Healthcare as a Moral Issue

"Them thats got shall get
Them thats not shall lose
So the Bible said and still is news"
--Billie Holliday, "God Bless the Child"

The question of healthcare in America—who receives its benefits and on what basis, how one maneuvers one’s way through the system to receive the help one needs—has occupied a great deal of my thinking lately. I’ve been unusually fortunate in this regard, having a wife who knows how health insurance companies operate and a highly responsive referral coordinator with whom Karla has established first-name rapport. Now, on top of everything else, I’ve made it into USC’s medical network, where there is a high degree of communication and coordination between specialists in various fields, and where help really is only a phone call away. Once the system begins to work for you, you just take it for granted and quit asking critical questions about the system itself.

The reality, however, is that in America 21% of all adults, and 12% of all children, have no health coverage whatsoever. Among those living in poverty 45% have no insurance. (This doesn’t count the 31% who are on Medicaid or who receive some other form of public assistance.) In other words, the people who in their healthiest moments struggle to feed themselves and their families are the same ones who have no place to go when they are sick. Furthermore, the data on ethnicity and healthcare belie whatever notion we might have that racism is a thing of the past: blacks are 50% percent more likely than whites—and Hispanics 150% more likely—to be without insurance; the infant mortality rate among blacks is more than double that among whites, and the AIDS rate 9 times higher.

To concede that this is just the way things are, I think, shows a lack of moral imagination. Even more, if we who are the beneficiaries of this imbalance see no point in addressing it, then we are culpable of perpetrating an injustice. If, on the other hand, we will recognize our fundamental solidarity with men and women who, by reason of ethnicity or economic standing, do not have access to decent healthcare, it might awaken our imagination to conceive of a system that isn’t as dominated as ours is by market forces.

Michael Walzer provides a way of looking at this in his book Spheres of Justice. He points out that in any society there will be a complex array of social goods, each distributed according to its own criteria. So for instance, a society might recognize the value of luxuries, which are available to anyone who can afford them financially; education, which is available to whoever shows a basic capacity to learn; appointment to office, available on the basis of personal ability to carry out its duties; participation in the political process, available to whoever meets basic criteria of citizenship; and so forth. Of course, in such a system, all things aren’t distributed equally to all people. Everyone isn’t automatically entitled to the same amount of material wealth; everyone won’t attend the same number of years in school, or hold the exact same job, or attain to the same status of leadership. Inequality itself is not the problem.

The problem comes when inequality in one sphere becomes the basis for inequality in another sphere. To put it another way, when the criterion for distribution in one sphere becomes the criterion for distribution in multiple spheres, we wind up with a pattern in which one group of people can systematically dominate the others. I believe that a laissez-faire approach to the free market produces precisely such a system. Money, which is a perfectly logical criterion for determining who gets to enjoy luxury, becomes also the thing that empowers people politically, guarantees them a better education, opens doors to career opportunities, secures the means of producing more wealth, and gains access to adequate healthcare. Thus, the people who enjoy an abundance of that one social good are thereby in a position to monopolize all the social goods. It’s not enough to stoop to the cliché that the rich get richer and the poor get poorer. Rather, the rich live longer, gain more political power, attend better schools, receive greater honor in society, and pass their privileges onto their descendant, so that the poor find themselves increasingly hindered from obtaining the most basic goods necessary to live as dignified members of the community.

I’m not an economist, so I’m not qualified to lay out some alternative plan. But as an ethicist and a pastor, I do see it as my task to address people’s moral imaginations at least enough for us to say collectively, “This is not the best we can do.” Perhaps we can begin by debunking the notion that market forces are best left alone, without any kind of political intervention or any underlying commitment to the basic well-being of the community’s least advantaged members. If we have the moral and political will to honor our brothers and sisters who have been excluded from basic human goods, such as adequate health care, and to see to it that they have access to those goods that will enable them to participate fully and healthily in the community, then I believe that we will begin to develop ways to make that happen.