Millions of Americans are being crushed by the costs of the COVID-19 pandemic and the devastating job and income losses. This disruption of their personal and professional lives has been compounded, not only by state lockdowns of whole sectors of the economy, but also by the suspension of routine tests and medical procedures in order to prioritize the care of an anticipated surge of coronavirus patients.
Not surprisingly then, Americans rank health care as a top issue going into the 2020 elections. Well before the onset of the COVID-19 pandemic, however, health care was generating persistent public dissatisfaction and bitter political conflict.
A Dysfunctional Status Quo
For ten years, the Affordable Care Act (ACA) of 2010 has largely defined the health care status quo. When President Barack Obama signed the Affordable Care Act into law, he made a series of high-profile promises: that Americans would be able to keep their health plans and their doctors; that the “typical” American family would see a $2,500 annual reduction in their health costs; and that Americans would enjoy the bounteous benefits of robust personal choice and health plan competition in individual markets.
None of these results materialized. Since 2014, millions have lost their existing health care coverage. While private health plan enrollment began its decline in 2015, the rapid ACA coverage growth was overwhelmingly attributable to a massive expansion of the troubled welfare program Medicaid. Meanwhile, most ACA plans narrowed their networks, thus reducing patient access to doctors, hospitals and specialty care. In the nation’s individual markets, personal choice and health plan competition virtually collapsed. Instead of the promised reduction in health insurance costs, ACA premiums and deductibles soared. Between 2013 and 2018, ACA premiums increased by 125 percent, and annual deductibles for individuals and families rose to many thousands of dollars each year. While the law insulated lower income persons from these rapidly rising costs through a complex system of generous taxpayer subsidies, middle class Americans suffered.
As the former Chairman of the Maryland Health Care Commission, I monitored the state’s health care cost increases, as well as the quality and performance of Maryland’s 47 acute care hospitals. Of course, aggregate numbers don’t tell the whole story; the plight of individuals and families rounds out the dismal picture. In 2018, a healthy young Maryland couple of my acquaintance, blessed with two young children, paid $1,300 per month in ACA premiums, with a family deductible in excess of $12,000. In effect, the young couple was carrying the equivalent of two mortgages; their monthly home mortgage payment was $1,300. Though ineligible for ACA insurance subsidies, the husband was a successful entrepreneur and, as a self-employed worker, was able to deduct the family’s large insurance costs under the current tax law. If he had been an ordinary worker, however, under current federal tax law the family would get no federal tax relief at all.
That makes ACA coverage unaffordable, other than for upper income Americans wealthy enough to buy unsubsidized coverage in the individual markets. Not surprisingly, the Center for Medicare and Medicaid Services (CMS) reports that between 2016 and 2018, 40 percent of the decline in ACA enrollment was among unsubsidized persons. In short, current law is pricing millions of middle-class Americans out of health insurance coverage.
The situation was worsened for that same Maryland couple by the pandemic. With the shutdown of the economy, their income plummeted. They moved to another state and were forced to rely upon public assistance by enrolling in Medicaid.
The Single-Payer Solution
Reform is necessary. However, the substance of reform, as the Catholic Church has long emphasized, must aim to secure simultaneously the good of the individual person and the common good of society. The single-payer solution is not the answer and opposition to it is not tantamount to opposition to either universal access to coverage or universal access to care. Every person should have access to health coverage and care, and government financial assistance to the poor and the sick can ensure that objective. However, when it comes to the financing and delivery of health care, a multi-payer system of private, competing health plans would better serve those objectives, while expanding personal choice for individuals and families, lowering costs and improving quality.
Nonetheless, with the onset of the pandemic, many prominent “progressives” in the House and Senate, such as Sen. Bernie Sanders of Vermont and Rep. Alexandria Ocasio-Cortez of New York, have argued that the national medical emergency and its economic consequences justifies the abolition of America’s unique combination of public and private health insurance coverage and replacing these arrangements with a single-payer system of national health insurance. The leading Congressional single-payer bills in the House (HR 1384) and the Senate (S. 1129)—dubbed “Medicare for All”—are broadly similar in content, and crystal clear in their legislative language.
