Health Care: Freedom to Not Care?

Over the last two years or so, as our country has debated reforming our health care system, I have been hearing a decent amount of mean-spiritedness toward those who can't get affordable health insurance or who can't get it all.  I used to believe that Americans generally shared a commitment to the goal of universal access to health care and that the debate was over whether the Affordable Care Act (aka "Obamacare") was a constitutional way or, even if it is, the best way to get there.

I'm not so sure anymore.  While I think most Americans do still share that goal, based on what I hear people say, a far too large segment have come to the conclusion that we should continue to be the only major industrialized country in the world without it.  They seem to think that the poor (and not-so-poor) and the sick are in some way different from us and undeserving of being a part of us.  I even heard today someone who called himself a libertarian say that we should repeal the Reagan-era law that requires hospitals receiving Federal funds to provide emergency care without regard to ability to pay and that, if people can't pay, tough luck, deny them care.

I have to believe that this is very much a minority view, and that most Americans, Democrats, Republicans, and Independents, believe that we do have an obligation to help those who need it.  In fact, if we call ourselves Christians and have any sense of what that means, we must know that, to answer Cain, we are our brothers' and sisters' keepers (Gen. 4:9).  (In fact, if you consider yourself a good Catholic, you should know that your Church expressly considers access to basic health care to be part of the common good, which everyone has a right to enjoy.)

I recognize that, despite liking many of its components (but not the individual mandate), most people don't like Obamacare.  But, I suspect that if you ask them what we should do if the Republicans get their wish and the Act is struck down or repealed, you get a fairly incoherent answer, like the one Mitt Romney gave Jay Leno last night on The Tonight Show (as reported by the Washington Post):

LENO: So you would make the law stand for children and people with preexisting conditions.

ROMNEY: People with preexisting conditions—as long as they’ve been insured before, they’re going to continue to have insurance.

LENO: Suppose they were never insured?

ROMNEY: Well, if they’re 45 years old, and they show up, and they say, I want insurance, because I’ve got a heart disease, it’s like, `Hey guys, we can’t play the game like that. You’ve got to get insurance when you’re well, and if you get ill, then you’re going to be covered.’

LENO: I know guys at work in the auto industry, and they’re just not covered...they’ve just never been able to get insurance. And then they get to e 30, 35, and were never able to get insurance before. Now they have it. That seems like a good thing.

ROMNEY: We’ll look at a circumstance where someone was ill, and hasn’t been insured so far. But people who have had the chance to be insured—if yu’re working in an auto business for instance, the companies carry insurance, they insure all their employees—you look at the circumstances that exist. But people who have done their best to get insured, are going to be able to be covered. But you don’t want everyone saying, `I’m going to sit back until I get sick and then go buy insurance.’ That doesn’t make sense. But you have to find rules that get people in that are playing by the rules.

Romney's recognition of the adverse selection problem that the individual mandate is designed to solve makes sense; after all, he included that mandate when he was governor of Massachusetts.  The bigger problem is that, when asked what should be done for those with pre-existing conditions, who lack insurance, he couldn't, or wouldn't, answer.

And then we come to the Supreme Court.  As noted by Dahlia Lithwick on Slate.com, "It’s always a bit strange to hear people with government-funded single-payer health plans describe the need for other Americans to be free from health insurance. But after the aggressive battery of questions from the court’s conservatives this morning, it’s clear that we can only be truly free when the young are released from the obligation to subsidize the old and the ailing."  Now, if the justices are, as I think, in the Federal Employees Health Benefit Plan, as I am, it isn't totally Government-funded--we pay premiums--and it isn't single payer.  But her basic point is a good one.  Those most against Obamacare are those who already have insurance.  We have it; why should we care about anyone else?  Tough luck, suckers!  Justice Scalia even seemed to not have a problem with getting rid of the obligation for hospitals to provide ER care to all.  (“Well, don't obligate yourself to that.”)

This morning in America’s highest court, freedom seems to be less about the absence of constraint than about the absence of shared responsibility, community, or real concern for those who don’t want anything so much as healthy children, or to be cared for when they are old. Until today, I couldn’t really understand why this case was framed as a discussion of “liberty.” This case isn’t so much about freedom from government-mandated broccoli or gyms. It’s about freedom from our obligations to one another, freedom from the modern world in which we live. It’s about the freedom to ignore the injured, walk away from those in peril, to never pick up the phone or eat food that’s been inspected. It’s about the freedom to be left alone. And now we know the court is worried about freedom: the freedom to live like it’s 1804.

Some Republicans, Like Paul Ryan, seem to idolize the selfish theology of Ayn Rand.  Is this fantasy the kind of country we want to live in?

