Dr. Edward Feser has written the best piece I've yet read...

... on the health care debate and the principle of subsidiarity. I've had some readers asking me to flesh out some of my thoughts along the same lines, but I'm very happy that Feser (whose blog has become one of my favorite reads), beat me to it, as he does a splendid and thorough job. I'm providing a couple of excerpts here as carrots (but without a stick!), but I heartily encourage folks to read the entire post:

Now the Church definitely rejects the radical libertarian position that government can never, even in principle, justly intervene to help even the neediest citizens to acquire services of this sort. Catholic social teaching affirms the principle of solidarity, according to which we have, by nature, positive obligations to one another that we did not consent to and that the state as a natural institution can in principle step in to assist us in fulfilling when necessary. But the Church also firmly rejects the leftist tendency to regard governmental action as the preferred or even the only appropriate means of fulfilling our obligations to others. And she firmly rejects too the egalitarian tendency to regard our obligations as extending to all other human beings in an equal way. Contrary to what the libertarian supposes, the individual is not the basic unit of society; contrary to what socialists, communitarians, and many liberals suppose, “society” or “the community” as a whole is not the basic unit either. The family is the basic unit, and it is to our family members that our obligations are the strongest and most direct, with positive obligations to other human beings, though deriving from natural law rather than consent, becoming less strong and less direct the further they are from the family. Hence my obligations to the local community are stronger and more direct than they are to the nation as a whole; and my obligations to the nation as a whole are stronger and more direct than they are to the community of nations.

This approach is enshrined in another central principle of Catholic social teaching, the principle of subsidiarity, according to which the needs of individuals, families, and local communities ought as a matter of justice to be met as far as possible by those individuals, families, and communities themselves.

After providing a good list of key texts on the principle of subsidiarity and the priority of the family to society as a whole and to the state, Feser writes:

There can be no question, then, that while the Church allows that government can legitimately intervene in economic life and in other ways come to the assistance of those in need, she also teaches that there is a presumption in justice against such intervention, a presumption which can be overridden only when such intervention is strictly necessary, only to the extent necessary, and only on the part of those governmental institutions which are as close as possible to those receiving the aid in question. This surely follows from the principles of subsidiarity and the priority of the family. And it surely rules out not only libertarianism but also the sorts of policy preferences typical of socialists, social democrats, and egalitarian liberals.

It is important to emphasize that this is not a mere pragmatic consideration. For a central government, or any level of government, to intervene when it is unnecessary for it to do so is not merely not required. It is not merely unwise. It is, in the words of Pius XI, nothing less than an “injustice,”“gravely wrong,” a “grave evil and disturbance of right order.” It is disturbing, then, that the USCCB does not balance its emphasis on the Church’s teaching about the “right to medical care” with equal emphasis on the principle of subsidiarity – a principle which has a longer history in Catholic social teaching than the (very recent) affirmation of a “right to medical care,” and which has a much more sophisticated and worked out theoretical basis in Catholic moral theology and natural law theory than the latter right has ever been given. (Astonishingly, the USCCB’s online summary of the basic principles of Catholic social teaching includes no reference to subsidiarity at all; and its more extended online overview of Catholic social teaching mentions subsidiarity only once, in passing, without explaining what it means.)

In particular, it is disturbing that no consideration of subsidiarity or the rights of the family seems to have informed the USCCB position on the health care bill, which, as I have noted already, seems to allow that the bill is acceptable or even required by Catholic teaching apart from the elements concerning abortion and coverage of illegal immigrants. How does respect for a “right to medical care” justify the federal government forcing every citizen to buy insurance, of a kind the government (rather than parents or individuals generally) decides the citizen needs? How does it justify increasing government power to determine for citizens what sorts of treatments are worth paying for? How does it justify moving towards a de facto monopoly as health insurance companies are transformed into heavily regulated government contractors? How does it justify the bill’s “marriage penalties”? Even apart from considerations of subsidiarity and the independence of the family, it is hard to see how such policies could be justified; in light of those considerations the policies seem positively immoral.

Again, it's definitely worth reading in its entirety. And, yes, I've also said, it is frustrating—unbelievable, really—that the USCCB has almost completely ignored major principles of Catholic social doctrine in analyzing the issues of health care, government, and all sorts of related matters.

