I am encouraged by the national debate on health care. I hope that the Congress will pass a far reaching bill that will touch the lives of all Americans on the scales I have mentioned above. As a Presbyterian I am theologically interested in the issues that are being debated. At its heart I think the central theological issue is couched in the question: Is health care a right or a privilege? Like most questions with this sort of dichotomy I expect the answer will be found in an amalgamation of the two. For me, I think health care is a right. However, I can understand how those with significant financial means and varying theological perspectives might feel otherwise.

The notion of health care being a right emerges out of the theology of stewardship. Stewardship implies and connotes a sharing of one’s resources. In many religious communities stewardship is experienced in the sharing of money and time. The same notion applies in regard to health care. It is a sharing of resources. Some seem to fear that in that sharing quality, freedom, and quantity will be decreased or maybe even lost. I would suggest just the opposite. My experience is that the quality of health care is driven by those involved and the technology that is continually evolving. I see no reason for that to change for the worse because the brightest and best are still attracted to health care and the technology is on a continual upward climb. Clearly freedom will be enhanced and expanded as people have options that are not necessarily available to all at this time. The issue of quantity is a moot question, in that we currently are providing health care for many people unable to provide any financial support. When the emotionally and politically exhausting debates are over and the dust has cleared it is my contention that we will adequately move on with improved health care for all.

Click here for a full text transcript of the conversation.

Host Ira Flatow said in his introduction:

“Lost in the fray [of acronyms and actuarial tables] is the whole reason to have the health care debate in the first place…we’re going to try to reel it back in to talk about our values. What role do they play in shaping health care policy?”

Flatow noted that in its recent collection of essays, Connecting American Values with Health Reform, “The Hastings Center has tried to bring values back into the discussion.”

Len Nichols, health policy director at the New America Foundation, also participated in the show. Nichols, a health economist who wrote an essay on stewardship for the Hastings Center collection, said that passage of the final health care reform legislation is contingent on leadership that promotes shared values. “It is sometimes true is that those values seem to differ among political antagonists….but when you probe deeply and get in a dialogue you find out the values are actually shared,” Nichols said. “I believe most people share them and therefore we will end up with a bill that moves our country forward.”

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

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.

This is the introductory essay in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner.  The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

Our mandate was to provide recommendations about what health insurers should and should not do with genetic information. This was the early 1990s; there wasn’t much information available about an individual’s genes, but the avalanche of genetic information was gathering strength. The first few pebbles had arrived recently, and ever larger ones, such as the tests for genes linked to breast and ovarian cancer, would appear soon. We had time—not a lot, but some—to plan for how private health insurers would deal with information about our genetic risks for diseases, from the rare and inexorable progression of Huntington’s disease to far more common ones such as Parkinson’s, diabetes, and heart disease. Health insurers were accustomed to shaping policies according to the risks people presented. If someone with cancer was like a house afire, someone with a genetic risk of cancer was a house with a smoldering pile of rags in the corner.

The standoff in that room, though, was puzzling. We asked the insurers if they believed that everyone should have access to insurance whatever their risks: Yes, they agreed, everyone should have access to insurance. So, they were in favor of universal access, right? No, they adamantly insisted, universal access would be the death of the  industry. Finally, we understood what frightened them: to insurers, universal access meant that people could sail along without any insurance coverage until the day they became ill, when they could march into the insurer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Everyone should have to pay their fair share and, when they needed care, their health insurance would be there to cover the cost. We described it as universal participation.  Fine, said the insurers, we can agree with that.

Among the lessons I learned from chairing the task force (including: Don’t fly from England to San Francisco and expect to control a contentious meeting), one stands out for this collection of provocative essays: understanding what’s at stake in a public policy debate is as vital as it can be elusive.

Connecting American Values with Health Reform is our effort to identify what is at stake amidst the swirling confusion of proposals for delivery systems, financing, cost control, and other details necessary for any practical reform. These details, though, are instruments carrying with them the impedimenta of history, habit, and interests.  To see things afresh, it helps to return to foundational questions: What do we want health reform to accomplish? What values should our institutions and practices be built upon, embody, and achieve?

The language of values has another virtue: Unlike health policy mavens, most Americans are baffled by the alphabet soup of program acronyms, economic models, and the difference between cost-benefit and cost-effectiveness analyses. Heck, most of us can’t explain the difference between Medicare and Medicaid. But we all understand what values are, and we can defend our preferences among them. Which leads to another reason The Hastings Center undertook this project.

Values can be wielded like cudgels to batter your opponents. That, unfortunately, has been all too common in recent political discourse. But values worth taking seriously — including all the values addressed in this collection of essays – are far more subtle, multifaceted, and interesting ideas that can cross political boundaries. Liberty, Bruce Jennings reminds us in an echo of Isaiah Berlin’s classic formulation, includes both freedom from and freedom to — and each of those meanings of liberty deserves attention in health reform. Liberty can mean the freedom from the imposition of a particular health plan and physicians; but it also demands a health care system that does not deny a would-be entrepreneur the freedom to pursue her vision, a freedom not available to the parent of a child with diabetes, for whom health insurance would be unaffordable outside the protective umbrella of a large group policy.

We chose the authors of these essays to represent a broad spectrum of beliefs. We assigned each of them a particular value to address, but we did not tell them what to say about it, other than to display the complexity residing within each value and spell out the policy implications of taking that value seriously for American health reform.

In reading these essays, I found moments of great illumination and insight along with occasional areas of disagreement; familiar ideas displayed in new and revealing aspects; new arguments, distinctions, and concepts. I was provoked, enlightened, and occasionally surprised. I hope that other readers will have a similar experience.

Most of all, I came away convinced that values are the beating heart of health reform, that these authors have begun a marvelous conversation about those values, and that the implications for American health reform are concrete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice.  Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform.

Second, when we acknowledge, as we must, that our goal is health, we are obliged to think much more broadly than our patchwork system of health care. Healthy children, healthy adults, and healthy communities are the outcome of many factors—from decent housing and safe areas for play and exercise to good jobs and schools.  Health care, crucial for episodes of acute illness and for the care of chronic diseases, is a significant but not dominant determinant of a community’s health. As responsible stewards of community resources, we should invest our finite public funds according to where they will do the most good. At times the best investment for health may be in education, job creation, or environmental protections, not in health care.

Third, the practice of individual underwriting in health insurance—making it harder to get the sicker you are — should be given a prompt funeral and buried with a stake through its heart. A concept such as actuarial fairness — which makes good moral sense in commercial insurance where risks are voluntary and the losses measured in money — has no place in deciding who gets access to the health care they need.

Fourth, efficiency and communal responsibility are essential if we are to have an affordable, effective, and sustainable health care system. This will require, at a minimum, systematically studying and improving the quality
and effectiveness of what we do in the name of health care. It will also require restructuring incentives so that providers are rewarded for results rather than for the numbers of procedures or tests they perform. There is good evidence that such changes would also lead to a higher quality of care.

Finally, the concept the task force developed more than fifteen years ago—universal participation—may be one whose time has finally come. The core idea is simple enough: everyone should be responsible for participating in whatever way is appropriate; when anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them. I was delighted to find the concept, if not the term, endorsed so often in these essays.

Whatever combination of private and public programs we choose, it’s a good time to connect American values with American health reform.

Thomas H. Murray is the President of the Hastings Center.