The House and Senate measures would transfer vast regulatory authority to the Secretary of the U.S. Department of Health and Human Services (HHS) and other federal officials. Both would abolish nearly all existing private and employer-sponsored health programs. In substance, both bills would ignore the principle of subsidiarity, centralizing virtually all authority over health care financing and delivery in the federal government, and thus overriding state government authority and the intermediary institutions of civil society, local associations and organizations, in providing coverage and care.
These bills would explicitly deprive Americans of any right to secure alternative health care coverage, regardless of their personal preferences. Both would also impose restrictions on doctors and patients who wish to contract with each other outside of the newly established national health insurance system. The relevant language of each measure is broadly similar: If a physician or other medical professional contracts with a patient outside of the national health insurance system, the doctor must refrain from receiving government reimbursement from treating all other patients for a specified period of time, thus guaranteeing that few, if any, physicians would be able to operate independently of the government program. In substance both measures would render virtually all doctors and patients fully dependent on the powers of the federal government.
In addition, in both bills the federal government would define the kinds of health care benefits and medical services all Americans must have, including mandatory coverage of abortion, along with participation requirements for physicians and other medical professionals to provide these services or face exclusion from the national program. In substance, both measures would violate the sanctity of life, personal freedom of conscience and religious liberty.
Universal access to coverage is not the same as universal access to care. If health care is a legal right—a government entitlement free at the point of service—then it is what economists call a free good. The demand for a free good is unlimited. Unlimited demand, at any given point in time, must collide with limited supply; access to care is not, and cannot, therefore, be universal. Rationing, of course, occurs in all systems. Rationing decisions in single-payer systems are primarily budgetary, bureaucratic, or political meaning that government officials must, in some way or another, establish a scheme for determining who gets care, as well as how, when, and under what circumstances they get care.
Waiting lists are the primary rationing mechanisms. A team of researchers writing for the Journal of the American Medical Association reported in 2018 that 39% of patients in Canada, which is a single-payer system, and 19% of patients in Britain, the oldest model of a single-payer system, had to wait more than two months to see a medical specialist compared to only 6% of patients in the United States. British patients must often wait for hours in Britain’s overcrowded and understaffed emergency departments. By the end of 2020, with British hospitals and other medical facilities trying to cope with the pandemic, British waiting lists could approach nearly 10 million patients. In normal times, British waiting lists are routinely scandalous. In 2017, there were 4.1 million British patients on the waiting lists of the National Health Service (NHS), including waiting lists for cancer surgery. Nor do British patients get timely access to breakthrough medications.
Congressional sponsors, as noted, claim that the substitution of broad-based federal taxation for private health insurance costs would result in most American families paying less for health care than they do today. Sen. Sanders concedes that his proposed program would require broad-based taxation on the general population, not just high taxes on the economically advantaged few. Examining his initial (2016) proposal, however, Professor Kenneth Thorpe of Emory University, a former advisor to President Clinton, estimated that the Sanders proposal—if it were fully funded—would require a 14.3 percent payroll tax, as well as a 5.7 percent income-related premium; in other words, a level of taxation equal to 20 percent of payroll. Thorpe concluded that 71 percent of all working families would pay more for health care than they do under the current system. A 2020 Heritage Foundation econometric analysis broadly confirmed Thorpe’s findings, estimating that the program would require a tax of 21.2 percent on earnings, and 73.5 percent of Americans would have less money in their pockets. Over 156 million Americans today have employer-sponsored coverage—roughly half of the American population—and those households losing job-based coverage would experience an average income reduction of $10,554, which means about 87 percent of those households would be worse off.
Some academic specialists estimate that a single-payer system can indeed achieve lower levels of household and national health care spending. It is theoretically possible, of course, to achieve such fiscal objectives if, and only if, federal officials would enforce either serious caps on national health care spending (global budgets), regardless of the demand for services, or impose severe reductions in medical reimbursements unlike anything Americans have previously experienced.
