Aprehendite disciplinam

Now certain prominent Bishops in the USA have weighed in on Health Care Reform, that national debate which appears to be producing more heat than light, a phenomenon that in physics this would result in thermodynamic death- but the economy of human politics is not tied to thermodynamics, is it?

What matters here is that the institutional leaders of an organization that originated many of the concepts now known as “health care”, are speaking out, that institution being the Catholic Church. The Church has a long tradition of health care and has provided it in many forms and may thus authoritatively speak to such matters. But are these institutional leaders, the Bishops, speaking effectively to the issue or are they only addressing scripted “talking points” on abortion, euthanasia and illegal immigration? Are they speaking meaningfully to these issues or do they only utter the expected position statements?

It is time for lay Catholics to put aside childish things, things like party affiliation and political liberalism and conservatism to look at what is important in health care from a Catholic perspective. This is especially important since governance and politics are the proper domain of the laity CCC 898-899. Great issue has been made about abortion provisions in the health care bill, something which the Bishops oppose and rightly so. The USCCB position, written in 1993, states:

Consequently, we continue to oppose unequivocally the inclusion of abortion as a health care benefit, as do three out of four Americans (cf. April 6, 1993 New York Times poll).

The legalization of abortion by Roe v. Wade in 1973 does not carry with it the implicit or explicit provision that procuration of an abortion is a “right” or an “entitlement” , thus the secular society while allowing for this provision must be reformed to understand that the procuration of an abortion, while free from criminal prosecution, does not entitle a woman to public funding for this procedure, nor should health care workers be required to provide or assist in abortion nor make referrals to those who provide these services. This actually would be a good first start if only the extremists in the Pro-Life movement would allow for a process which would begin by restrictions of this sort followed by a restrictive licensing of these facilities that these services. The pro-life movement has failed to gain the changes it seeks primarily because of its wrong headed party affiliation and its association with a “war president”, as well as its obstinate refusal to abandon established methods that have failed to gain results.

Repressive credentialing and licensing would make it economically unfeasible to provide abortions or run a clinic and thus limiting this choice of profession to idealists and zealots. Indeed, repressive forms of regulation, certification and credentialing have been used to restrict pluralism in health care in the United States, why can these measures not be used to greater effect on abortion providers and clinics? In fact, elective abortion is such a fringe procedure that has no medical benefit whatsoever and abortionists should be licensed apart from the practice of medicine as quasi-medical technicians. The years of medical training that doctors undergo aren’t necessary to perform abortions- it is a waste of medical education to become an abortion doctor, indeed these are hardly doctors at all but little more than uterine evacuation technicians. Indeed the use of paraprofessionals in the abortion industry would save the skills of medical doctors for where they are truly needed in primary care where a critical shortage of physicians exists.

But I digress, the 1993 position paper by the USCCB states;

We commend to the leaders of our nation the following criteria for reform:

• Respect for Life. Whether it preserves and enhances the sanctity and dignity of human life from conception to natural death.
• Priority Concern for the Poor. Whether it gives special priority to meeting the most pressing health care needs of the poor and underserved, ensuring that they receive quality health services.
• Universal Access. Whether it provides ready universal access to comprehensive health care for every person living in the United States.
• Comprehensive Benefits. Whether it provides comprehensive benefits sufficient to maintain and promote good health; to provide preventive care; to treat disease, injury, and disability appropriately; and to care for persons who are chronically ill or dying.
• Pluralism. Whether it allows and encourages the involvement of the public and private sectors, including the voluntary, religious, and nonprofit sectors, in the delivery of care and services; and whether it ensures respect for religious and ethical values in the delivery of health care for consumers and for individual and institutional providers.
• Quality. Whether it promotes the development of processes and standards that will help to achieve quality and equity in health services, in the training of providers, and in the informed participation of consumers in decision making on health care.
• Cost Containment and Controls. Whether it creates effective cost-containment measures that reduce waste, inefficiency, and unnecessary care; measures that control rising costs of competition, commercialism, and administration; and measures that provide incentives to individuals and providers for effective and economical use of limited resources.
• Equitable Financing. Whether it assures society’s obligation to finance universal access to comprehensive health care in an equitable fashion, based on ability to pay; and whether proposed cost-sharing arrangements are designed to avoid creating barriers to effective care for the poor and vulnerable.

