3.3 Greater Good Test Case (Health Care)

 We finish chapter 3 in the series, "What Would Jesus Vote?" Here is the series so far:

1. Would Jesus Even Vote?
2.1 (He would vote) As a Kingdom Citizen
2.2 We're citizens in two kingdoms
3.1 (He would vote) for love of neighbor and enemy
3.2 (He would vote) for the greater good

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Test Case: American Health Care
8. This discussion is all fine and good in the abstract. But where the rubber begins to hit the road is with specific issues. This is where our tribal sensibilities and gut assumptions begin to overwhelm our reason. It is also where our lack of expertise can begin to bite us. Things that seem obvious to us on a superficial level may become more complicated when we dig into the details.

Nevertheless, we need to explore the issues if we are going to make any progress toward a more Christlike approach to our political engagement. The question of health care seems like a good test case for the concept of the greatest good for the greatest number. So we gulp and step into deeper waters.

Let us start with the most general question. Would Jesus want as many as possible to have access to good health care whether they are believers or not? The answer seems pretty obvious to me. After all, healing and exorcisms stood at the very heart of his earthly mission. As far as we know, there wasn't a person he didn't heal if they sought him for healing.

To repeat some things we've already pointed out. God sends the much-needed rain on the righteous and unrighteous (Matt. 5:43-48). He sends the much-needed sun on both the righteous and the unrighteous. What would Jesus vote? At least at first glance, it sure seems like Jesus would vote for as many people as possible to have health care.

So what might prevent a Christian from supporting universal health care? Someone might try to show that it isn't economically feasible. Perhaps someone could argue that providing universal health care in some way lowers the overall average health care. Someone might argue that it is unconstitutional in some way, or a Christian might argue it is somehow unbiblical or unethical. 

Let's look at these counterarguments. Since the Affordable Care Act (ACA) is the current American option on the table, let's use it as our point of discussion. We can add that the United States is the only major Western country that does not provide universal health care in some configuration. Canada uses private providers funded by taxpayers to provide it. The United Kingdom has a government-run system funded by taxpayers. Germany and France have a mixture of providers funded by taxpayers, and the government oversees the system.

9. This is as good as any place to have an aside about the socialist boogie man. There is a fair amount of illogical rhetoric that says, "If you believe the government should run anything, you're a socialist." This is irrational on the merits. There is a spectrum of options from a government that runs practically everything to one that runs very little. Here is a spectrum:

• Truly Socialist: North Korea and Cuba would be examples of true socialism. North Korea currently allows no private enterprise and the government runs everything. It is a horrible place to live.
• Social Democracies: Sweden and Denmark have very high taxes to provide extensive governmental services, and their markets are heavily regulated. Nevertheless, they also allow significant economic freedom and have a vibrant private sector. They consistently score among the happiest nations in the world.
• Social market economies: Germany and France have less government regulation than Sweden but still have significant government-run services. The private sector still runs freely despite being a strong welfare state. They consistently score higher than the US on the World Happiness Report.
• Capitalist welfare states: Canada and the United Kingdom are capitalist countries that still provide significant social services based on taxes.
• Free Market Capitalism with some Welfare: The United States and Australia would have fewer taxes yet and fewer government services. Still, we have Social Security and Medicare. We have public education and a postal service, not to mention an army and police that are government-run.
• Libertarian Leaning States: Singapore and pre-2020 Hong Kong are/were examples of states with few government services and very limited government intervention in private enterprise. Nevertheless, Singapore does have some government services relating to housing and healthcare, and Hong Kong was returned to China's control in 2020. 
• Anarcho-Capitalist countries: There ain't any. Without any government, you would just have human chaos.

You can see that the US is nowhere near socialist, and no current candidates come anywhere close to socialist. Logically, you can't simply dismiss proposals by saying, "That's socialist." I call that "labelism," and it's a nothing burger. You need to have an argument as to why a specific proposal is good or bad.  The US currently has a number of government-run services that we will talk about throughout our journey. 

Let me also say, "prove it" to those who think privatization is always better for the greater good. I would say it is often good, but we should consider each case individually. For example, having a centralized national defense surely works far better than if you had a host of competing mercenary and private military groups running around. Talk about a civil war waiting to happen! And don't like a particular conflict? Just quit.