Related Links from Insight Scoop:

• Controlling the overseeing of the coercion of the regulation of..., etc., etc. (March 24, 2010)
• Is the pending health-care reform legislation "a grave evil"? (December 16, 2009)
• Bishop Samuel J. Aquila: "The means of providing access to health care..." (September 1, 2009)
• On poisoned water and the principle of subsidiarity (August 17, 2009)
• Governmental expansion and the principle of subsidiarity (March 4, 2009)
• On one hand, this should be obvious... (December 5, 2008)

Comments

[T. Shaw]

This health care leviathan will wreak havoc on the economy. The devastation will far outweigh any good.

[Shaun G]

Let me say first that I recognize the principle of subsidiarity, not only because it is Church teaching but because it makes sense to me.

That said, I wonder whether there might be a competing principle that (at the very least) makes it more difficult to discern whether the government should be involved in health care, and if so, at what level (e.g. local, state, or federal).

The competing principle is, like subsidiarity, a bedrock principle of Catholic social justice, and what's more, the Catechism lists it as one of the "sins that cry to heaven for vengeance": depriving a laborer of his just wages.

This is the problem we face: Unless younger, relatively healthy people are compelled to purchase health insurance, they (or a subset of them, anyway) are going to consider it an "unnecessary" expense -- which both 1) affects the risk pool, driving up everyone else's premiums, and 2) makes it more likely that a hospital will be stiffed if they do in fact suffer an unforeseen major medical emergency.

And although it may be seen as a "softer" crime to deprive a large hospital of payment for services rendered, rather than to deprive an individual doctor of payment of services rendered, the fact is, somebody's getting stiffed.

I would love to hear some solution to this problem by those opposed to a legal mandate to buy health insurance.

[Carl E. Olson]

Sean: I fail to see the sense of your argument for a couple of reasons (I'm sure there are others):

1. There is already evidence that the health care legislation is going to result in the loss of numerous jobs because taxes on employers are going to rise quickly and substantially. Which is, I think, a clear case of depriving laborers of, well, labor, and of course just wages.

2. A strong case can be made that a core problem with health care in the U.S. is not the health care, but the way that insurance is regulated by the government--the same federal government that claims to now be fixing the problem. But the increase in more mandates and regulation is not going to help doctors and hospitals, nevermind patients, but will most likely make everything worse, resulting in poorer health care and far less choices.

3. If the federal government can "compel" (I prefer "coerce") you and I to buy a product (insurance) from a private company--the first time this has ever happened in U.S. history--then what stops the government from "compelling" us to purchase this, that, or the other thing? Young adults, who are generally in far better health and who are usually trying to get some financial footing in life, are going to be stuck with costs, perhaps even quite large costs, that will deprive them of big chunks of their wages.

4. Here is one proposed solution to the problem that doesn't require massive takeovers and control by the federal government. Here is another (PDF format) and more (also PDF).

5. Consider an analogy to public education. Prior to the 1880s or so, compulsory public education didn't have much of a foothold in the U.S. Prior to the 1960s/1970s, public schools were still largely controlled at the local/state level. Now, with few exceptions, public schools are overwhelmingly controlled by the federal government. And guess what? The amount spent continues to increase dramatically, and the academic results continue to worsen dramatically. Expect the same general results with nationalized health care. Consider that Massachusetts state treasurer Tim Cahill has written of the Mass. plan implemented in 2006, "The universal insurance coverage we adopted in 2006 was projected to cost taxpayers $88 million a year. However, since this program was adopted in 2006, our health-care costs have in total exceeded $4 billion." The chances of the national system coming close to projected costs are very, very remote. After all, when was the last time the federal government came in under budget on any project of any decent size? Higher costs will require more taxes, causing higher unemployment, etc., etc.

[S. Quinn]

I agree, Shaun, that anyone getting stiffed is wrong. People often file for bankruptcy so they do not have to pay various creditors, rationalizing that they are companies that can absorb the loss, but those "companies" are made up of PEOPLE who may themselves have subcontractors to pay, etc.Not to mention that those people have children, bills of their own, etc. A bankruptcy lets YOU off the hook at the expense of all kinds of people who are themselves innocent, or who employ innocent people who did the work for you that needs to be paid. So I get that it is bad to stiff hospitals.

