06 April, 2017

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.

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

5 comments:

  1. Thank you for articulating my same thoughts so well!
    Another one of the many ways that the means of acquiring health care services and lowering their costs could be addressed is through healthcare sharing ministries, like Samaritan Ministries. My family and I are members of Samaritan. If subsidiarity and healthcare are going to be talked about, those advocates of single payer systems cannot deny that healthcare sharing ministries are proving single payer systems unneeded and unwarranted.
    Thank you again to responding to Jack's article.

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  2. David,

    A single-payer system may not necessarily be the best system, but I fail to see how it can be condemned as absolutely contrary to subsidiarity. Subsidiarity, after all, is defined pretty loosely - "to assign to a greater and higher association what lesser and subordinate organizations can do" - there's a lot of room for prudential judgment here. And a single-payer system could well be administered by the several states, not centrally. I'd prefer a decentralized system of cooperatives, but I'm not sure that that is practical in our mobile society. Are we to endure our present lack of system unless we can have the best kind of health care system?

    Thomas Storck

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  3. Tom,

    My problem with a "single payer" scheme is that it encompasses all aspects of paying for health care, including those which can very practically be paid by either private solutions or by more local branches of government assistance. I do believe that health care is a right, like food, and I believe Catholic Social Teaching supports that view. However it is not a right in the sense that you don't have to pay a just price for the services or food you receive. This, I believe, is an individual responsibility and the social responsibility for assisting those in need applies particularly to those who cannot afford to do so. I quote again from the Compendium of Catholic Social Doctrine: "The initiative, freedom and responsibility
    of lower orders of society must not be supplanted."

    In regard to the mobility of our society. The difficulties of coverage for getting medical care "out of the service area" is a man-made complication, one which I believe is created by both the insurance companies and government regulations. However, if a means of payment is there, then why should service be denied even when abroad, and why should payment be denied just because you were abroad?

    Let's say, for example that you have a subscription based medical coverage for general health and check-ups. In addition to that, you have guild or company based insurance to cover more serious illnesses. Then you have a county or state based coverage for extreme cases that go beyond the financial capabilities of the lower orders.

    This is admittedly more complicated, but I think it applies the principle of subsidiarity according to Catholic teaching in ways that a single payer system does not.

    In regard to prudence, I certainly agree that social assistance at at the state level is needed for our current situation. Therefore, I would advocate it - as the Church proposes - a temporary solution while the system gets adjusted to be more in line with subsidiarity. However, the advocates of single-payer I have heard and read don't suggest it as temporary in any way. It is not only proposed as a permanent solution for paying for all health care, it is proposed to be administered at the federal level, depriving even the states of their role. How is this subsidiarity?

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  4. You wrote, "It is not only proposed as a permanent solution for paying for all health care, it is proposed to be administered at the federal level, depriving even the states of their role. How is this subsidiarity?"

    Well, it evidently isn't subsidiarity, but it's also not what I advocate. And I'm surprised, since in Canada their system is administered by the provinces, that the single-payer advocates you've encountered here want a centrally-based system.

    With regard to your point about one being obliged to pay a just price for health care - of course, health care is not free like sunshine is, we would need to pay for it by taxes. But if we look at society as made up of a community, not a bunch of individuals who happen to live near each other and are essentially in competition with each other, then certainly there is nothing wrong with our paying for it with tax money, just as we pay for our common defense with tax money - indeed, for our common aggression in too many cases!

    Thomas Storck

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    Replies
    1. Even if it is administered at the state level, I think there are still legitimate objections to saying that a single-payer system is truly compatible with subsidiarity. If the state controls the payments, it will control what it pays for. What leeway will there be for alternative treatments outside of those the government approves? With the authority set at such a high level of society, how will the common person have an effective voice against abuses? How will the small health care provider be fairly represented against the giant medical corporations and their lobbying power?

      Also, since subsidiarity is not merely a political idea, but a principle of reason, it needs to be applied consistently.

      The basis (as I have heard it, and which was reiterated in Mr. Quirck's article) for advocating a single payer system for health care is that all of the following are true:
      1: Access to healthcare is a fundamental human right.
      2: The poor cannot afford even preventive health care.
      3: Some medical treatments are so expensive that even the middle class cannot afford them when needed.
      4: The current system does not adequately address the issues of access.

      Well, if these facts justify a single-payer system for health care, then why not for food? Certainly points 1, 2 and 4 apply to food? Will we provide a single payer system for food? If not, then why the inconsistency in the application of a universal principle?

      We have government systems in place to help provide access to food, but they are not one-size fits all - let's absorb everybody into this assistance program even when they don't need the assistance - systems. They specifically target those in need. We have similar programs for housing? They may not be perfect, but they don't usurp the roles and responsibilities of everyone. Why can't this be done with health care?

      As Pius XI said in Quadragessimo Anno, "Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also 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."

      We can even say the same thing about the argument of the common defense. It is a natural role of government to provide for the common defense of its citizens against foreign and domestic aggressors. Other than the participatory role of serving in the military, this is not the function of the family or the local community. Therefore the comparison of national defense to accessing health care is not valid. A better comparison would be to other forms of law enforcement. We have the FBI and federal marshals. We have state patrols and police. We have county sheriffs. We have municipal police departments. We have our right to keep and bear arms to defend ourselves.

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