Capitalism aims to maximize profit. Its intrinsic goal is to provide as little as it can get away with at minimum cost. When Bolivia privatized its water supply, it led to a disaster that ended with the government renationalizing it. A private company, without government regulation, will cut as many corners as it can to maximize profit. These dynamics suggest that when essential services are in view, the government may be better suited as the provider -- or else it had better regulate thoroughly.

Let's put a pin in that conversation and come back to it as we move through various topics. We'll take a case-by-case approach with the repeated dictum, "Prove it."

11. First with regard to cost. Because emergency care is regularly provided to individuals who cannot pay, both a thoroughly adopted ACA system or a single-payer system like Canada/Britain would lower or significantly lower the overall cost of health care in America. Healthcare costs in the US are significantly higher than those of Canada, Britain, Australia, Germany, France, etc. Meanwhile, our life expectancy is lower. On the merits, we have no bragging rights here. On the numbers, we are not providing a greater good to a greater number in the area of healthcare.

12. A second concern is health care quality and wait times. Because of those who aren't covered and because of the higher cost of health care, the US does not provide better health care for its population on average. It would rank lower on average among the countries we have been considering. Places like the UK emphasize primary care, so there can be wait times for elective care, but there is no extensive wait for essential care. 

In England, one can walk into an emergency room and get immediate service. When I was a student in England, I was a little shocked that we immediately went to the hospital when a Rugby player sprained his ankle. My family avoided the hospital like the plague because of the high cost of emergency room services. 

My father had some sort of heart event a few weeks before he finally died. They didn't go to the hospital even though Medicare would have paid. In my opinion, years of avoiding the emergency room were in play. My mother actually hung up on 911 when he died, thinking a twitch of his toe might mean he was still alive. I have another family member who eventually had a heart attack after failing to get proper medical care for diabetes. Again, in my opinion, none of the above would have happened in Canada or Great Britain where the mindset is just different.

Australia supplements its essential public care with private insurance options. In this way, it maintains a baseline of public health while providing options for those who can afford more for elective services. At least on the surface, a system like Australia seems to provide the best of both worlds. It seems to provide a greater good for a greater number than the American system, which largely caters to the privileged -- a differentiation that finds no basis in the Gospels. The Gospels give us every reason to think that Jesus would reject such a class differentiation.

The ACA of course was based on a Republican-designed system utilized in Massachusetts and involves a market-based approach based on competition between private insurance companies. In other words, it is a capitalism-based system. One has to wonder if it would have enjoyed widespread Republican support if it had been proposed by a Republican administration! Of course, then, it might face widespread Democratic opposition. One has to wonder the extent to which opposition to the ACA has been about partisanship rather than substance.

13. What, if any, opposition to it can be made on biblical or Christian principles? Wayne Grudem in his Politics According to the Bible has made several arguments against the ACA and similar health care proposals. [4] Probably the most serious concern he had was its provisions for contraceptive care and abortion. However, the Supreme Court decisions Burwell v. Hobby Lobby Stores, Inc. (2014) and Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania (2020) have mitigated those concerns. Similarly, the repeal of Roe v. Wade has changed that dynamic as well. It is really a side issue rather than an objection to universal health care per se.

Grudem is also concerned that it dulls personal responsibility. Rather than having to steward one's resources and count the cost for one's choices, one can take health care for granted. Healthcare becomes devalued because it is in such easy supply. Instead of reserving the emergency room for real crises, one now goes for a sprained ankle.

I feel this one a little bit. But I feel this one as someone who has health insurance. Is it better for everyone to have access to healthcare, or is it better for those of us with healthcare to grow from having to make careful choices about using what we have? It seems like an argument for the privileged rather than one that is concerned for the greater good of all. 

Again, knowing what I know of the Gospels, Jesus seemed more concerned that the crippled beggar (without health care) be healed than that the Pharisee grow in personal responsibility by making disciplined choices (can't even think of a story like this). In the end, I believe Wayne Grudem and others are unable to see beyond their Western glasses to read the Bible on Jesus' terms.