NetsforLife

 


After our Eucharist Sunday at St. Christopher's, the Rev. Janice Tidwell, a deacon at Christ Church in Macon, spoke to us about the NetsForLife program to help eradicate malaria in sub-Saharan Africa.  This program, which is strongly supported by Episcopal Relief & Development and our Diocese of Atlanta, provides specially treated mosquito nets to 17 countries.  The nets both directly keep mosquitos from biting and infecting people, often younng children, and the treatment in the nets kills the anopheles mosquito--the only known mosquito to transmit malaria--thus helping to break the infection cycle.  Research has shown that when three-quarters of the people in a community use the nets properly, malaria transmission is cut by 50%, child deaths are cut by 20%, and the mosquito population drops by as much as 90%!  Since 2008, NetsforLife has delivered over $5.6 million nets and this helped reduce worldwide malaria deaths by about 200,000 last year (according to World Heath Organization statistics).

It only costs $12 to buy a a net.  Help support the Episcopal Church's NetsforLife Inspiration Fund, where a group of donors has promise to match every gift made through May 25, 2012, up to a total of $430,000!  (Of course, you don't have to be an Episcopalian to do this.)

Why I like "Obamacare"

I haven't cared much for the term "Obamacare", mainly because it's pejorative usage quickly became more about the President and less about the care.  I saw in a Politico article today that the Obama campaign has decided to embrace the term and emphasize the things that people like about the Affordable Care Act, often until they learn that these things are a part of it.  I think that's wise.  There is no point for the re-election campaign to try to pretend that President Obama didn't have anything to do with it, so they should try to turn the term of abuse to their advantage.

I suppose this is a planned bumper sticker:

What do I like about Obamacare?

First, it's a first step, and an important one, on the goal of providing real access to health care to all Americans.  I have trouble understanding how anyone can oppose that as a goal, although there can be different ways of reaching that goal.  The Catholic Church expressly considers access to basic health care to be part of the common good, which everyone has a right to enjoy.  My own denomination, the Episcopal Church, as well as many others, also supports the creation of a system that provides basic health care.  When people talk about repealing Obamacare, we should ask what they would set in its place and how would that point us towards that goal?

Second, on a personal level, Obamacare has allowed us to include our adult son on my health insurance policy.  Before, when he turned 22, he came off my policy and the only options were far more expensive.  According to the National Center for Health Statistics, 2.5 million more young adults now have health insurance because of this.  Because this group is generally very healthy, the impact on premiums has been small (about 1%). 

Third, preventive services, including cancer screenings, vaccinations, and well-child visits, are now provided with no co-pay, co-insurance or deductible.  I make a point of reviewing my plan each year and I had always been amazed at how poorly we covered preventive services.  We would make it more expensive for the patient to be checked than to treat the preventable disease, even if the cost of the health care needed to treat the disease was far more expensive!  With this new requirement of Obamacare, we will spend less over time and have a generally healthier society.

Fourth, insurance companies can no longer cancel your insurance coverage, often retroactively, because of a technical mistake or minor omission on an application.  This was called rescission, and would usually happen when you had a major, expensive, illness.  Your company would go back and look for a technical reason to rescind your policy and not only refuse to cover you, but demand that you repay anything they had paid on your behalf!  Now, to do this, the company has to show that you intentionally misrepresented or omitted significant information.

Fifth, a serious illness will no longer prevent a person from having access to affordable insurance.  Some people have been uninsured, not by choice, but because they have pre-existing conditions that caused them to either be unable to get insurance at all or they had to get policies that excluded the condition that was most likely to cause them to need health care in the first place!  In the 1980s, when I was director of the child support office in Montgomery, Alabama, one of my clients could not afford to get off welfare (which she wanted to do) because she would then lose her Medicaid coverage and one of her children had a severe medical condition that would not be insurable.  Now, under Obamacare, the Pre-Existing Insurance Plan, or PCIP, provides primary and specialty care, hospital care, and prescription drugs, with no exclusions for pre-existing conditions.  A citizen or legal resident must have been without coverage and either have a pre-existing condition or been denied coverage because of one. 

And these are things that are in effect now. 

We need to remember what the point of health insurance is.  It is to spread the costs of health care more evenly across the population over time.  I have had health insurance through my employer for over 26 years.  In all but two of those years, I likely paid more in premiums than my plan paid out for my health care, so in those years I helped cover other peoples' costs, with the understanding that this could have to work the other way.  And it did.  In 2010, I paid far, far less in premiums than my plan paid for my health care.  So other people helped cover my health care in 2010.  And there is nothing wrong with this, in either direction!  This is how a community works, helping one another for the common good. 

War and Justice

A week or so ago, a friend of mine posted a story on Facebook about Attorney General Eric Holder's speech at Northwestern on the legal justification for killing without trial terrorists who are American citizens.  (You can read the speech at http://www.justice.gov/iso/opa/ag/speeches/2012/ag-speech-1203051.html).  She said that she had doubts, but that wasn't an area of law she had much experience with.  I replied that I hadn't read his speech, but that I did have experience in that area (28 years as a military lawyer before my retirement) and I would find it and read it.  Now I have.

