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Government, Health Care, and the Principle of Subsidiary Function

The comments in my last post on health care were thought provoking and insightful. I especially pondered Jonathan’s questions about “subsidiarity”. He referenced the papal encyclical Quadragesimo Anno by Pope Pius XI. I was not familiar with this document so I perused it on the Vatican web site. I think Jonathan’s comments refer specifically to this component of the document:

79. As history abundantly proves, it is true that on account of changed conditions many things which were done by small associations in former times cannot be done now save by large associations. Still, that most weighty principle, which cannot be set aside or changed, remains fixed and unshaken in social philosophy: Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish help to the members of the body social, and never destroy and absorb them.

80. The supreme authority of the State ought, therefore, to let subordinate groups handle matters and concerns of lesser importance, which would otherwise dissipate its efforts greatly. Thereby the State will more freely, powerfully, and effectively do all those things that belong to it alone because it alone can do them: directing, watching, urging, restraining, as occasion requires and necessity demands. Therefore, those in power should be sure that the more perfectly a graduated order is kept among the various associations, in observance of the principle of "subsidiary function," the stronger social authority and effectiveness will be the happier and more prosperous the condition of the State.

I believe these paragraphs capture very well the principles that I think should guide government involvement in health care. Human dignity is preserved when personal responsibility is demanded. The function of the government is to act as a safety net. This net needs to be strong and tightly woven to ensure that everyone has access to a rationally defined minimum level of health care. This rational definition of the minimum acceptable level of health care needs to be based on science, principles of natural law, and the common good.

As I said, this is a safety net. I believe market forces will offer those who want to spend the money an alternative. Consider the government health care option a functioning un-air-conditioned Yugo. Private health care payment options are almost any other functioning vehicle on the road. Both will get you from point A to point B. The Yugo just doesn’t give you the style, comfort, gizmos, and gadgets of those other vehicles. If you want style, comfort, gizmos, and gadgets, the cost should come out of your pocket—not the taxpayer’s pocket. The task of designating which health care is standard equipment on a Yugo and which health care is optional equipment will require the wisdom of Solomon and a spine with Herculean strength.

In the comments of my previous post, Jim suggests that this has already been accomplished with the Medicare/Medicaid program. Not so. The Medicare system is focused on the care of senior citizens except for cases of premature disability. These senior citizens have contributed to the funding of their care through their payment of payroll taxes. Medicare is not a program of care for the indigent. It is not meant to be a bare bones program. These citizens have a right to expect some semblance of a return on their investment. Even so, many seniors do opt for a private insurance alternative. They assign their Medicare benefits to be paid to a private insurance company because they feel they get more for their money by joining one of these private HMO’s. Others want the luxury of getting more personal attention from their doctor. They pay a premium fee to join a concierge medical practice. They want more than the government can provide and are willing to pay for it.

Medicaid is a hodge-podge of programs mandated by the federal government and administered by the individual states. Eligibility and benefits vary from state to state. The benefits are highly influenced by local politics and emotions at the expense of rational deliberation. I believe trying to impose a government-funded program using Medicare and Medicaid as models would result in an overwhelming tax burden. I also believe that while private industry may not have your good health as its primary objective, the market incentives to produce a quality product (health care) in an efficient manner will serve patients better than a socialist styled government program.

An example of this is evident in my experience trying to arrange physical therapy appointments for my daughter. Tricare stated the local military physical therapy facility has the capacity to provide care for my daughter. Therefore, they will not pay for her to receive care from a civilian provider. Fair enough. However, when I call the military facility to schedule her initial appointment that needs to be within five days of her surgery, I am told there is nothing available for at least two weeks. I go back to her surgeon who puts pressure on Tricare to either have my daughter seen within five days by the military provider or refer her to a civilian provider who can see her in the appropriate time frame. A second call to the military provider then produces an appointment. What changed? My daughter’s appointment was labeled as a new post-operative evaluation. The computer template for appointments did not have any slots designated for new evaluations available. When I called the second time, the front desk employee got up from his desk and obtained the authorization needed to change one of the follow-up slots to a new evaluation slot. My first phone call had reached someone who was unwilling to make that effort. Instead, she just insisted there was no available appointment in the prescribed time frame. She was willing to let appointment slots go empty and physical therapists stand idle instead of doing what it takes to appropriately serve the patient. In a privately run facility those empty appointment slots are directly reflected as a negative factor on the balance sheet. Such indifference to filling appointments would not be tolerated. It really doesn’t bother me that the motivation is profit instead of an altruistic vision of providing health care. The result is the private facility is more responsive to a patient’s health care needs. The patient is better served.