I will set aside for a later chapter the argument of Grudem and others that Romans 13 does not allow the government to provide services to its people like healthcare. In my opinion, this takes Paul's comments way beyond anything he was saying. Paul is not giving a comprehensive view of the state in Romans 13. 

And, even then, he calls the state a servant for the Romans' good. If the Roman government had decided to use the tax money it collected to provide healthcare for its citizens, I have to think that Paul would have approved. More on this question in chapter 6.

14. That leaves us with one last objection, and that is the individual mandate. The way the ACA was meant to work financially was that everyone was required to have health insurance or else to pay a fine. After all, the way insurance works is that there are enough healthy people paying for insurance to offset those who need health services. By requiring young people who are not as likely to need health services to pay toward it, the system became financially viable.

Suffice it to say, the Republican-controlled Congress in 2017 kiboshed the individual mandate. Interestingly, premiums for the ACA have still remained relatively stable. Only about 8% of Americans are not covered with some sort of health insurance at the moment, down from 16% before the ACA. All in all, the ACA would seem to be somewhat of a success, although it arguably would have even greater success if it had bipartisan support.

It does raise a bigger question of whether it is biblical for me to have to pay for someone else. Some would view the individual mandate as tantamount to stealing. You are taking my money to pay for someone else.

But this is a pretty Western cultural way of thinking -- hyperindividualistic. It's not biblical thinking. After all, what are taxes but a way of collecting money to provide services to everyone as needed? And the Bible unanimously says to pay taxes. And the collection could be for you. You don't know when you'll need medical help.

In the end, this all strikes me as a self-centered way of thinking, not a biblical one. The spirit of Scripture is rather, "Whoever has the life of the world and sees a brother in need and withholds his compassion from him, how can the love of God abide in him?" (1 John 3:17). Isn't this also part of the message of the Parable of the Good Samaritan in Luke 10? In other words, it seems more like the selfish mindset of the world to resist giving to those in need. Shouldn't a person with a biblical, Christlike heart gladly give -- even sacrifice -- for the good of others? It's God's money in the end anyway, not mine. [5]

We will return to some of these questions more extensively in the chapters that follow. I will make the case that the American capitalistic system makes money something different from something concrete like a hammer. If you come into my garage and take my hammer, that's stealing. But the system of money in a country like America is a little different. The Gross Domestic Product (GDP) isn't even tied to something concrete like a gold standard. Its value is much more abstract. More to come.

15. In the end, it seems fairly clear to me that -- on this one issue -- Jesus would vote for as many people to have healthcare as is practically possible. If you think of it, giving away free healthcare was a major theme of Jesus' earthly ministry. He did not cater to the wealthy and privileged who could pay for his services. He targeted "the uncovered," so to speak.

In the end, objections to something like the ACA seem to me almost entirely based on tribalism. In some cases, it is based on what I would see as extreme ideology. But in general, one side suggests a solution so the other side opposes it. It could have been flipped, and it might be the opposite. Mitt Romney could have become president and proposed something like the ACA, and maybe Democrats would have staunchly opposed it.

What would Jesus vote? On this one issue, I think he would vote for as many people to have healthcare as possible.

[4] Wayne Grudem, Politics According to the Bible (Zondervan, 2010).

[5] Ron Blue, God Owns It All: Finding Contentment and Confidence in Your Finances (Lifeway, 2016).

The Parable of the Insistent Treasurer

There was once a treasurer, who had the key to the city's treasury.  On the day that he was supposed to unlock the treasury to pay all the workers in the city and the people that the city owed, he decided to take a stand.

You see, the mayor of the city had convinced the leaders of the city to require everyone to get a doctor. Some people said, "I already have a doctor, but now I'll have to pay more to help others who don't." Some said, "Why should I have to get a doctor when I don't need one right now?"  Others said, "This new rule is too complicated and will actually make things worse."  Of course many also saw it as a wonderful thing and believed that almost everyone in the city would now actually have a doctor.

