With Liberty and Justice for All

Note: May I acknowledge my belief (and bias), based on my life experience, that a single-payer system would best serve the nation.

Liberty and justice. Let us look at each of these two core values of the American experience in light of the current access to healthcare crisis.

Liberty is freedom: freedom from bondage, freedom from want, freedom to choose, freedom to be and to do. A key libertarian text by Isaiah Berlin, titled “Two Concepts of Liberty,” defines freedom as the absence of obstacles to possible choices and activities, obstacles put there by alterable human practices. It would seem that lack of access to care is a huge and alterable obstacle to life, liberty, and the pursuit of happiness in our society.

Currently, individual freedom is severely limited by our fragmented, market-based healthcare system. We all know people and have patients who can’t leave their jobs because they need to maintain their health benefits, for themselves or their children. People are not free to start new businesses or take creative leaps because they cannot afford to lose benefits. An elderly person may lose his or her home and savings in order to gain access to a nursing home. Medical bills are the number one cause, over 62 percent, of personal bankruptcy, with three-fourths of those having health insurance when their illness strikes. (Himmelstein 2009)

In his 1991 encyclical, the pope spoke of the task of the state and of “the idolatry of the market.” From a moral standpoint, Pope John Paul II warned, “There are many human needs that find no place in the market. It is a strict duty of justice and truth not to allow fundamental human needs to remain unsatisfied, and not to allow those burdened by such needs to perish.” (Catholic Conference of Kentucky 2008)

To me there are several signs of a mature nation, one key sign being access to healthcare for all its residents. Sometimes I feel that our country is like a teenager, who says, “I know, I know, I know,” refusing to listen to advice, and then crashes the family car. If one looks at healthcare in America, the car has already crashed. Another obstacle to our achievement of universal access to healthcare may be the belief that, even if our situation is bad, it is American and still the best. A mature America would learn from other nations that a universal healthcare system does not have to hinder personal choice; it can encourage it.

In nations with true universal access to care, a person with a disease knows that they will receive healthcare. They know if they change jobs, if they lose their job, or if they start their own business, they will still have healthcare. They know that if their disease worsens and they need extensive healthcare costing a great deal, they will not reach their policy’s financial limit. They need not fear that their benefits will run out before their disease is cured.

Many philosophers describe a classic conflict between liberty and equality, that they are mutually exclusive. Others say that the ideal solution is a balance between the two. I believe that “equality” in healthcare can lead to increased liberty, or, differently put, that social responsibility, well taken, can increase individual freedom.

Freedom is the core of being American. Looking at access to healthcare through the lens of freedom may help us move the dialogue forward. Universal access to care, using a single-payer model, would increase freedom from fear, freedom from poverty, and freedom from want. It would also increase freedom to act and freedom to choose.

In the past, employer-provided or individually purchased private health insurance plans provided greater freedom of choice. With each year the plans have more limits and additional charges. With these limits, liberty and autonomy are diminished rather than enhanced. In many ways, one could say that many of these plans have become unjust.

Often in life, out of our fear, we create what we fear. I would like us to recognize that in our fear of loss of freedom to choose our healthcare, we have given away our freedom and created a very unfree non-system. I would like us to, as Bob Marley, teaches, “emancipate ourselves from mental slavery and free our minds” around this issue.

The other ethical term we will address today is justice. In Judaism, the word for charity is the same as the word for justice: tzedakah, i.e., to do what is just, what is fair. It is not only charity to help the poor, it is justice. Islam, as well, teaches that doing justice between two people is sadaqah, which means voluntary charity. Thus we use the term “underserved medicine” rather than “charity” or “poverty medicine” because implicit in the term is that our society is under-serving a large segment of the population.

“A just society will not allow the marginalization of the poor and the exclusion of the disenfranchised from access to healthcare. Decent healthcare available to all is a moral imperative. (U.S. Catholic Conference of Bishops 2004, and CCK 2008) So if we feel it is good and just, as a mature nation, to provide access to healthcare for all, what is stopping us? How do we stymie ourselves?

As when we embark on anything new in our lives, we often stumble over fear of change, fear of loss of freedom, fear that we won’t do it right, fear that we will waste money. If there are 47 million people without medical access and 108 million without dental access, we certainly aren’t doing right. Studies from the Government Accountability Office repeatedly indicate our system wastes enormous amounts of money. In our yearning for what used to be, i.e., affordable health insurance that gave freedom, we have not faced the fact that that situation is long past. What we now have is a system that is very ill.

So, who will lose freedom in a universal healthcare single-payer system?

The pharmaceutical companies will probably have to face price controls and negotiated prices. The insurance companies certainly will be less powerful, although they will still be able to insure people for perks that are not always medically needed, e.g., a private nurse or a single-bedded room.

The for-profit medical companies, such as one large healthcare corporation that recently published an almost billion-dollar profit in the first quarter of 2009, will probably have less room for profit. These groups may feel less free, but if we can create a system that leads to a greater sense of individual freedom for the patient — who we must remember is the first priority — as well as increased freedom for the practitioner to practice medicine the way they believe, and not to have to worry about a patient’s coverage, then perhaps it is time to look at those choices.

The current administration would invite everyone to the table. I find this disturbing. To use an extreme analogy, in the waters off Somalia, we would not invite the pirates to the table and say, well, with what solution could you keep your piracy within limits, but you would still have adequate piracy income? I am worried that in the current healthcare discussions in Washington, DC, with everyone at the table, the table will become so heavy that it will sink.

The proposal of a healthcare mandate, a requirement that everyone acquire some sort of health insurance, limits liberty and is unjust. It shifts the concept of a right to healthcare and a society’s responsibility to provide healthcare to a requirement to individuals to purchase healthcare. In shifting the argument, it sidesteps the issues of liberty, justice, and rights. It equates healthcare, a life necessity, with other activities that are options, e.g., if you want to hunt, you need a hunting license, if you want to drive, a driver’s license, but health and illness are not always within our control. Although good health and prevention activities help to reduce the need for healthcare, we all know of individuals who have lived very healthy lives and still developed cancer or other conditions. Healthcare is not a lifestyle choice; it is a life necessity. To require it shifts the argument away from the core right of a human being to health and the core responsibility of a mature society to provide it. That does not mean that healthy behavior should not be rewarded, but it does not substantiate the goal of a mandate. I do believe that a healthcare system that values a humanistic, preventive, empowerment approach, will prove the most cost-effective, but it must be for all.

Single Payer — Patients: High Liberty & High Justice
Single Payer — MDs: Mid Liberty & High Justice
Single Payer — Corporations: Low Liberty & Low Justice

Mandate — Patients: Low Liberty & Low Justice
Mandate — MDs: Mid Liberty & Low Justice
Mandate — Corporations: High Liberty & High Justice

Status Quo — Patients: Low Liberty & Low Justice
Status Quo — MDs: Mid Liberty & Low Justice
Statue Quo — Corporations: High Liberty & High Justice

It saddens me that a nation as wealthy as we are and a leader in so many other ways has not matured to face our responsibility to provide access to care. The great learning before us is that social responsibility, appropriately taken, can increase rather than decrease individual freedom. As a nation of individuals, we must look at the values of liberty and justice, as well as compassion and responsibility, and act maturely, acknowledging a right to healthcare, as the United Nations has proposed, and letting go of fear. We must get about the task of achieving that right.