Whom would Jesus cover? A biblical, ethical lens for the contemporary American health care debate.

• Author: Baker, Jeffrey R.

1. INTRODUCTION II. THE CURRENT STATE OF AMERICAN HEALTH CARE FOR THE UNINSURED A. Private Insurance B. Existing Public Coverage 1. Medicare 2. Medicaid 3. SCHIP 4. Veterans Administration C. Demographics of the Uninsured 1. Adults without Children and the Uninsured Generally 2. Children and Their Parents D. The Effect on the Health of the Uninsured III. IS ACCESS TO HEALTH CARE FOR UNINSURED AMERICANS A MORAL ISSUE THAT SHOULD SPUR REDRESS BY CHRISTIANS? A. The Sick and Poor B. Justice C. Community Burdens IV. IF ACCESS TO HEALTH CARE FOR UNINSURED AMERICANS IS A MORAL ISSUE, WHAT SHOULD BE THE BIBLICAL, ETHICAL RESPONSE IN NATIONAL HEALTH CARE POLICY? A. Philosophy of Government and the Religious Community B. Policy Considerations V. CONCLUSION I. INTRODUCTION

   The United States spends more per capita on health care than any other developed nation by orders of magnitude, yet nearly 47 million people, including nearly 9 million children, do not have health insurance. (2) The vast majority of uninsured Americans are working poor people who make too much to be eligible for current public coverage and who make too little to afford private insurance or exorbitant private care. Despite a "safety net" of public and private charity, this lack of coverage causes unmistakable disparities in care, health, medical outcomes, quality of life and life expectancy.

   Biblically, two questions spring from this "gap" in care. First, is access to health care for our uninsured neighbors a moral issue that should spur redress by a conscientious community? Second, if so, what should be the response in national health care policy? As demonstrated here, access to health care in America is a matter of wealth. In the light of scripture, this situation implicates at least two broad, moral imperatives: the call to care for the poor and sick and the aspiration toward justice regardless of social and economic status.

   Christians, individually and in congregation, should respond with private care and public policy, making judicious use of democratic voices in the government, the law and the marketplace. Christians participate as voters and policy makers, as providers and consumers, so Christians have a responsibility to seek just, wise, efficient and excellent care for our sick and poor neighbors. If the goal is to provide equitable access to health care for all, we must struggle with attendant forces of federalism, individual autonomy, the free market, profit-motives, the pace of technological innovation, timely and beneficial service, soaring costs, service rationing, the demands of taxpayers, and the economics of distributive risk.

   This paper attempts a view of the contemporary health care debate in America though the prism of Biblical scripture and proposes that people of faith should recognize the current state of the American health care system as a moral crisis of justice and charity. First, I provide a survey of the current state of American health care for the uninsured, describing the demographic and economic circumstances of the uninsured and the resources available to them when they need medical care. Second, I ask whether, in light of scripture, this state of affairs presents a moral question that should drive our communities to action, and I answer in the affirmative. Third, I ask, if access to health care for uninsured Americans is a moral issue, what should be the ethical response in national health care policy, and I ask whether progressive use of the State is an appropriate option for Christians in light of apostolic teaching on government and the religious community. Observing the community of Christians described in the New Testament, I suggest that in the American republic, Christians rightly should consider the use of public, governmental policy to address an unjust health care system.

2. THE CURRENT STATE OF AMERICAN HEALTH CARE FOR THE UNINSURED

   The United States spends more per capita on health care than any other nation. (3) According to the Kaiser Family Foundation, in 2003 the United States spent $5,711 per capita in total health care expenditures. (4) The next highest spender in 2003 was Luxembourg with $4,611 per capita in total health care expenditures. Canada spent $2,998 per capita, and the United Kingdom spent $2,317 per capita.

   In 2003, health care accounted for 15.2% of the United States' gross domestic product, the highest percentage of GDP of any comparable nation-state. (5) In 2005, total health care expenditures in the United States accounted for 15.3% of GDP; the next highest reported by the CDC was Switzerland at 11.6%. (6) This percentage of GDP grew by 6.4% from 1990 to 2003, a faster rate of growth than any other developed nation. By comparison, health care comprises 7.8% of the United Kingdom's GDP, and it grew by 1.8% over the same period of time.