Nevertheless, the law passed and despite repeated attempts by the treasurer to defeat the new rule, he was foiled at every turn. He took it to the judge but the judge did not stop it.  He tried to get a new mayor, warning the people they would have no other chance to change the rule. But the people re-elected the same mayor as before.  Most of the city accepted that the new rule was going to happen, even those who had opposed it.

But the treasurer was re-elected too, and on the day that he was supposed to unlock the treasury he decided to take one last stand.  "I will not unlock the treasury to pay the city's bills unless the mayor and other city leaders will stop this new rule or at least delay it until I can think of another way to destroy it. Unless they will change or at least delay, then the workers in the city will go without pay and we will not be able to pay the other cities from which we have borrowed. A sizable minority of the people in the city agree with me, and we will take our stand on principle because the leaders and majority of the city are wrong."

I don't know how the story ends.  How do you think it ends?

Living the Love Command: Health Care

continued from yesterday
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...Another issue that has embroiled the United States in recent years has to do with whether the government should orchestrate a system that provides health care to all Americans as much as possible. Such laws are incredibly complex and involve multiple angles. For example, there is the question of whether such a system would break America financially and thus inadvertently cause far more harm than any good it might do. There is the question of whether the United States government would administer its part of such a system efficiently, or whether such programs tend to turn into cumbersome bureaucracies.

But there are also some philosophical and theological questions that are often raised for which we have clearer answers from the values of Jesus. Would Jesus object to a tax on me that would benefit others? Certainly he would object to an oppressive tax, one that did harm to me and especially one that primarily functioned to make someone else rich. But the New Testament unanimously teaches that believers should pay taxes (e.g., Mark 12:14-15; Rom. 13:7; 1 Pet. 2:13) and unanimously discourages hoarding personal wealth.

At the very least, Jesus would commend those who give to others who are truly in need. “Do to others what you would have them do to you” (Matt. 7:12). Surely a normal person, the person Jesus has in mind, would want medical help when he or she needs it. Giving so that others might have medical help is thus very much in keeping with Jesus’ values.

Most of us are not the sort of expert who could speak authoritatively about whether a particular law might be a good one or might be effective to provide health care to all people. But the initial bias of the Jesus follower will inevitably be that if it were possible for me to contribute in such a way that more people would have health care, then my spirit will want to do that. The bias of a Christian toward the goal is not ambiguous—it is toward helping others in need. Only the way in which that need might best be provided might be ambiguous for the Christian.

Although we shouldn’t have to provide further support, the New Testament is full of instruction that unequivocally endorses this attitude. “Carry each other’s burdens, and in this way you will fulfill the law of Christ” (Gal. 6:2). “In humility value others above yourselves, not looking to your own interests but each of you to the interests of the others” (Phil. 2:3-4). “As we have opportunity, let us do good to all people, especially to those who belong to the family of believers” (Gal. 6:10).

There are other questions of course. Even though this is the attitude Christians should have toward helping others, should a Christian support forcing those who do not have the mind of Christ to contribute to the help of others. I personally believe that God grants a good deal of freedom to others to disobey his will. He will set the world straight eventually, but for now he largely lets us self-destruct with our own selfish and sinful behaviors.

The case is different when my selfish behavior and freedom hurts someone else. So God surely would want me to stop a murderer from exercising his or her freedom to murder. So at what point does providing for the health of others, including saving the lives of others, move out of the realm of God’s allowance for personal freedom and move into the realm of moral obligation? At what point do we fine the priest and the Levite for not helping the mugged Israelite, and make it a law to be a good Samaritan?

The end of the whole discussion is that specific legislation will be complicated and will require the expertise of many to determine whether it is advisable or not. What is clear theologically is that Jesus would have supported a system that provided health care to those who did not have it. He would have spoken harshly to those who resisted it for selfish reasons, just as Matthew 25 speaks to those who could have helped the hungry and thirsty, but chose not to do so. The spirit of Jesus is clear, even if we might take different positions on how to work out those values.

Republican Advice...

Adam Thada mentioned in a comment that David Wright had linked to this article. I finally read it and liked a good deal of it too. Here is the better part of it:

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1) One of the worst things about the Democrats' plan is the method of financing: an increase in tax on high-income earners. At first that tax bites only a very small number, but the new taxes will surely be applied to larger and larger portions of the American population over time.

