…and the call for Stewardship of the collective resources…is clear…
—Thomas Aquinas

This essay appears in the Hastings Center’s Connecting American Values with Health Reform ^[1] Collection, available here ^[1].

To exercise stewardship, or not—that is the question. Why put the point that way? Because one path leads to an abundant life, and the other is a dishonest, if elaborate, form of suicide.

Stewards distinguish themselves first by accepting responsibility, and then by acting on that responsibility to preserve, protect, and nurture something precious, through recurrent threats, for the purpose of delivering that precious thing to future generations.

Who may confer and who must accept responsibility for stewardship of our health resources and the health of our population?

Some libertarians today argue that society is a myth, that no one has responsibility for the outcome of hundreds of millions of health-related decisions, and that anyone who asserts such responsibility and tries to act upon it is both an arrogant tyrant and an existential threat to the essential freedoms upon which our nation was founded. Nothing (and no tiny group of argumentative people) has ever been more profoundly wrong.

Thomas Jefferson, that true student and teacher of liberty, amended John Locke’s famous trilogy (life, liberty, and estate) and wrote that all people have an inalienable right to life, liberty, and the pursuit of happiness. Jefferson also wrote: “Liberty is to the collective body, what health is to every individual body. Without health no pleasure can be tasted by man; without liberty, no happiness can be enjoyed by society.” What does the right to life mean if one does not also have access to known and widely available life-preserving and life-enhancing diagnoses and treatments? How can one meaningfully pursue any individual definition of happiness if one cannot afford essential care for a sick child, a breadwinner, or a disabled spouse or parent? In short, what is life and happiness without health?

At the same time, what is happiness if “too much” of your hard-earned income or wealth is taxed away, even it is taxed to pay for the critical needs of others? Especially if “too much” is defined subjectively (as it must be in the end), based on one’s personal understanding of the facts?

Crisis and Covenant

For an unusual but very helpful way of answering these questions, put recent work by the Institute of Medicine alongside some ancient teachings in Leviticus, the third book of the Torah and of the Old Testament in the Christian bible.

The Institute of Medicine’s 2009 report, America’s Uninsured Crisis: Consequences for Health and Health Care, affirmed and updated its 2002 conclusion that roughly twenty thousand Americans die every year because they do not have access to routine but efficacious care because they lack health insurance. This means that over the fifteen years since we stopped debating the Clinton plan for comprehensive health reform, we have lost three hundred thousand of our fellow citizens to our collective failure to ensure coverage for all. No one doubts that the main reason the vast majority of the uninsured lack coverage is cost. That is to say, we effectively ration care — and life — by income, and every student of and participant in our health care system knows it.

Chapter 23, verse 22, of Leviticus admonishes the landowner at harvest time to leave a bit of the crop in the field so that it may be “gleaned” by the poor and the alien. Later books written by Moses and by later prophets (as well as the Qu’ran) used the more frequently taught and remembered formulation, “widow, or¬phan, and stranger.” Why was feed¬ing the hungry such an important ad-monition? Because otherwise those on the fringes of community might starve, having no established property right to food (you had to be an adult male to own land in ancient Palestine)—and preventable starvation was simply unacceptable. It violated the sacred covenant with God. Every human being was made in the image of God and therefore had the right to participate in the life of the community—the right to life. Landowners were called to be stewards of their own “estate,” and of the fruit of their labors (in Locke’s sense), so that no one would starve, even those who did not share family, tribal, or even reli-gious connections. Even in America, where social solidarity is nowhere near prophetic or even European standards, we have food stamps and food banks. We honor the ancient covenant to feed the hungry in every community.

Health care has become like food. It is a unique gift, capable of sustaining and enriching lives stricken with illness. Since all of us could be stricken with serious illness, since all of us could lose our job and our insurance tomorrow, all of us are also potential “strangers,” which is to say that our commitment to the covenant is ulti-mately self-interested, as it was in biblical times. That does not make it less sacred.

At the same time, it is important to read the call for stewardship implicit in Leviticus carefully. Leviticus does not say to bring the poor home and cook for them; it says, Leave some of the harvest in the field for them to glean. Our oldest obligations have always been mutual: it is perfectly and morally acceptable to expect personal responsibility from the beneficiaries of our covenantal largess.

Leviticus also does not say to leave all the food that one poor person might want, nor does it admonish the landowner to make sure that everyone has the exact same amount of food. Leviticus expects the landowner to exercise stewardship over his resources so that his own self-interest is preserved, as well as the fundamental requirements of fellowship within the community. That is what stewardship is: leaders have to take care to set rules and make key choices to prevent imbalances that would lead to unacceptable outcomes, such as some being left out altogether or the land being overworked or abused and losing its productive capacity.

Policy Implications

Mapping this ancient lesson onto stewardship requirements for our health care system seems straightforward to me. Political, economic, and health system leaders — the “landowners” — must make sure that our system serves all of us at a basic level (and not just all Americans, but all residents and visitors, if you interpret “stranger” in the Biblical sense, as I am recommending). At the same time, rules and choices must be made so that the system will be sustainable over time, and thus able to serve all of us in the future.

Those rules include restructuring insurance markets to make them both fairer and more efficient. We should require all insurers to end discrimination based on health status and all individuals to purchase insurance (or enroll in a public program for which they’re eligible). The choices include a sliding scale subsidy schedule that ensures affordability, and reforming payment structures in the Medicare program to realign provider incentives so that they engender a far more efficient delivery system. The savings from this, plus reducing the current regressive tax subsidy for employer-provided health insurance, should be enough to make our financing and delivery systems sustainable over time.

Changing the system along these lines will likely require constant reevaluation of system performance in access, quality, and cost dimensions. At the moment, spending 16 percent of the national gross domestic product (almost twice the average in developed nations) yet leaving 16 percent of our population out of the system (while other developed nations typically include all of theirs) is prima facie evidence that our system needs a fundamental realignment of incentives and redistribution of access rights. Such change simply cannot be afforded, however, unless we also simultaneously undertake an effort akin to the “parting of the waters” to improve the efficiency of our health care system. This will not be easy, but the payoff in social cohesion will be worth it, and the ancient admonition of stewardship demands no less.

Len M. Nichols, PhD, directs the Health Policy Program at the New America Foundation. Previously, he was the vice president of the Center for Studying Health System Change, a principal research associate at the Urban Institute, and the senior advisor for health policy at the Office of Management and Budget.