Health Subsidiarity, or Solidarity, or Socialism (Take Your Pick)

[Cross-posted to Front Porch Republic]

The debate over health care reform in the Senate has moved into overdrive, with one possible compromise following another in rapid succession. The two crucial issues upon which the ability of the Democratic leadership to get the 60 votes needed to effectively move forward hinge are, as most folks who follow these things already know, the coverage for abortion services provided by many private insurance plans, and the exact make-up of the government-run "public option" insurance plan--or, as right now seems likely, whatever kind of regulated marketplace emerges in exchange for killing it. It is all, I frankly confess, way too much for me to be able to follow with the sort of patience and expertise it deserves, especially since I know everything could change by the time I finish this post. The most I can do is offer a slightly wider theoretical perspective, on why I am--mostly, anyway--on board with what the Democrats are trying to make happen, despite the fact that it may very well create a national bureaucracy that is neither particularly local nor especially democratic, two huge concerns of mine.

The very short answer is, blame Catholicism. But since, of course, I'm never satisfied with very short answers, I'll go further.

I'm not Catholic, but Catholic thinkers--including, but not limited to, various pontiffs--have played a large role in my thinking about community and justice. Probably the primary reason for this is that the various strands of Catholicism provide one of the few deeply thought out attempts to authoritatively situate Christian morals and duties into modern, pluralistic polities. Central to the majority of these strands is the oft-abused but still essential concept of subsidiarity. I can't do worse than to quote my old dissertation advisor here, Steve Schneck:

The root of the word is the Latin subsiduum, which is also the same root for our English word subsidy. Subsiduum was used, among other things, in reference to the morally weighted giving from those who had to those who had not...So, from its original root, subsidiarity invokes that hallmark idea of Catholic social teaching: the preferential option for the poor. Moreover, it shares with its root a context in the social order as a body-like whole, in which everyone has moral obligations vis-à-vis others in light of the common good. From subsiduum eventually comes the Latin subsidiarius, which refers to a person to whom a subsiduum should be given. In Roman-based systems of law, courts’ concern with compensation to a subsidiarius was to avoid either overcompensating or under compensating. Overcompensating, it was reasoned, undermined the ability of those in our care to take responsibility for their own duties to the community and society. It sapped initiative. Under compensating, just the reverse, would not provide enough subsidy to those depending on us for them to fulfill their potential for themselves and the social order.

Subsidiarius, thus, hints at an ethic at the heart of any correct understanding of subsidiarity, especially in application to questions about the proper role of government in executing public policies. Subsidiarity requires that policies be performed by the most appropriate level of the social order to achieve results without too much overage or too much underage in the application of power or resources. Overage creates unwanted dependency. Underage fails to fully satisfy needs relative to the common good.

This isn't strictly an argument for subsidiarity as doctrine, of course; if anything, it's an argument for common sense in the application of Christian principles of charity. Who wouldn't want those in a position to give anything--money, first aid, advice, whatever--to be those in a position to know what exactly what was needed, and how it was needed, and how much, with the real needs and the integrity of the person in mind? But Catholic reflections on subsidiarity further allow that a "common sense" solution is also one that will work towards the common good of the whole community: strengthening the capabilities of and the relationships between individuals throughout the various "levels of the social order," as Steve puts it, will be generative of more positive, more moral results overall. This makes sense to me; it appeals to my communitarian instincts, and it seems substantiated by events I've witnessed throughout my life, in my family and in my congregations and in the communities and societies I've lived in.

Of course, what does that have to do with health care reform? Nothing, necessarily: Steve concludes by observing "nothing in Catholic social teachings, including the idea of subsidiarity, requires that America’s health care crisis be addressed with a particular policy approach, whether by state, private enterprise, voluntary associations, or anything else," and I assume he's correct. That being said, this way of framing the question gets to the heart of the matter. Surely actual health care--the actual doctor or midwife or nurse examining you, healing you, offering you succor and relief--needs to be and ought to be as local and face-to-face as possible. But given that we have (for the most part gladly!) embraced many of the technologies and monopolistic reforms (such required medical degrees and licenses) that have limited, concentrated, and thus skewed the availability of the kind of extensive, often life-saving, medical care which doctors, midwives and nurses can provide these days, costs come into the equation. So the question is rephrased, as a commenter named Rex rephrased it in this post of mine from last summer: can medical insurance be local? So rephrased, the question becomes a different one entirely.

