America’s health care system is insane. As David Goldhill observed in a 2009 Atlantic piece, asking an insurance company to pay for a routine visit to the doctor is like filing an auto insurance claim every time you fill up. Because they don’t have to worry about out-of-pocket expenses, patients try everything, no matter how much it costs or how remote the chances that it will help. Insurance costs don’t rise because insurance companies are especially greedy. Costs keep rising because of dynamics inherent in the system.
We’ve got the best medical gizmos in the world, but wizardry doesn’t necessarily translate into better care. My father, a general practitioner of the old school, spent hours with his patients, and often found that a long conversation was as therapeutic as medicine. Some were his patients from delivery to death. Today, patients spend less than five minutes each time they visit the man or woman who knows the most intimate details of their physical lives.
And stuffing the federal government between patient and doctor doesn’t help. Since insurance drives up costs, requiring insurance won’t lower them. As Thomas Sowell puts it, “it is amazing that people who think we cannot afford to pay for doctors, hospitals, and medication somehow think that we can afford to pay for doctors, hospitals, medications and a government bureaucracy to administer it.” Amazing, unless you recognize that the government administration’s purpose will be to determine what people really need, which will inevitably be less than what people think they need.
Whether Obamacare stands or falls, we need to rethink American health care in a more fundamental way. Jacques Godbout’s analysis of The World of the Gift offers a framework for imagining alternatives. Following Albert Hirschman, Godbout describes three spheres of modern society, characterized by “exit,” “voice,” and “loyalty.” The sphere of “exit” is the market, where relationships are functional, temporary, and contractual. In the market, you can walk away. Politically, people in a democracy want a “voice” at the ballot box, in town meetings, and in other venues of public debate. Families, churches, and neighborhoods are organized around more intimate and more permanent relationships involving personal “loyalty.”
There are serious drawbacks to providing health care exclusively through the market or through the state. Understandably, many Americans have reservations about leaving something as essential to human flourishing as good health to the chance allocations of the market. Doctors know things that butchers or cobblers don’t. Even when he pays for care, a patient is not a customer.
When the state dispenses services, Godbout points out, it “seeks either to supplant the primary networks or to make use of them in order to achieve its objectives.” States “constantly strive to define people’s ‘real’ needs in their stead.” Rather than taking account of individual differences, a bureaucracy “tends to make decisions independent of personal relations and characteristics, on the basis of abstract criteria derived from rights.” Despite rhetoric to the contrary, state-run health care is not public charity or gift-giving. The motives and structure of government services are inevitably and dramatically different from personal giving or charity. With health care, this is a fatal weakness. Impersonal health care is not care.
The alternative is to shift health care as much as possible to the sphere of personal service and interpersonal loyalty. As a midwife, my wife conducts pre-natal exams, attends births in the family’s home (no matter how long it takes), and makes a series of postpartum visits. She fields phone calls at all hours throughout the pregnancy and beyond. Many of her clients are young women from our church, and those who start out as “clients” often end up as friends. She doesn’t take insurance or Medicaid, so her overhead is minimal. She provides intimate, professional care to healthy moms and babies, at a fraction of the cost of a hospital birth.
This model could be extended to other areas of primary care. A physician friend has long dreamed of becoming a church physician, providing services at low prices or gratis, his base salary paid for by a church or Presbytery. If a physician set up a practice on this model, if he refused both private insurance and government funds, he could get by with a small office and a tiny staff. He could carry a black bag and do most of his work with house calls. Because she is a community of salvation (which derives from the latin salus, which means health), the church is an ideal setting, but a doctor to set up a similar practice through a community co-op.
Something like this vision of care has long guided the church, a pioneer in health care for nearly two millennia. It’s still viable, and more necessary today than ever. It won’t happen without a fight, and the most strenuous opposition will come from the professionals of the current system. For example, in some states, medical lobbies have ensured that midwifery is highly restricted or illegal.
Providing health care in the sphere of “loyalty” doesn’t overhaul the system, but it is an advantage: Communities, churches, and individuals don’t have to wait on Congress to personalize care or provide services to patients without insurance. In the long run, it might chip away at the system by helping to confine insurance to its proper role—providing emergency help for expensive, specialized procedures and treatments.
If it survives, Obamacare will only cause more turmoil. If it’s repealed, we’re back to the insurance-driven system that everyone admits is a mess. Meanwhile, women will get pregnant, and kids will get the sniffles and break bones. Individuals, community organizations, and churches have an opportunity to respond with low-level, low-cost, personalized service. We need a fresh start, and disciples of the divine physician should take the lead.
Peter J. Leithart is on the pastoral staff of Trinity Reformed Church in Moscow, Idaho, and Senior Fellow of Theology and Literature at New St. Andrews College. His most recent book is Athanasius (Baker Academic).
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