October 18, 2007

October 18, 2007 | Commentary on Health Care

Freedom to Choose<br>Clear-conscience health reform

If rising costs, declining quality, administrative hassles, and coverage gaps aren't reasons enough to reform American health care, here's one more: conscience concerns.

Consider this: 46 percent of American workers participate in employer-sponsored health-care plans that subsidize abortion. That means many Americans praying on Sunday for the protection of unborn children are paying on Monday with their insurance dollars for others to abort them.

Freedom of conscience for physicians and pharmacists is a familiar concept. Now it's time for patients to have a conscience option when it comes to choosing health coverage. Freedom of conscience -- for both provider and patient -- should be the rule in health care, one of the most sensitive areas of human life.

Reforming health care is about more than reducing costs and expanding individual coverage, important as those are. Health care reform should empower Americans to choose plans that are affordable, high-quality and consistent with their ethical and religious convictions.

Part of the problem is that Americans don't have direct control over issues of either cost or conscience. Third-party decision-makers do. They are at the fulcrum of the current health-care system, setting the rules for coverage. The kinds of benefits financed through health insurance are determined largely by employers, insurance executives, managed-care network, officials or government officials. Patients' personal choice is very limited.

As biomedical advances push us into increasingly murky ethical depths about everything from prenatal to end-of-life decisions, the moral map should not be left to the third-party decision-makers. Even worse is the prospect of handing the moral compass to anonymous bureaucrats in a single-payer government system. There's more to be feared about a national health system than poor quality care and rationing.

With moral dilemmas looming large in areas like genetic engineering, human embryo research and end-of-life treatment, patient empowerment is more vital than ever. Public consensus in law should be achieved where possible -- on issues such as human cloning and the creation of animal-human hybrids. But the variety of ethical issues involved in personal care will be difficult to resolve in legislatures, and undesirable to leave to court decisions. Instead, they should be put to the test of individual conscience. If individuals and families had control of their health care dollars, they could "vote with their feet" when choosing which health plans and medical procedures to subsidize with their insurance premiums.

Once empowered with the freedom to choose their health coverage, families need safe havens to which they can turn. They need new arrangements that aren't feasible under the present system. For example, plenty of Americans have moral qualms about paying for abortion, and plenty of American doctors have moral qualms about providing them (and therefore decline to do so). But the current system doesn't allow providers and patients to get together and organize health insurance plans around shared values.

In an alternative model, membership associations such as professional and faith-based organizations could sponsor or endorse a health-insurance plan in which participating doctors and patients agree on clearly established ethical parameters for care. Trusted intermediaries like the Knights of Columbus, Southern Baptists, or the Salvation Army, for example, could help individuals and families navigate the moral and fiscal complexities of health care coverage by negotiating with an insurance company to offer a group plan that meets their standards.

Such a faith-based health plan is available to one of the few groups in America with a wide choice of plans: federal employees. The Federal Employees Health Benefits Program (FEHBP), the largest group insurance system in America, is a national consumer-driven market for federal employees, retirees, and their families. They can choose a plan from a large pool of health care options (278 plans participated in FEHBP in 2006). One of these federal employee plans is the Order of Saint Francis Healthcare System, run by an order of Catholic nuns in Illinois, who are very clear about their governing values for the care of human life, from conception to natural death. Regrettably, only federal employees in the region can select this option, but this is precisely the kind of plan that could proliferate if there were true choice in health-insurance design.

Unlike these federal employees, most Americans don't have access to health-insurance plans that are governed by religious values. This lack is emblematic of a general limitation on personal freedom, a central defect of the American health-care system.

To expand families' freedom to choose cost-effective health-insurance plans consistent with their ethical and religious convictions, policymakers should change tax and insurance rules in these ways:

  • Allow Americans to choose their own health plans. In addition to conventional employer-sponsored health plans, Americans should be allowed to choose plans sponsored or endorsed by professional associations or faith-based and religious groups.
  • Eliminate discrimination in the tax code. To make this choice a reality, federal and state tax codes should treat all types of plans equally and stop giving preference to employer-based health plans.
  • Reduce mandates. State mandates drive up costs and raise conscience concerns. Thirteen states, for example, require health plans to cover in vitro fertilization (IVF). Thirty states mandate coverage of contraception. State-level reform offers the occasion to expose mandates to popular debate.
  • Open up health-insurance markets. State mandates define and limit the kind of health insurance available to individuals and families -- and often prevent them from getting the specific kind of coverage they want at an affordable price. To address this, some states are considering reforms that would create a statewide health insurance "exchange," or marketplace for health-care plans. Consumers would have multiple choices in such a marketplace, and employers could contribute a specified amount (a "defined contribution") to the health plans designated by their employees. Plans -- including those organized around shared moral values -- would compete with each other directly for consumers' dollars.

Individuals and families can no longer afford -- financially or ethically -- to be passive recipients of third-party decisions. They should be free to control their health-care dollars. Americans need the freedom to choose health care they can trust.


Jennifer A. Marshall is director of domestic-policy studies at the Heritage Foundation and author of Now and Not Yet: Making Sense of Single Life in the Twenty-First Century(Multnomah, June 2007).

About the Author

Jennifer A. Marshall Vice President for the Institute for Family, Community, and Opportunity, and the Joseph C. and Elizabeth A. Anderlik Fellow

First Appeared in NRO