Before I go into what he said, a little background for framework.  There is a fundamental difference between war and criminal prosecution.  Military operations are not predicated on the commission of a crime.  If I take an enemy soldier prisoner, we are allowed under international legal norms to detain that person for the duration of the conflict, without any assertion that what that soldier was a crime.  For that reason, we aren't required to hold any kind of hearing to keep him.  Similarly, if we attack an enemy soldier, we aren't doing it because he committed a crime, its simply because he's an enemy soldier.  (And, yes, history shows that women can and do fight, be captured and die in combat.  I am simply using the masculine pronoun for simplicity.)

When I say "enemy soldier", that has a meaning in the law.  An enemy soldier is considered a "lawful combatant".  To have that status, he must be a member of an armed force of a state and wear some type of distinguishing clothing.  Everyone else is an "unlawful combatant".  A civilian has no legal right to engage in combat, and, as long as they aren't attacking our forces, civilians can't be targeted.  Members of non-state actors like al Qaeda don't qualify as "lawful combatants".  This doesn't mean that they have no rights if detained; it means they must be treated humanely and their status determined by a lawfully constituted tribunal.

Sorry about the length of this digression, but you will see nowhere do I talk about citizenship or trials or due process.

Now, in his speech, Attorney General Holder talked about the successes we have had trying terrorists in Article III civilian courts.  This was in opposition to proposals that all such trials be by military commissions at Guantanamo.  He said there are times that it makes sense to use a court and there are times when it make sense to use a commission.  Some of the considerations are status (the accused is not a member of an al Qaeda linked group), citizenship (by statute, U.S. citizens can't be tried by a commission), the offense charged (commissions have a more limited list of offenses they can address), and international cooperation (some countries won't cooperate with us if a person were to be tried by commission).

He then turned to when we can use lethal force.  He pointed out that the use of "all necessary and appropriate force" against the threat of attacks by the Taliban, al Qaeda and similar groups was authorized by Congress in 2001 (Authorization for Use of Military Force, Pub. L. 107-40).  This therefore qualifies as an armed conflict and under international law, we can take action against enemy belligerents wherever they may be found.  While we must respect another country's sovereignty, established norms allow us to act without a country's consent, if that country is unwilling or unable to deal with a threat in its territory.

It is completely legal to target the adversary's chain of command, including senior military leaders.  Holder referred to the World War II targeting and shooting down of the plane which carried Japanese Admiral Yamamoto.  This concept was a justification for the killing of Osama bin Laden.

If a US citizen takes part in the planning or execution of violent attacks against Americans, their citizenship does not give them immunity from targeting.  Even with that lack of immunity, the Government believes that the Fifth Amendment's Due Process clause does require a determination that the individual poses an imminent threat  of violent attack against the US, capture is not feasible, and that the operation be conducted in a manner
consistent with the four fundamental law of war principles which govern the use of force.

The principle of necessity requires that the target have definite military value.  (An example of this principle can be seen from the Saddam Hussein's Victory Arch in Baghdad.  In Desert Storm, when General Schwarzkopf wanted to have the Air Force destroy it, he complained that the lawyers wouldn't permit it without a showing of necessity, which he couldn't make.  It's still there today.)

The principle of distinction means that only lawful targets--combatants, civilians directly participating in hostilities (including the chain of command), and military objectives--may be targeted intentionally.  Under the principle of proportionality, the anticipated collateral damage must not be excessive in relation to the anticipated military advantage.  (There is no rule that collateral damage must be completely avoided.)  The principle of humanity requires that we not use weapons that inflict unnecessary suffering.  (The textbook application of that rule is the prohibition of glass shrapnel, which can't been seen as well on x-rays.)

Are there limitations to this concept?  Holder said that this concept only applies when a U.S. citizen who is a part of al Qaeda is found outside of the U.S.  There is no "hunting license" in the United States and it is contrary to our traditions to have our military carrying combat operations on U.S. soil.

For that is what they are--combat operations.  (We are now transitioning to what Paul thinks of this.)  For that reason, they must be carried out by our military and not the FBI or CIA and absolutely not by contractors.  But, I think from a legal point of view, this is no different than if an American citizen decided to serve as a senior German officer during World War II.  That citizen would be as much a legitimate military target as the German citizen serving with him.  The same concept applies today.

[To comply with Defense Department rules, I probably should say that the views presented here are my own and do not necessarily reflect the views of the Department of Defense or its components.]

Back Again

It's hard to believe almost two years have gone by since I last posted here. As is normal in life, there have been changes. Pertinent to this place, I no longer preach at my church as we now have a full-time priest and a full-time deacon to do that and they're far better than I am. I'm content to listen and learn.

Education for Ministry is in the home stretch of my final year. This will likely be a good place to record how it feels to complete what has turned out to be a significant experience in my life.

And we have an election this year. Another opportunity to discuss values.