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Recent national polls suggest that the American people continue to be deeply divided over the Patient Protection and Affordable Care Act (ACA), also known as “Obamacare,” which will pass a significant milestone this week with the opening of state-based health care insurance exchanges. An NBC News/Wall Street Journal poll conducted in early September revealed that 44% of respondents believe the law is a bad idea, while 31% favor it. Those numbers are echoed in a similar poll conducted in late August by USA Today and the Pew Research Organization. But of the 1,000 respondents to the NBC News/Wall Street Journal poll, only 30% claim they understand the law well or very well, while nearly 70% admit they don’t understand the law well at all, or only somewhat. That’s really no surprise given that the original legislation, as enacted, was 906 pages long.
Obamacare rests on four legs. First, there is the creation of health care insurance “exchanges” – marketplaces – in each state. In these exchanges, private insurers will compete for the business of individuals and families who do not now avail themselves of health care insurance through employers. This will include not only the presently uninsured, but self-employed people, low and moderate earners with only partial or expensive health care insurance, workers currently enrolled in subsidized public plans, and others.
Second, there is a mandate to insurers known as guaranteed issue and community rating. Essentially, it says that no insurer can deny coverage, while also limiting the scale of premiums that insurers can charge based on medical history. As one might expect, this mandate could get expensive for the insurance industry.
To cover those additional costs, Obamacare includes a third leg, what is known as the “universal mandate,” which says that all persons – young and old, healthy and sick – must obtain coverage or pay a fine. The universal mandate is intended to expand the health care insurance customer pool by driving those who are young and healthy – in other words, those who often avoid buying insurance – into the market. The entry of these customers, it is hoped, will offset the costs of guaranteed issue.
The fourth leg is public subsidies for those who can’t afford even the lowest premiums in their state exchanges. This would be accomplished by an expansion of Medicaid, the current health care insurance program for those in poverty.
What many people may not know is that the ACA grew out of conservative Republican soil. The universal mandate, the most controversial element in the plan, was an idea first hatched by the conservative Heritage Foundation in the 1980s. Later, when Hillary Clinton was planning a much more European style overhaul of the American health care system, Republicans in Congress proposed an alternative that was Obamacare in embryonic form. And of course the ACA itself was largely modeled on Mitt Romney’s highly successful reform of health care in Massachusetts. In keeping with its conservative provenance, what Obamacare does not do is set up a system of government health care delivery, as is found in the United Kingdom (and, for that matter, in the US military). Nor does it make the federal government the “single-payer” for health related expenses. The majority of Americans will continue to pay premiums to private insurers, either directly or through their employers. Those insurers, in turn, will pay health care deliverers for services rendered, much like what happens now. In some cases, the federal government will pay some portion of those premiums directly to insurers on behalf of their customers. And in other cases the federal government will pay health care providers directly, as is currently the case with Medicare and Medicaid. In essence, Obamacare essentially reorganizes the private health care marketplace in order to achieve universal participation rather than erecting a kind of national health system.
But of course, the devil is in the details, and the ACA has been highly controversial from the start. The United States Conference of Catholic Bishops (USCCB), with some reluctance, opposed final passage of the original legislation on three grounds: that the bill allowed for federal funding of abortions through those plans that offer abortion coverage; that the conscience provisions built into the bill were insufficient; and that the bill did not afford adequate coverage for immigrants. The second of those concerns was deepened significantly when the Department of Health and Human Services (HHS) issued a mandate in 2012 that would require all employers to offer contraceptives coverage as part of their employee health insurance packages. Church organizations themselves, such as dioceses and parishes, could claim an exemption, but that was not the case for institutions distinct from the hierarchical Church, such as hospitals, universities, and the like. Similarly, private employers and others who might object to contraceptive coverage on religious grounds were denied an exemption. Timothy Cardinal Dolan, Archbishop of New York and President of the USCCB, framed the bishops’ objection succinctly when he said that the mandate represents the “raw presumption of a bureau of the federal government to define a church's minister, ministry, message, and meaning.”
Aleteia asked several prominent Catholic critics of the ACA for their thoughts on the law. George Neumayr, an author and contributing editor to The American Spectator, sees a broader and darker purpose to the ACA. “Obamacare represents one of the greatest government-directed assaults on religious freedom in American history,” he said in response to our request for comment. “Obama shrewdly saw that federal control over medicine would serve as his most effective instrument of social engineering, as government dominion over health care means government dominion over all stages and dimensions of life. The contraceptive mandate is just the beginning in the coercive transformation he has in mind.”
Writer and blogger John Zmirak likewise detects a conspiracy against the Church. The ACA, he said, “is un-American, and inimical to the freedom of the Church. That was the intent of the laws’ authors. There is no way that any federal system of health care would NOT include birth control and abortion. We critics of the law knew that beforehand. The bishops who supported the bill should have listened to us.”
Stephen Krason, a professor of Political Science and Legal Studies at Franciscan University of Steubenville, frames his opposition to the bill in terms of the American political tradition of limited government. “It is not so clear that the federal government has a role in legislating matters such as this,” Krason said, noting that the Federalist Papers prescribed a national government concerned only with large matters of public policy. “The middle class will particularly suffer from this, particularly those working in the private sector, because all indications are that health insurance premiums will balloon. It is difficult to say quickly what could be an alternative to the health care law. There may be a wide range of options that sober-minded decision-makers could consider. The important thing is that it doesn't have to be – and should not be – a federal government solution.”