John Médaille wisely observed in a fine, follow-up post of his on health care reform that insurance programs almost invariably end up replicating the classic tactics of a monopoly, and this is especially the case when the insurance plans which most Americans use to pay for their medical care is tied to their place of employment; employers and insurers easily can--and regularly do--collude to create obstacles and perverse incentives that keep most employees committed to their (often increasingly restrictive) plans, not to mention creating pools of applicants (how many children do you have? what is your health history?) that often leave people with serious health needs out in the cold. Ideally, our system of employer-provided insurance would be scrapped entirely, making room for something a little bit more amenable to individual choice. But, given the realities of our political system, the prospect of insurance companies supporting a move by the national government to encourage alternatives to the sweet deals they have worked out with their various corporate and institutional parties over the years was never likely. Could, by contrast, the government impose common requirements upon all independently offered health care plans, so as to minimize the aforementioned skewed distribution of resources and costs? John rightly, I think, observed that if you were going attempt that kind of half-way reform, you might has well just have a single-payer arrangement, like they do in Canada. That would at least cut down on the duplication of administrative costs.

But the difficulties of our political system rise up again: single-payer was also never a truly serious option in this prolonged debate (though some have managed to keep the idea alive in the House version of health care reform, on a state-by-state basis). Which brings us to what we have in the Senate today--not even a half-way reform, but a quarter-way reform, at best. Still, even this quarter-way reform injects the national government into the question of medical insurance, through various acts of regulation, and through the possible creation of a nationally administered market of insurance exchanges (which may or may not include a government-run insurance plan, perhaps tied to existing government plans like Medicare, perhaps not). To many progressives, that's more than good enough; it means many millions of Americans who either cannot obtain insurance or who are driven into medical bankruptcy by tragedies they were unable to fully insure themselves against will have the coverage they need to survive, and perhaps even flourish. But to those who take seriously the principle of subsidiarity, the question is more complicated.

Susan McWilliams recently wrote an essay which focused on young adults who cannot obtain insurance; her conclusion was that any society that had a grasp on its own common good would develop a sense of "intergenerational awareness," which would bring us to recognize more fully the injustice and harm involved in so many young people having to forgo proper medical care because of the costs involved. The young should not, I think, be the primary target of concern here--following Christian teachings, I think the poor should be--but her post was a good one, perhaps especially because of the exchange it prompted between several commenters, John Médaille among them. In response to complaints (once again!) about "socialism" and health care, John trenchantly responded that "[i]n any community, there are obviously some services which need to be socialized," adding that if "one is really opposed to socialism, then one ought not to pull that socialist lever in his home, the one that makes his waste disappear in a whirlpool into the socialized sewage treatment system." I think that puts it just about right: assuming one does not reject the modern age (including modern medical care!) entirely, and assuming one accepts at least the bare outline of Christian teachings about both the common good and the integrity of the individual, the question is not "will the final Democratic health care reform proposals involve socialism?" but just simply "what level of socialism should we have?" Consider a couple of thoughts on this basic question.

E.D. Kain, building off some things I've written before, makes the point that if you care about local community, what you're likely really caring about is the individual and collective opportunity which the absence of centralization and monopolization makes possible...and that, therefore, you should probably be in favor--at least insofar as medical insurance goes--of some sort of national action to make "a national marketplace that is at once able to sustain large cost-sharing pools and also be highly competitive." Erik and I likely disagree on many of the particulars of the proposals and compromises being discussed right now, but we seem to be on the same page when it comes to recognizing that localism is best understood as a defense of local places which makes other, more populist options available, and not necessarily a restriction to local places, as they can very easily imitate all the sins of larger polities. (Something I've discussed more here.) Why a national market? Because our economy is national; our society is national; large employers--and the insurance companies they join together with, those very insurance companies that, for better or worse, the Democrats have chosen to work with and build upon, rather than oppose--are national. This is not something that can be done on a state-by-state basis (though obviously further, more radical or challenging reforms could be).