That said, it since ANY company can get stiffed by deadbeats, should we demand (say) that people who don't want or need a product share the risk with those who do? Should we force EVERYONE to help bear the burden of bills for ANY company on the chance that their real customers won't pay? I take it that is what governments want us to do when they ask, I mean tell, citizens to bail out private companies like banks or car makers. When does it end?

But then someone might say doctors and hospitals are different from car companies and banks, and we DO need to force people to buy insurance...and force the insurance companies to
a)take all comers, even those with pre-existing conditions;
b) pay everything, even preventive care (kind of like asking your car insurer to buy your tires and your house insurance company to buy your furnace filters)
c)Pay forever - no lifetime cap.

Only then it is not "insurance" which is a product that a company CHOOSES to sell and we CHOOSE to buy to lessen our risk. It's "welfare." It's essentially the destruction of the product called "insurance" (because it is unsustainable - no company can pay all that and survive) which may very well be what the Obama administration wants.

[Randy]

It does seem like the principle of subsidiarity is incompatible with the concept of insurance. Insurance is based on the notion of spreading risk over a large number of people. Subsidiarity wants the number of people to be small. So if you agree that the basic question is how to regulate insurance and not whether or not insurance is the right answer at all then subsidiarity seems like a red herring. I think the bishops are right to focus on the right to medical care. That is basically a life issue. Life issues are always high on the pecking order.

[Shaun G]

Carl,

I have heard versions of your Objection #3 before, almost all of which include (as you did) the claim that this is the first time in history that Americans will be compelled by the government to buy a product or service from a private company.

But I don't see why that is really so shocking to conservative sensibilities.

Think of it this way.

While this may be the first time in history that Americans will be compelled by the government to buy a product or service from a *private* company, it is certainly not the first time in history that Americans will be compelled by the government to buy (via taxes) a product or service from the government. We pay for police that way, we pay for libraries that way, and we pay for a multitude of other government services that way.

Now, given a choice between being compelled to buy a product/service from a private company or being compelled to buy a product/service from the government, I would think conservatives would be much more comfortable with the private option, since they tend to think that government screws up any program it tries to run, or at the very least runs it less efficiently than a private operation would.

Not only that, but if you're paying for a private product/service yourself, you can be assured that you personally will reap the benefits. In the case of health insurance, it means that you yourself will receive the insurance coverage. Whereas if you're paying for a government product/service through taxes, your money may very well be paying for OTHER people to receive the product/service. So for those reasons, too, I would think conservatives would be much more comfortable with the private option.

Now that I've established that given the choice between being compelled to buy a private product/service and being compelled to buy (via taxes) a government product/service, conservatives would prefer the former ... let me therefore conclude that if conservatives are comfortable with the idea of being compelled to buy (via taxes) *ANY* government product/service, be it police or libraries or what have you, then the idea of being compelled to buy a private product/service should not be all that shocking.

Granted, you can argue whether it is good or bad for us to be compelled to buy any *specific* private product/service -- health insurance, etc. -- but the mere idea of being compelled to buy a private product/service *as a mere idea* does not seem to be something to get all worked up about.

Oh, and by the way -- this is completely off-topic, but I thought you'd find it funny. It's from The Onion:

"Increasing Number Of Parents Opting To Have Children School-Homed"

http://www.theonion.com/articles/increasing-number-of-parents-opting-to-have-childr,17159

[Brian J. Schuettler]

"It does seem like the principle of subsidiarity is incompatible with the concept of insurance. Insurance is based on the notion of spreading risk over a large number of people."

Randy, read this from The Hastings Center:
So often the political debate in America revolves around two seemingly conflicting values: solidarity and subsidiarity. William Sage touched on the former. Opponents of health care reform often talk about the latter. But it is the intersection of these two values that matters most to American politics, and nowhere more so than in the health care debate.

Subsidiarity found its first articulation in Catholic social teaching. Basically it’s the investment of authority at the lowest level of an institutional hierarchy possible, essentially relegating centralized authority to a secondary or subsidiary role. In other words, the group closest to whatever task or problem should tackle that problem first, and only when they’re not able to should a higher authority step in. In social terms, this might break down something like this: first, individuals are responsible for their own social welfare, then families, then communities, then local governments, then state governments, and finally the federal government.

