Subsidiarity vs. Single Payer

In his article, “Subsidiarity and the Single Payer,” Jack Quirk argues that a Single Payer system for health care services is consistent with the principles of subsidiarity and Catholic Social Teaching. He concludes his article by stating that the “principle of subsidiarity cannot legitimately be used to argue against a single-payer healthcare system. … Those who argue against it will need to avail themselves of something outside of Catholic social teaching for support.” His argument seems to depend on two points which I think are incorrect. The first is that the question of subsidiarity “does not turn on jurisdiction, but on competence. Subsidiarity is not federalism.” The second is the fact that some health care services are very expensive, and the fact that health insurers in the United States lack the power to contain those costs, means that the highest level of government has the right and responsibility, according to the principles of subsidiarity, to step in to assist paying for all health care services. This response is an explanation of why I believe he is wrong on both points.

When Mr. Quirk says subsidiarity does not “turn on competence,” it isn't clear if he means the term in the sense of "ability." However, it is clear that he is proposing competence as opposed to jurisdiction, and he seems to equate jurisdiction with federalism in his article. Subsidiarity is based on human nature and the natural and moral laws. This is what determines who has the natural role for given responsibilities, and those who have a role have a natural jurisdiction, which we could also call competence, to fulfill it. Following the principles of subsidiarity, we understand that the higher orders of society have the function and responsibility to provide assistance (subsidium) to the lower orders when needed. This is why the state has no right to usurp a parent’s role in educating children, but does have the right to assist (but not to compel) parents with the education of their children. The Church teaches that “it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do.” [1] One can use subsidiarity to determine what roles are proper to the different levels of society. In other words, competence in the sense sense of Catholic Social Teaching is not incompatible with jurisdiction, and we can discuss jurisdiction and authority without resorting to, or resulting in, federalism.

The initiative, freedom and responsibility

of lower orders of society must not be supplanted.

“Subsidiarity, understood in the positive sense as economic, institutional or juridical assistance offered to lesser social entities, entails a corresponding series of negative implications that require the State to refrain from anything that would de facto restrict the existential space of the smaller essential cells of society. Their initiative, freedom and responsibility must not be supplanted.” [2] Just because a condition is common across the country does not make it the responsibility of the federal government. If the assistance can be rendered community by community by more local social institutions or governments, then the federal government would be violating the principle of subsidiarity if it took over the role of rendering that assistance. The federal government could only justify stepping in where those more local institutions didn’t already exist or lacked the resources to address the issue. “In light of the principle of subsidiarity, however, this institutional substitution must not continue any longer than is absolutely necessary, since justification for such intervention is found only in the exceptional nature of the situation.” [3] In other words, part of that assistance would be to help establish the more local institution and help it to arrange acquiring the necessary resources on its own so that the assistance being given will become unnecessary. In addition, the principle of subsidiarity means that the federal government cannot step in where the more local institutions exist and have the ability to deal with the issue at the local level.

Many people assume that only the federal government can afford to adequately assist those in need. This is simply not true. If the taxes to provide this assistance were collected by the state rather than the federal government, then the state could render the assistance. If they were collected by county government rather than the state, then counties could render the assistance. If the principle of subsidiarity were really being applied, then the tax structure would be distributed so that higher levels of government would not need to step in except where the need went beyond the more local governments.

In regard to the supposed inability of health insurers to contain the costs of health care, in what way does this justify implementing a single payer system? It is arguable that the payment structure imposed by those insurers (and the government) have contributed to the overall increase of costs. Insurance companies make money from people paying premiums. Therefore, it is beneficial for them if the costs of even relatively inexpensive health services remain high enough to make the overwhelming majority of people rely on insurance to pay for all health care.

“An absent or insufficient recognition of 
private initiative – in economic matters also – and the failure to recognize its public function, contribute to the undermining of the principle of subsidiarity ...” [4]

Our current model of providing and paying for health care is not the only possible one. To take just one example, subscription based medical providers have proven to make general and preventive care very affordable for the average family. For poor families who cannot afford the subscription, the costs are low enough that religious and other more local organizations or government can render the assistance of paying for their subscriptions. If we implemented this type of system as a standard, medical insurance would only be needed for emergencies and long term conditions and for particularly expensive procedures. This would lower the overall costs of insurance making it more affordable for families and making local institutions more capable of assisting those who cannot afford insurance. Subscription based medical services is only one of many ways that the means of acquiring health care services and lowering their costs could be addressed.

Single Payer is proposed as a permanent solution established at the highest level of government to render assistance that could be rendered by more local social institutions and governments if we only had the will to give those more local institutions and governments the ability to perform their roles. It is not limited to assisting with only those health care costs which are prohibitively high or only those people who cannot afford other means to pay for health care. In the name of “assistance” it usurps the responsibilities of the family and more local institutions and absorbs their natural roles into the highest level of government. It might be true that assistance from the federal government will be needed during the process of implementing better access to health care and transitioning the role of government support to more local levels. However, as a permanently instituted system, Single Payer is clearly a violation of the principle of subsidiarity and Catholic Social Teaching.

Continued in Part 2

Notes:

[1] USCCB/LEV, Compendium of the Social Doctrine of the Church, 2011 [Kindle edition], Section 186

[2] Ibid. Emphasis in the original

[3] USCCB/LEV, Compendium of the Social Doctrine of the Church, 2011 [Kindle edition], Section 187

[4] Ibid.

Title photograph from Wellcome Images. Licensed under the Creative Commons Attribution 4.0 International License