Respect for life; thus euthanasia and abortion should not be funded, however neither should extreme fertility measures including in vitro fertilization, sperm and ovum donation. Respect for life should also restrict public funding for contraception, tubal ligation and vasectomy, even condoms should not get public funding.

Priority concern for the poor: while essential to Catholic social teaching may be hard to legislate in a secular government because of shifting definitions of what is considered “poor”. Poverty needs to be defined and in a consumer society where a large industry has grown providing cosmetic surgery and medical aesthetics it would be a matter of time before some obese poor would clamor for liposuction and tummy tucks and file discrimination suits because they were denied such treatments. Clearly the problem of definition obtains here as well as what would constitute medical treatment. Thus, would cosmetic services need to be restricted from any health care provision and then what else…? Eventually restriction of medical resources to medical necessity would lead to what is braodly called a “rationing of health care” because one needs to have OBJECTIVE criteria upon which to base cost-benefit. Thus only demonstrably beneficial services would be funded at the exclusion of others, other services would be delayed pending a trial of conservative prior to assignment for surgery. For example the famous charge that knee replacement surgeries would be delayed ignores the fact that standard of care requires a trial of non-surgical interventions including medication and physical therapy prior to surgery. Nevertheless, the American consumerist mentality demands immediate assignment to surgical treatment and these trumped up charges that Granny would not get her knee surgery are simply based upon a hamburger stand perspective that wants its order “supersized” upon demand without regard for the lack of evidence based indications for the procedure:

The general consensus among orthopaedic surgeons on indications for an operative procedure, carried out by a postal survey, were (a) severe daily pain and (b) x ray evidence of joint space narrowing.82 There are no evidence based guidelines to support this, however. No RCTs have compared TKR with non-surgical interventions. Annals of the Rheumatic Diseases 2003;62:1145-1155; EULAR RECOMMENDATIONS 2003.

Consumerism of the type that drives the purchase of automobiles has a limited place in health care and health care decision making.

So, to revisit the argument- what constitutes being “poor” and how does one then equitably assign medical care so that the preferential option for “the poor” does not become a form of reverse discrimination?

Universal access: already the shrieks about “illegal aliens” have become a rallying point against health care reform. Nevermind these “illegals” already drain the resources of emergency rooms and trauma centers across the country because that is where they now go for their health care. A health care reform must address the issue of immigration reform, and immigration reform must address broader issues like those which afflict the countries of origin and the conditions there that these immigrants are fleeing. The argument that denying illegals access to universal health care in the United States is an essential part of health care reform mistakenly overlook the economic forces responsible for the importation and domestic retention of these “illegals”. The business of human trafficking and the economy built around housing and selling the labor of illegal immigrants in this country is one which has not been uncovered but it exists in a vast underground economy that the Bishops of the United States are uninformed of. The dynamics of this underground slavery and its existence in the United States, its perpetuation by the blind eye of law enforcement and its toll on families is one which needs to be investigated, uncovered and condemned by the Bishops – perhaps through exposing this grave injustice the American Catholic Church could recover the moral authority it has lost through the cover up of sexual molestation by so many of its priests in the recent decades. Until then the Bishops can write what they please but have lost the public respect for the scandals of Boston and elsewhere.