Zmirak, too, sees a federal solution as a break with the American tradition and as a violation of Catholic principles. “A federal law enforcing a common system of health care on hundreds of millions of Americans violates subsidiarity,” he said. “The president has no more business arranging every American's health care than he does choosing which foods each of us buys at the supermarket – however important nutrition is to health … this is a power-grab by the federal government that is intended to be irreversible.”
So, from a Catholic point of view, is the ACA a lost cause? Not quite. The faithful application of Catholic Social Teaching (CST) to an issue as labyrinthine as health care insurance frustrates easy conclusions – or at least, it ought to do so. There is no question that Obamacare, when viewed through the lens of CST, presents serious problems. But to demonstrate the complexity of the issue, let’s look at the funding of abortion. It is true that Obamacare permits private insurers to offer abortion services, including those plans in which insured persons receive subsidies for their premiums. On the other hand, the law gives great latitude to states in designing their health care exchanges. As a result, since the passage of the ACA, 23 states have to one degree or another banned abortion services from the plans that will be offered in their exchanges. Abortion advocacy organizations like Planned Parenthood and the National Women’s Law Center have been howling about it. What difference does it make? Potentially quite a bit. Various studies have found that up to 87% of private insurers today offer at least some coverage of abortion procedures, which means that many Catholics have been paying for abortion through their pooled premiums whether they have known it or not. Even the Archdiocese of New York has, no doubt unwittingly, been participating in a private health insurance that covers some abortion services. Now, under Obamacare, Catholics and Catholic employers in states like Missouri and Virginia will be able to select a health insurance plan that they know, with certainty, will not implicate them financially in abortion.
That’s just one example of the complex set of new realities being created by the ACA. But it’s important to remember the original impetus for the law was not to reduce costs – although that’s a hoped-for outcome – but to ensure access to affordable health care for the millions of Americans who don’t presently have it, as well as hundreds of thousands of families that are routinely driven into penury by denial of coverage based on pre-existing conditions, or revocation of coverage based on dollar caps or even illness. For Catholics, the dignity of the human person is an essential first principle, but so are the primacy of the family, the preferential option for the poor, the common good, and solidarity. Those principles don’t argue for one approach or another when it comes to health care insurance, but surely they indict a regnant system in which millions are left behind by what Pope Emeritus Benedict XVI called the “commercial logic” of the health care marketplace, and in which the leading cause of family bankruptcy is unpaid medical bills. Obamacare is certainly not perfect – it must be amended to add or bolster protections for life and conscience – but it does address significant injustices in the present system, in accordance with Catholic teaching.
Then there is the issue of subsidiarity, which was mentioned or alluded to by those quoted above. As one writer has noted, subsidiarity is not a catch-all argument against the role of government. It is a methodological principle that simply means that a function should be performed at the lowest appropriate level in a given social order. Subsidiarity is not the same as the American liberal tradition of “limited government,” although the two may dovetail nicely from time to time. In the Church, subsidiarity means that it is inappropriate for the Holy See to manage the details of a religious order’s election of superiors or the finances of a bishop’s chancery. On the other hand, it is entirely appropriate for the Holy See to promulgate binding rubrics for the celebration of Holy Mass, which is why every priest is guided by something called the “General Instruction on the Roman Missal.”
According to the Catholic tradition, government is a natural institution with the positive mission of securing the common good. This includes physical protection of the population, but it also means maintaining a just juridical order and ensuring the conditions and means that enable integral human development. The State acts in accordance with the principle of subsidiarity when it encourages subordinate governments, mediating institutions (like the Church), and individuals to act freely in accordance with their appropriate rights and responsibilities, all the while reserving to itself the obligation to do likewise. In the case of Obamacare, it is not clear that the law necessarily violates subsidiarity. As noted, the ACA doesn’t nationalize either the health care delivery or health care insurance markets. A private citizen is still free to choose his private insurer, just as he remains free to choose his private podiatrist or internist. Rather, the ACA nationalizes the principle that affordable health care ought to be universally accessible, and establishes mechanisms for making that principle a reality. This has long been a goal shared by the bishops of the United States. The Compendium of the Social Doctrine of the Church, citing Gaudium et Spes and two papal encyclicals, says unambiguously that the “demands of the common good are dependent on the social conditions of each historical period and are strictly connected to respect for and the integral promotion of the person and his fundamental rights. These demands concern above all the commitment to peace, the organization of the State’s powers, a sound juridical system, the protection of the environment, and the provision of essential services to all, some of which are at the same time human rights: food, housing, work, education and access to culture, transportation, basic health care, the freedom of communication and expression, and the protection of religious freedom. (#166)”
Unfortunately, as so often happens, the debate over Obamacare has been caught up in a wider partisan and ideological battle between competing liberal visions, one left and one right. Much of the commentary on both sides, even when offered by Catholics, mirrors these visions and filters Church teaching through them. But we’re called to do the opposite; we’re called to filter the culture through the lens of the Gospel and the authentic teaching of the Church, including her social doctrine. In so doing, we may see clearly what needs to be corrected or done away with in the ACA, but we may also see what ought to be preserved and cherished.