Subsidiarity and Solidarity in Health Care Reform

So often the political debate in America revolves around two seemingly conflicting values: solidarity and subsidiarity.  William Sage touched on the former.  Opponents of health care reform often talk about the latter.  But it is the intersection of these two values that matters most to American politics, and nowhere more so than in the health care debate.

Subsidiarity found its first articulation in Catholic social teaching.  Basically it’s the investment of authority at the lowest level of an institutional hierarchy possible, essentially relegating centralized authority to a secondary or subsidiary role.  In other words, the group closest to whatever task or problem should tackle that problem first, and only when they’re not able to should a higher authority step in.  In social terms, this might break down something like this: first, individuals are responsible for their own social welfare, then families, then communities, then local governments, then state governments, and finally the federal government.

In many ways, subsidiarity flies in the face of the more universalist notion of solidarity.  Subsidiarity requires that small groups and individuals tackle problems, while solidarity demands that we all band together.

Nevertheless, if we’ve learned anything from the health care debate, it’s that for any meaningful reform to take place, we need to find ways to make competing ideas work together.  More people need to be covered for less money.  Somehow more government involvement in the health care industry also has to lead also to less of a financial burden on federal and state budgets.

The nature of health insurance is one of cost-sharing.  Lots of healthy people buy into a larger cost-pool in an act of voluntary, if unintentional, solidarity.  Insurers, at least in theory, compete against one another for customers, the competition leading to a decentralized system of coverage and care.

The American health care system, however, has instead erected a status quo which relies entirely on employment for health coverage.  Coupled with a ban on interstate sale of insurance, this has led to much smaller cost-sharing pools and very little actual competition, with one insurer often dominating entire cities or regions.  The sale of insurance is bound to each individual state and fifty different sets of rules and regulations govern insurance sales across the country.   Consumers of health care are almost always bound to their employer’s choice for health coverage – and worse, should they lose their job, find themselves suddenly without any insurance at all.  Essentially, the American system has eschewed both solidarity and subsidiarity, in favor of an ad hoc system found nowhere else in the industrialized world.  In the end, this has led to skyrocketing costs.

Beyond cost-control, solidarity is the driving force behind health care reform.  The argument that no modern, industrialized nation should be without universal coverage is compelling.  But other Western nations have found ways to take this principle of solidarity, and achieve it through far more decentralized means than Canadian-style single payer, or the expensive socialized medicine of the UK.  The Dutch have achieved universal coverage entirely through fierce competition between private insurers, and the Germans use a system of exchanges that allow German workers to move from job to job without losing insurance.  The Swiss, who have made an art of subsidiarity, have achieved universal coverage through competing non-profit insurance plans.

The problem with American politics is that so often our leaders view bipartisanship as a path to the worst of all possible outcomes – the uninspiring middle-road wherein nobody is happy and little is achieved.  What many European models have shown us is that competing values can actually be used to achieve effective compromise.  Perhaps conservative means can lead to progressive ends, or vice versa.  In the health care debate, competition and subsidiarity are the best tools to create quality, affordable health care for the most people, and with the right implementation they can be used to achieve universal coverage.  In this way subsidiarity, rather than a competing value, becomes a complimentary one, and we find our solidarity through competition and individual choice.  Universal coverage can be achieved from the bottom up rather than from the top down.

What could be more American than that?