Comprehensive benefits: at issue is preventive care, health should be funded to provide disease preventions strategies as well as treatment which requires medication or surgery. nevertheless, it will be hard to argue against the funding of contraception since many women, including many Catholic women, believe that contraception is an essential part of preventive health care. Again, this begs the question of the extremes of health care in this country including funding for things such as aesthetics (botox and restylane injections), cosmetic surgery, gender reassignment therapy, do we exclude alternative and complementary medicine – what metrics are to be used to include specific modalities at the exclusion of others and how will this be provided in a consumerist society that wants what it wants when it wants it? The oft cited argument that Granny will be denied a hip replacement fails because the little cited fact exists that  there is no evidence to support the belief that total hip arthroplasty a greater benefit than internal fixation. Why should Granny get the hip replacement when internal fixation may be just as good? There are those who argue that the physician patient relationship is sacrosanct and that the physician recommendation should be given priority, thus justifying demand for all sorts of medications, surgeries and procedures that have no merit over medications, procedures and surgeries that are less costly and may in fact pose less risk to the patient. The physician must be expected to follow accepted practice standards and evidence based guidance – yet the sources of these guidelines and standards must be diverse so that they do not become the dictates of the monopoly of special interests.

Pluralism: the argument the Bishops make for the participation of charitable, faith based and voluntary sources of health care is a good point. However the Bishops ignore the greatest barrier to full participation by all sources of health care and that is malpractice insurance. Malpractice lawyers have done the greatest harm to the practice of medicine in this country and because of he escalating cost of malpractice coverage and the restrictions that malpractice insurance providers place upon what they will cover the provision of low cost or free health care to these who would benefit is blocked because of fear of lawsuits and the infeasibility of insuring these activities. Clearly, many more health care providers would open charitable endeavors IF the fear of tort were not so omnipresent such that nobody is willing to treat pro bono for fear of suit from opportunistic grifters and their attorneys. The Bishops in their concern for social justice must address this aspect of medical reality in their ongoing clamor for treating the poor and disenfranchised.

Of concern also are the many restrictions which are encountered in the billing process, the CPT and ICD-9 codes that go into each and every bill submitted for reimbursement from private insurance, Medicare and Medicaid. the system is inefficient and is a great source of waste and mismanagement, especially in Medicaid and Medicare. For the diverse, pluralistic sources of health care which the Bishops advocate to function, clear and concise patterns of reimbursement must be detailed so as to avoid the risk of being accused of fraud when simple errors in billing occur due to the current complexity of the billing process.

Quality: The Bishops must address the monopolies which maintain a stranglehold on healthcare providers, hospitals and clinics through the restrictive process of issuing credentials by JCAHO, the ABMS and its affiliated specialty boards, the State Medical Boards and the AMA which have made an industry exacting fees for certification exams, institutional reviews and certificates in the name of “quality control” but which in reality have become little more than forms of legal racketeering restriction the number and type of medical practioners, hospitals and clinics in the US through byzantine credentialing and review processes. This alone is a major reason health care costs have skyrocketed, in part to maintain the number of FTEs dedicated to meeting the demands of these credentialing agencies. One could argue that there is a need for licensure and quality control and indeed this is not disputed, however there should be COMPETITION in the marketplace to allow for more diverse avenues of credentialing and certification. At this time an unseen oligarchy controls credentialing of healthcare in this country and it must be deposed from its monopolistic stranglehold which has been largely responsible for the restriction of pluralism in American health care.

Only with malpractice reform and the reform of healthcare certification can any sane health care reform take place.

Cost containment and controls: the issue of defensive medicine is not small and a great deal of the cost of medical care is directly the result of the organized assault on doctors and hospitals from malpractice attorneys as well as the increasing cost of obtaining malpractice insurance. Add to this the cost of maintaining credentialing and certification, plus the cost of medical training itself and then we have a real picture of why costs are as they are. Furthermore, the use of technologically sophisticated equipment in the USA is no cheap nor are may diagnostic tests that are required for diagnosis and treatment monitoring. I will also add that many of the medications on the marketplace now are verysophisticated and reflect the developments in molecular and cell biology over the past two decades. The specificity and design of many pharmacologic agents are exquisite and the cost of developing these is not cheap. So despite the complaints that Big Pharma is making itself rich at the expense of the people fails to consider the amount of sophisticated science, research and development that goes into the production of medication, yet there are those who maintain the naive  belief that this should all be free because people have a “right” to it.