Peter Lawler, who himself isn't much of localist or populist, takes profound exception to this possibility, arguing, contra my own Christian Democratic sympathies, that "genuinely subsidiarity-minded Porchers [making reference to Front Porch Republic there] should be the most extreme opponents of the Pelosi/Obama health care reforms," and that "I'm all for subsidiarity as described by our philosopher-pope," which is why he opposes "European cradle-to-grave dependence on government." Two points of order here. First, how would the "Pelosi/Obama (what, Senator Harry Reid doesn't get a shout-out?) health care reforms" creative "cradle-to-grave dependence on government"? As outlined above, we are dealing with a lousy situation when it comes to medical insurance, with the majority of insurance plans being tied to employment and being run like little monopolies; and moreover, we are looking at a potential set of reforms that doesn't even go half-way towards making that lousy situation at all more reliable for most American citizens. This is not, in other words, a reform proposal that will result in hundreds of millions of Americans throwing themselves at the national government's feet. Second, while I am no expert in Catholic writing or thinking, it seems to me that Pope Benedict has made it clear that subsidiarity must be conjoined with "the principle of solidarity" since the former without the latter will result in "social privatism" (Caritas in Veritate no. 58). I take this to be a re-iteration of the fundamental point of the commonweal which is served through the providing of subsiduum in the first place: as the whole society is bound more closely together and made more just through common actions of interpersonal aid, so should those attempting to find the right levels of aid--in health care, or in anything else I suppose--be open to the role that society-wide actions (which, in the United States today, means federal government actions) may play in fostering such. Not in replacing all other agencies and actors who do such fostering, of course, but merely in doing something. Like, say, in structuring some national, equitable, reliable insurance markets, perhaps.

I realize a lot of Catholics aren't too impressed by Commonweal, considering a somewhat Catholic-lite magazine, but from this outsider's perspective, J. Peter Nixon's recent analysis of subsidiarity and the health care debate seemed persuasive to me:

In his 1991 encyclical Centesimus Annus, Pope John Paul II was critical of the tendency of the modern state to take on an ever-expanding range of functions to the detriment of private initiative. Pope Benedict echoed these criticisms of the "social-assistance state" in his recent encyclical Caritas in Veritate. Both encyclicals, however, also argue that the state must play a role in structuring markets so that the benefits of economic growth are equitably shared. The 2003 Compendium of the Social Doctrine of the Church attempted to summarize these key aspects of subsidiarity by noting that the principle must be understood in two senses, "negative" and "positive." Negatively, the state should refrain from restricting the initiative, freedom, and responsibility of the smaller cells of society. Positively, the state should provide the necessary economic, institutional, and juridical assistance that allows these cells to flourish....The principle of subsidiarity reminds the state that its role is to support and sustain the institutions of civil society, not to replace them. Nevertheless, to the extent that threats to those institutions arise from the workings of the market, Catholic social teaching envisions an active role for the state in their defense....

Health-care reform will increase the role of the federal government principally in the areas of financing care for the uninsured and regulating the health-insurance market....[P]roviding insurance to those who are not well served by our employer-based system has long been a responsibility of the federal government. While some of this expansion in coverage will come from expanding public insurance programs like Medicaid, most will come from subsidizing employers and individuals so that they can purchase private coverage. The second way in which the federal role is likely to expand is in the area of insurance regulation....For the most part, these expansions of the federal government’s role in health care are designed specifically to address problems that lower levels of government have failed to solve. While the number of uninsured has been above the 40-million mark for more than two decades, very few states have been able to marshal the resources needed to extend coverage to this population. States have also faced a difficult time in reforming insurance laws to eliminate various types of coverage exclusions. [Thus the] case for a federal role in these areas is strong.

I am not the sort of progressive (assuming I am any sort of progressive--which I suppose I am, though a fairly odd one) who believes that the key to making our polity a more just, more community-minded one is to simply grant more power and more reach to the most powerful actor around, the federal government. There are many ways in which I think it ought to be--needs to be!--restrained and cut back. But here, in this rather particular matter of medical insurance, I don't see it. Call it socialism, call it solidarity, call it subsidiarity, call it whatever you want: from my study of the proposals under debate--which, as I said at the start, is hardly expert, though I do my best--they are not programs which will doom all efforts to preserve local communities and popular democracy, or even force people necessarily to choose between those goods on the one hand and a more just and equitable providing of patented American-style complicated health coverage on the other. They are, instead, relatively legitimate "subsidiarian" efforts that will maybe, just maybe, make locality and democracy that much easier for ordinary people, with ordinary health concerns, to achieve.