   Health care and related subsidy or entitlement programs account for about 42% of the federal budget. (7) Medicare, Medicaid and SCHIP accounted for 21% of the federal budget in 2007, about $572 billion. (8) Medicare spending consumed two-thirds of that bill, providing health care coverage to more than 40 million people over 65 or with disabilities. (9)

   These public programs amount to about 45% of total health care expenditures in the United States. (10) Private health insurance is the largest single source of health care spending, accounting for about 36% of health spending in 2005. (11) In 2006, among Americans under age 65, 16.8% were uninsured, and 66.5% were insured through private carriers. Among children under 18, 9.3% were uninsured. About 60% of children were insured privately, and about 32% were insured by public health coverage. (12)

   Remarkably, health care spending has exceeded economic growth for at least the last 30 years. The United States' gross domestic product rose by 7.4% annually from 1970 to 2005, but health care spending rose by 9.8% annually over the same period. (13) The cost for private, employer-based health insurance premiums have risen by 78% since 2001. (14)

   Despite these massive costs and expenditures, approximately 46 million Americans, including 8-9 million children do not have health insurance of any kind. Although the United States massively outspends the nearest developed nation on health care, 16% of the population lacks affordable, predictable access to medical care.

   Dr. Lawrence Brown in the New England Journal of Medicine observes that the American health care system actually is a non-system, a patchwork of uncoordinated, often adversarial, interests and entities plumbing the patients' marketplace:

   [T]he U.S health care system consists not of two sectors (public and private) but three, one of which, the safety net, rarely gets proper attention and is poorly understood. The safety net encompasses public and voluntary hospitals, community health centers, public health clinics, free clinics and services donated by private physicians. Configurations of safety-net providers vary markedly among communities, as does their financing, a shifting patchwork of funds from Medicaid, the State Children's Health Insurance Program (SCHIP), the federal disproportionate share program, tax levies, foundation grants, state appropriations, commercial payers, and other sources. These institutions often live on the financial edge, but with 11th-hour infusions, they mostly manage to stay afloat. This fact is of paramount importance, for these providers also extend a safety net for the legitimacy of the health care system as a whole. That Americans who lack coverage "still get care," as President Bush recently declared, drains moral urgency from the health care reform enterprise. This self-congratulatory proposition is half-true: many of the uninsured can make an appointment or drop in for care at a safety-net venue. Should they become seriously ill, however, and need referrals to specialists, inpatient care, high-tech procedures, or a regimen of prescription drugs, access becomes unpredictable and spotty, an ugly exercise in rationing. (15) These pieces do not create an evenly distributed, economically rational system where patients engage providers with any legitimate choice or bargaining power. Instead, geography and affluence drive access to medical services, and endemic incentives in medical education, state government, industry and research create pockets saturated with luxurious medical care and expansive swathes lacking basic services.

   In broad terms, American patients fall into three categories: the privately insured, the publically insured and the uninsured. For those who enjoy private insurance, American health care is among the best, if not the best, in the world. For those who receive public coverage, they may face limited options and lesser care than the "gold standard," but they receive regular access to adequate care. For the uninsured, access to medical care often depends on inconstant charity, ad hoc improvisation, self-imposed rationing or the imposition of immense financial burden, and this lack of access causes poorer care and worse outcomes. (16)

   1. Private Insurance

      Employer-provided health insurance is the overwhelming source of medical insurance, covering about 90% of privately insured people under age 65. (17) Sixty percent of all employers offered health care benefits in 2007. (18) The likelihood of receiving medical insurance as an employment benefit depends greatly on the size and age of the business. (19)

      The average cost of premiums for employer-provided health insurance for families was $12,106 in 2007, including worker and employer contributions; for coverage of singles, the average annual premium is $4,479. (20) Since 2001, these costs have increased by 78%. (21)

      On average, workers contribute 16% of the premium for single coverage and 28% of the premium for family coverage. (22) The average contribution by employees for single coverage is $58 per month, and employees contribute $273 per month...