Republicans champion lower taxes and faster economic growth. We need to start thinking now about how to get rid of these new taxes on work, saving and investment -- if necessary by finding other sources of revenue, including carbon taxes.

2) We should quit defending employment-based health care. The leading Republican spokesman in the House on these issues, Rep. Paul Ryan, repeatedly complained during floor debate that the Obama plan would "dump" people out of employer-provided care into the exchanges. He said that as if it were a bad thing.

Yet free-market economists from Milton Friedman onward have identified employer-provided care as the original sin of American health care. Employers choose different policies for employees than those employees would choose for themselves. The cost is concealed.

Wages are depressed without employees understanding why. The day when every employee in America gets his or her insurance through an exchange will be a good day for market economics. It's true that the exchanges are subsidized. So is employer-provided care, to the tune of almost $200 billion a year.

3) We should call for reducing regulation of the policies sold inside the health care exchanges. The Democrats' plans require every policy sold within the exchanges to meet certain strict conditions.

American workers will lose the option of buying more basic but cheaper plans. It will be as if the only cable packages available were those that include all the premium channels. No bargains in that case. Republicans should press for more scope for insurers to cut prices if they think they can offer an attractive product that way.

4) The Democratic plan requires businesses with payrolls more than $500,000 to buy health insurance for their workers or face fines of $2,000 per worker. Could there be a worse time to heap this new mandate on smaller employers? Health insurance comes out of employee wages, plain and simple. Employers who do not offer health insurance must compete for labor against those who do -- and presumably pay equivalent wages for equivalent work.

Uninsured employees have now through the exchanges been provided an easy and even subsidized way to buy their own coverage. There is no justification for the small-business fine: Republicans should press for repeal.

That platform is ambitious enough -- but also workable, enactable and likely to appeal to voters. After 18 months of overheated rhetoric, it's time at last for Republicans to get real.

I've been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes, it mobilizes supporters -- but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead.

Now the overheated talk is about to get worse. Over the past 48 hours, I've heard conservatives compare the House bill to the Kansas-Nebraska Act of 1854 -- a decisive step on the path to the Civil War. Conservatives have whipped themselves into spasms of outrage and despair that block all strategic thinking.

Or almost all. The vitriolic talking heads on conservative talk radio and shock TV have very different imperatives from people in government. Talk radio thrives on confrontation and recrimination.

When Rush Limbaugh said that he wanted Obama to fail, he was intelligently explaining his own interests. What he omitted to say -- but what is equally true -- is that he also wants Republicans to fail.

If Republicans succeed -- if they govern successfully in office and negotiate attractive compromises out of office -- Rush's listeners get less angry. And if they are less angry, they listen to the radio less and hear fewer ads for Sleep Number beds.

So today's defeat for free-market economics and Republican values is a huge win for the conservative entertainment industry. Their listeners and viewers will be even more enraged, even more frustrated, even more disappointed in everybody except the responsibility-free talkers on television and radio. For them, it's mission accomplished.

For the cause they purport to represent, however, the "Waterloo" threatened by GOP Sen. Jim DeMint last year regarding Obama and health care has finally arrived all right: Only it turns out to be our own.

Historic Health Care Bill passes

I know that feelings run high on this one. Indeed, there will be challenges ahead of various kinds. Republicans in the Senate will try to stop the fixes. There will be legal challenges made, and we know that the make-up of the Supreme Court leans "conservative." Frankly, might a Republican Congress and President completely reverse it in three years?

In any case, I wanted the historical marker here. If you can do it civilly, what is your prediction for the days to come--specifically (generic ranting isn't what I'm looking for)? Do you agree with the independent budget office that it will reduce the deficit over 100 billion dollars in ten years and a trillion in 20? Does it foretell a huge defeat for the Democratic party in the Fall and next presidential election? Will there be riots? Will the insured forget about it if there is no real change to their insurance? Will those who have to get insurance ultimately be glad to have it? Will it lead to the greatest fracture between the states and the government since the Civil War? Will someone try to assassinate certain lead Democrats? Will history look back at this decision as a crucial moment in the decline of the United States as a superpower, or will history wonder why anyone ever argued against it?

