat difficult to find. Most of what you’ll find online is people talking about the rule, but not the rule itself. For those who prefer to read directly from the source, the rule is here:

    First, the rule covers preventive care for women and contraceptives approved by the FDA are included as preventive care. It does not cover sterilizations or actual abortifacients. Yes, emergency contraception (the so-called morning after pill) is covered. But that’s not an abortifacient. Moreover, that’s not as black and white even in Catholic doctrine and practice as it appears. Catholic rules currently allow Catholic hospitals to provide rape victims emergency contraception if tests do not indicate that conception has already occurred. Locally, Seton has a policy in place for that practice.

    In my mind, then, the question really becomes whether or not Catholic institutions will provide their non-Catholic (and possibly non-Christian) female employees the option to select a health insurance policy that covers contraception or not. That’s a much more narrow question than the way I hear typically portrayed since the decision.

    From the discussion of the rule, it also appears that some states already require Catholic institutions like hospitals and schools to provide health insurance that includes contraceptive coverage. The HHS rule under the authority of the ACA simply expands those to a national rule. I hadn’t heard that wrinkle in the various statements by Catholic Bishops. Here’s the exact language.

    “Consistent with most States that have such exemptions, as described below, the amended regulations specify that, for purposes of this policy, a religious employer is one that: (1) Has the inculcation of religious values as its purpose; (2) primarily employs persons who share its religious tenets; (3) primarily serves persons who share its religious tenets; and (4) is a non-profit organization under section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii) of the Code. Section 6033(a)(3)(A)(i) and (iii) refer to churches, their integrated auxiliaries, and conventions or associations of churches, as well as to the exclusively religious activities of any religious order. The definition of religious employer, as set forth in the amended regulations, is based on existing definitions used by most States that exempt certain religious employers from having to comply with State law requirements to cover contraceptive services.”

    Frankly, I don’t have a problem with that definition. Of course, I’ve never had a problem with contraception. And after a miscarriage and then my wife’s diagnosis with an autoimmune disease, we decided it was time for me to have a vasectomy — that we were past our years when babies were an option. We certainly don’t consider that decision “morally reprehensible.” (And that’s more personal information than I usually ever share. In this instance, though, I believe it’s warranted.) Probably like many Americans, I find the Catholic objection difficult to understand.

    But the rule is even more narrow than I had recalled and which most comments about it indicate.

    My mother is the principal of a mission Catholic school (meaning most of the students aren’t Catholic) in the very depressed Pine Bluff area. I don’t question the value of Catholic hospitals, universities, and schools in our society. It would be a shame if the Bishops decided to close them. But I lean much more in favor of the rule than against it.

    And hardly anyone always agrees. Heck, my wife and I disagree on a ton of things. What’s important is that we can talk about our disagreements without the conversation degenerating into name-calling or worse.

    I really appreciate “meeting” you online. And since you come to the Austin area from time to time, perhaps we can actually meet in person one day.


  7. Doug Indeap
    Posted February 5, 2012 at 4:26 pm | Permalink

    Notwithstanding wild-eyed cries to the contrary, THE HEALTH CARE LAW DOES NOT FORCE EMPLOYERS TO ACT CONTRARY TO THEIR BELIEFS–unless one supposes the employers’ religion forbids even the payment of money to the government (all of us should enjoy such a religion).

    Questions about the government requiring or prohibiting something that conflicts with someone’s faith are entirely real, but not new. The courts have occasionally confronted such issues and have generally ruled that the government cannot enact laws specifically aimed at a particular religion (which would be regarded a constraint on religious liberty contrary to the First Amendment), but can enact laws generally applicable to everyone or at least broad classes of people (e.g., laws concerning pollution, contracts, fraud, negligence, crimes, discrimination, employment, etc.) and can require everyone, including those who may object on religious grounds, to abide by them. Were it otherwise and people could opt out of this or that law with the excuse that their religion requires or allows it, the government and the rule of law could hardly operate. When moral binds for individuals can be anticipated, provisions may be added to laws affording some relief to conscientious objectors.

    Here, there is no need for such an exemption, since no employer is being “forced,” as some commentators rage, to act contrary to his or her belief. In keeping with the law, those with conscientious objections to providing their employees with qualifying health plans may decline to provide their employees with any health plans and pay an assessment instead or, alternatively, provide their employees with health plans that do not qualify (e.g., ones without provisions they deem objectionable) and pay lower assessments.

    The employers may not like paying the assessments or what the government will do with the money it receives. But that is not a moral dilemma of the sort supposed by many commentators, but rather a garden-variety gripe common to most taxpayers–who don’t much like paying taxes and who object to this or that action of the government. That is hardly call for a special “exemption” from the law. Should each of us feel free to deduct from our taxes the portion that we figure would be spent on those actions (e.g., wars, health care, whatever) each of us opposes?

  8. Posted February 7, 2012 at 6:57 pm | Permalink

    That was my point, as well as, in my subsequent post on the topic the point that it’s pretty much limited to Catholic hospitals and universities and in many states they are already required to offer this sort of coverage.

  9. Posted February 7, 2012 at 7:04 pm | Permalink

    And that both institutions employ non-Catholics and make much of their money by selling services to the general public. My wife was just an inpatient in a Catholic hospital this past year after she developed sepsis following an outpatient procedure at that hospital. It certainly didn’t cost any less than any other hospital. They collected every penny from our insurance company and from us. Yes, they do offer some charity care, but modern hospitals are big business more than anything like a charity.

    At least the Seton hospital system is a non-profit, unlike the St. David/Columbia HCA for-profit behemoth that is our other alternative. But I don’t think that alone gives them a pass from offering their employees health insurance policies that provide the same coverage other businesses are required to provide for prescription contraceptives for women.

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