Therefore, to return to the idea of subsidiarity, I think the government does have a role in providing a safety net of necessary health care for every American. However, this safety net should not be considered the standard for health care. It should be the minimum amount of health care each individual is entitled to based on the principles of human dignity, natural law, and the common good.

Of course, in a topic this big and controversial, this is not the end of the discussion. I think we need to look at how those not utilizing a government run safety net pay for health care. I do not think the employer based insurance system works because workers change jobs too frequently. I like the idea of individual health savings accounts because it incorporates portability with personal responsibility. I'll save further discussion of this for a future post. Let the comments begin!


Caramore said…
Dr. Hunnell, would you be kind enough to provide your readers with some specific examples of the type of medical care that you believe would be appropriate for Medicare recipients to receive, but which you would nontheless consider unaffordable "luxuries" if given to the uninsured under the basic, "there is no air-conditioning in this here Yugo," health care plan that you appear to support for currently uninsured?
Catholic Mom said…
When defining what is basic health care it is easy to pick out the extremes. Childhood immunizations are definitely standard equipment. Botox injections are definitely on the luxury model vehicle. However, as you get closer to the middle things start to get grey. As I mentioned in my previous post, pre-natal care is required but a pre-natal ultrasound may be optional. Regular dental care is important but should every child get braces? Is treatment for acne cosmetic or a medical necessity? Is every American male entitled to access to Viagra? Is every episode of teenage angst a mental health problem that needs therapy? What I am saying is that if the care is coming at taxpayer expense then it needs to be based on sound science. Right now our method of allocating health care resources relies on who is lobbying the most effectively. In order to ensure everyone has access to quality primary care we need to make sure that we spend our limited health care dollars wisely. That means asking tough questions and being able to say "no" to special interest groups.
Nice article. I can see our situation here. I am selling optional private insurance along with life insurance in Canada so I am a bit "insider". Our private insurance is just "cherry on the top", most of the health care is covered. Recently there have been some attempts to spread private insurance, but have been stopped. It's really hard to find the line between -must- and -can-. You can't just set administrative rules "this is not life threatening". Even your example - botox. I can imagine somebody who has obsession to being botoxed and this improves his hapiness much more than let's say healthy dentice...
Best wishes!
Michelle said…
My fear of government involvement is the special interests who lobby to make certain things "standard features." Measles vaccine? Yes! Chicken pox? Maybe. HPV? No.

Like car insurance, I think everyone should be required to buy a minimum package of health insurance from private companies - minimum being emergency/critical care for everyone, and certain preventative things like vaccines or minimal prenatal care. I don't mind if the government pays for those who can't afford it, but I think the funds should go to private companies.

I also think that employers need to stop being the middle man and get out of the insurance business. Give every employee a sizeable raise and let everybody shop on their own. It's more work for the individual, but garners stability when people go from job to job.

I realize that I don't have the perfect solution, but the current system of governments or businesses providing insurance for private people means I'm stuck with benefits I don't want or need (for example: birth control pill coverage) but I may not have coverage I would like (eye care).
RAnn said…
Did you see the recent NEJM article about the Mass. program? It is a free article this week.
gramps said…
The real issue with healthcare is that we are trying to deliver care using a system designed in 1950 and bastardized by government, insurance, and employer needs with the patient left out of the mix. We will see a huge growth to concierge care in the US because people want to be treated as human beings, not cattle and they are beginning to understand you need to have a great primary care doctor with time to get off the hampster wheel to treat you as well as provide standard services such as online and telephone care. What is your health worth? Many will pay the price and live better lives and those left out will get garbage care. adding millions more to a broken system with not enough primary care docs will just about kill the system and it is coming at us with the next election of democrats into power. Find a good doc in this type of program and pony up the money or you are going to be in real trouble.

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