Again, civilly, specifically, what do you think the concrete consequences will be? If I remember, I might check back in a year to reflect on what things look like then.

National Health Care Conversations

This morning I was privileged to sit through the first "National Conversations" forum put together by Indiana Wesleyan University and co-sponsored by the Sagamore Institute, Christianity Today, and WFYI in Indianapolis. Here is the website, where you can watch the "civil conversation" today on health care.

It was very enjoyable. Knowledgeable people on multiple sides of the issue. Former Mayor Bart Peterson was the only one I had known of previously. There were advocates for removing state boundaries on buying insurance, advocates for reducing the way doctors are paid, advocates for innovation in rewarding wellness, advocates for a long term solution and not just a short term fix...

I really liked Peterson and am sorry he won't run to replace Evan Bayh. He basically said that both extremes are unconvincable and that we should be working with the moderates on both sides of the isle toward solutions.

I did have a typical dream, for which I would like to give credit for the inspiration to my nephew Alan Garcia. One of the complaints by the Dean of the IU Med School is that doctor's accumulate a debt of about $150,000 in school. Yikes! What about a med school that made you a nurse first and then a doctor? You would work as a nurse and get paid well for it while then going on to be a doctor.

I also had other brainstorms. Teaching hospitals associated with universities where this scheme was implemented, with salaries rather than pay according to how many tests you perform or patients you see.

One of the most interesting bits of data from the day was the fact that Americans pay more than any other nation for our health care and get significantly less health care for it. In other words, the amount of money we currently pay for health care would be enough to insure everyone in America if we had a health care system like any other developed nation in the world (Canada, Germany, Britain, France, etc...). Also, I forget the statistic, but some outrageous number of tests we have done here (30%?) are unnecessary.

The Perfect as the Enemy of the Good

I'm sure he didn't come up with it, but I so resonate with the line of Bill Clinton this past week: "Don't let the perfect become the enemy of the good." It goes right along with what I wrote earlier this week about compromise being far from a bad word the vast majority of the time.

Here Christians need to be especially careful. Most pop-Christianity confuses our clear belief in definite right and wrong with absolute right and wrong. I can think of little in the Bible that treats the vast majority of ethical decisions as a matter of absolutes, which by definition are exceptionless. Rather, the more normal expectation of the New Testament is that of universally valid moral expectation, with allowances for exceptional situations.

Jesus made exceptions to the sabbath rule and to purity rules--people trumped rules for him. Paul made exceptions to purity rules and, indeed, relegated vast portions of the Law to Jews alone, and only then when those portions did not conflict with the greater principle of the unity of the body of Christ. Were there ethics to which they did not make exceptions? Of course! But to get off on those issues (adultery, murder, etc) is to commit the fallacy of diversion. The vast majority of Christian ethical norms are universally valid with exceptions. Indeed, Paul treats the sabbath legislation in a relativistic fashion, as a matter of conscience (Rom. 14:5; Col. 2:16). In that case, he did not consider the sabbath rule even to be universally valid.

As I said earlier in the week, some is better than none almost all the time. Obviously the "want their perfect" liberal Democrats are unhappy, and the "do nothing" Republicans are unhappy. I don't know enough of the particulars of this health care bill to know what to think. But I am encouraged that it has been forged only by way of massive compromises. I am encouraged that the"government is your nanny" Democrats are unhappy. And I am encouraged that the "It's not my fault you live in a dumpster" Republicans are unhappy. And I am encouraged that Obama is not an idealist but a pragmatist.

We'll see, of course, but it seems to me that something is better than nothing. And this bill will apparently cut the deficit $130 billion over 10 years, with roughly 94% of eligible Americans covered. Christians can legitimately be upset about many potential elements of this equation--maybe it won't do what it says it will. Maybe it will lead to massive problems down the line, greater pain. Maybe it will reinforce various kinds of injustice. Maybe. I don't know.

But I don't see how we cannot legitimately hope that this bill will help a lot of people who currently struggle. We can't be disappointed if it actually turns out to do good for a lot of people, even though we can legitimately have significant doubts.