The prevailing view among prominent health care economists, liberal and conservative alike, is that such an outcome is highly unlikely. For example, scholars at the Urban Institute, a prominent liberal-leaning think tank, estimated that a single-payer program would require a federal spending increase of $34 trillion over ten years, and total American health care spending would increase by $7 trillion. Dr. Charles Blahous, a former trustee of the Medicare program, initially projected a $32.6 trillion increase in additional federal spending, and later emphasized that this federal and overall national spending would likely be higher. The Center for Health and the Economy, a conservative-leaning policy group, focused on the Sanders plan and estimated that federal spending could range between an additional $35-$45 trillion over ten years, while generating a deficit of up to $2.1 trillion annually. A Rand Corporation study estimated the combination of additional federal spending and comprehensive benefits plus the absence of cost-sharing could result in an overall annual increase in national health care spending ranging, depending on utilization, anywhere from 1.8-9.8%.
In summary, the adoption of a single-payer system covering more than 330 million Americans, particularly as outlined in the leading House and Senate bills, would guarantee a massive disruption of existing public and private health care coverage and delivery systems.
Note that the proposal is often framed within the language of rights—that every individual has a right to health care—which is particularly appealing to Americans who adhere to the Judeo-Christian ethic and have a generous regard for the poorest and most vulnerable among them. It is necessary, however, to look beyond the attractive rhetoric of the “right” in question to the practical application of the concept. In this case, when single-payer advocates define health care as a “right,” it usually means, in practice, the right of an eligible person to the benefits of a federal entitlement, specifically the defined set of health benefits and medical services that are outlined in statute, and modified, from time to time, by federal administrators through regulation.
The problem, is however, that no federal entitlement, such as a Medicare or Medicaid benefit, constitutes an individual “right” understood as a legal claim to something of value that is enforceable like a private contract. In fact, government officials can and do grant or withhold entitlement benefits; they modify, reduce or even eliminate them, depending on a variety of circumstances, including budgetary or political calculations, or in response to the incessant demands of other competing special interest groups. When the money is not there, neither is the care.
The Right Orientation
American health reform is necessary, and the rich tradition of Catholic social teaching provides a sound guide. In Centesimus Annus (1991), Pope John Paul II writes, “The Church has no models to present; models that are real and truly effective can only arise within the framework of different historical situations, through the efforts of all those who responsibly confront concrete problems in all their social, economic, political and cultural aspects, as these interact with one another. For such a task, the Church offers her social teaching as an indispensable and ideal orientation, a teaching which, at the same time points out that these need to be oriented towards the common good.”
In accordance with long-established Catholic social teaching, future health reform should reaffirm the sacredness and dignity of the human person, and that clearly includes the right to life, both at the beginning and the end of life. It would surely include the right of persons to exercise their personal freedom in making health care decisions that they deem best for themselves, while respecting the freedom of the person’s moral conscience in sensitive matters of medical treatment and the use of medical procedures.
Secondly, reform should embody the “preferential option” for the poor, making sure that government assistance is rightly targeted to low income persons who would not otherwise be able to afford coverage or medical care, while offsetting the heavy costs borne by persons with pre-existing medical conditions.
Thirdly, public officials should take the Catholic principle of subsidiarity seriously, and allow the intermediary institutions of civil society, including charitable organizations, to maximize their capacity for service, respecting their authority and their traditional roles. In the sphere of government, the principle of subsidiarity would reserve a powerful role for the states in managing matters of health care financing and delivery, including insurance regulation, in such a manner as would best stimulate innovation in care delivery, maximize economic efficiency and savings, and expand insurance coverage for their citizens, especially the poorest and most vulnerable.
American health care suffers from specific and sometimes severe weaknesses, among them rising costs, bureaucratic excess, gaps in coverage, and poor performance on certain measures of population health. The United States is, however, also the home of advanced medical science and technology and demonstrates an impressive responsiveness in treating and curing deadly diseases, like cancer and heart disease. Americans can improve upon what they have with carefully crafted reforms that avoid destroying the entire system of public and private care and coverage.
This piece originally appeared in The Pulse, WINTER 2020