People have a right to health care, it is true, but people, including those who work in health care and own hospitals and clinics, also have a right to make a living, run a business and benefit from the fruit of their labors. Those who propose that health care should be provided as a universal good from charity are hopeless idealists who overlook the injustice done to the health care worker. Nobody asks a farmer to give his produce for free although everyone has a right to eat, do they? Do we hear the leftists who most loudly proclaim Catholic social justice theory advocate the field worker do his labor out of the goodness of his heart and eat only what he does not provide freely to those who do not farm? Of course not and why should health care be any different? “Brother auto worker, give me my free car because I have a right to transportation and you may have a free car as well” – let us see how THAT would go over. At the heart of such presumption is envy and covetousness disguised as a preferential concern for the poor; envy and covetousness which would destroy all economies to make everyone poor so that nobody would earn profit from their labor. This is not Catholic social justice but a mockery of it, a thinly disguised Bolshevism which would deprive everyone of their right to property, a right at the core of Catholic social justice.

2402 In the beginning God entrusted the earth and its resources to the common stewardship of mankind to take care of them, master them by labor, and enjoy their fruits.¹⁸⁷ The goods of creation are destined for the whole human race. However, the earth is divided up among men to assure the security of their lives, endangered by poverty and threatened by violence. The appropriation of property is legitimate for guaranteeing the freedom and dignity of persons and for helping each of them to meet his basic needs and the needs of those in his charge. It should allow for a natural solidarity to develop between men.

The equitable balance between the right to health care of persons and the right to a just wage and fair profit is one which the Bishops in their zeal for justice in the health field need to address. Just as the virtue of temperance must obtain in which profit free of greed for health care providers must obtain, freedom from being oppressed by the greed of those who presume a right to the productive effort of others must be ensured. Indeed, the principle of pluralism would ensure this to a greater extent by allowing non-corporate, not-for-profit entities to economically compete.

The massive regulatory framework that pharmaceutical companies need to comply with is a major source of cost in the production of medication. The billions of dollars that must be spent on FTEs to assure regulatory compliance and to defend against legal prosecution and lawsuits must be considered in health care reform – these are costs that are not insignificant and which are passed on to the patient in the price of their medication. No doubt Big Pharma would be more open to providing medicine pro bono to the pluralistic sources of health care the Bishops advocate if they too were not restricted from doing so by the complex legislation that restricts them and fear of lawsuit.

Clearly the Bishops need to address the issue of waste in current publicly funded health care programs which care for the elderly and the poor, which restrict patients from obtaining the best health care through restricting reimbursement to providers and penalize providers with complex and punitive regulations.

Finally the issue of equitable financing is addressed and one which the Bishops have not yet tackled insighfully. The current regime of HMOs and health insurance companies needs to be deregulated and decoupled from employment. Health care coverage should be available for purchase by individuals and families in the same way that automobile and home insurance is. The expectation that the employer should provide health benefits should be eliminated, however should employers choose to provide a benefit as a competitive hiring package they should be free to to so, but only of the employees is allowed to opt out and obtain insurance independently.  In order to do this the Bishops must address the stranglehold labor unions hold on health care by demanding employer paid insurance: unions like the SEIU must be reigned in and its members allowed to contract freely in the marketplace for the best cverage available. Health care has suffered through the intervention of government and labor unions and these sources of interference are primarily responsible for the escalating cost of health care in this country.

The Bishops, while meaning well in their position statements, demonstrate a lack of insight into the complexities of the health care reform issue. By myopically advocating for “the poor” without actually defining what constitutes being poor in the US, and by broadly militating a pro-life stance without actually addressing specifics of how this should be done, they do a disservice to the broad spectrum of Catholic workers whose labor will be used to fund government reformed health care.

The Bishops in their pastoral concern need to address how this reform will impact all Catholics, not just the poor and the unborn, but also those who labor and pay taxes so that they too are not added to the growing ranks of “the poor”. The Church, once the home of health care, needs to advocate a place for its health institutions in the United States, a parallel framework which could provide for the poor and dispossessed independently of the current regulatory framework which forces it to work in a corporate manner and compete for funding tainted by morally unacceptable requirements. This would remove the barriers to the true charitable mission of the Church and its natural place in health care.