In many ways, subsidiarity flies in the face of the more universalist notion of solidarity. Subsidiarity requires that small groups and individuals tackle problems, while solidarity demands that we all band together.

Nevertheless, if we’ve learned anything from the health care debate, it’s that for any meaningful reform to take place, we need to find ways to make competing ideas work together. More people need to be covered for less money. Somehow more government involvement in the health care industry also has to lead also to less of a financial burden on federal and state budgets.

The nature of health insurance is one of cost-sharing. Lots of healthy people buy into a larger cost-pool in an act of voluntary, if unintentional, solidarity. Insurers, at least in theory, compete against one another for customers, the competition leading to a decentralized system of coverage and care.

The American health care system, however, has instead erected a status quo which relies entirely on employment for health coverage. Coupled with a ban on interstate sale of insurance, this has led to much smaller cost-sharing pools and very little actual competition, with one insurer often dominating entire cities or regions. The sale of insurance is bound to each individual state and fifty different sets of rules and regulations govern insurance sales across the country. Consumers of health care are almost always bound to their employer’s choice for health coverage – and worse, should they lose their job, find themselves suddenly without any insurance at all. Essentially, the American system has eschewed both solidarity and subsidiarity, in favor of an ad hoc system found nowhere else in the industrialized world. In the end, this has led to skyrocketing costs.

Beyond cost-control, solidarity is the driving force behind health care reform. The argument that no modern, industrialized nation should be without universal coverage is compelling. But other Western nations have found ways to take this principle of solidarity, and achieve it through far more decentralized means than Canadian-style single payer, or the expensive socialized medicine of the UK. The Dutch have achieved universal coverage entirely through fierce competition between private insurers, and the Germans use a system of exchanges that allow German workers to move from job to job without losing insurance. The Swiss, who have made an art of subsidiarity, have achieved universal coverage through competing non-profit insurance plans.

The problem with American politics is that so often our leaders view bipartisanship as a path to the worst of all possible outcomes – the uninspiring middle-road wherein nobody is happy and little is achieved. What many European models have shown us is that competing values can actually be used to achieve effective compromise. Perhaps conservative means can lead to progressive ends, or vice versa. In the health care debate, competition and subsidiarity are the best tools to create quality, affordable health care for the most people, and with the right implementation they can be used to achieve universal coverage. In this way subsidiarity, rather than a competing value, becomes a complimentary one, and we find our solidarity through competition and individual choice. Universal coverage can be achieved from the bottom up rather than from the top down.

What could be more American than that?

Read more: http://valuesconnection.thehastingscenter.org/2009/10/16/subsidiarity-and-solidarity-in-health-care-reform/#ixzz0jf9bFDfv

[Shaun G]

Randy writes:

"It does seem like the principle of subsidiarity is incompatible with the concept of insurance. Insurance is based on the notion of spreading risk over a large number of people. Subsidiarity wants the number of people to be small."

Actually, it's not the case that subsidiarity wants the number of people to be small. It's that subsidiarity wants the insurance program itself to be handled by the least centralized competent authority. Thus, if an insurance plan requires a large pool of people to achieve its purpose, then that's fine -- just as long as the plan itself is not handled at a bureaucratic level beyond what it needs to be.

Look at the Knights of Columbus and their life insurance program. Obviously, the more people who participate in the program the better -- but notice that if you want to get a KofC policy, you don't log onto a Web site and deal with a central agency; rather, you deal with an individual agent who lives in or near your community. That's subsidiarity.

[Brian J. Schuettler]

I forgot to mention that this subsidiarity/solidarity response should have been the thrust of the USCCB statement. Alas, it is not too late!

[Carl E. Olson]

Shaun: I'm buried with a host of duties and responsibilities, so cannot respond at length. But a couple of quick thoughts about this:

While this may be the first time in history that Americans will be compelled by the government to buy a product or service from a *private* company, it is certainly not the first time in history that Americans will be compelled by the government to buy (via taxes) a product or service from the government. We pay for police that way, we pay for libraries that way, and we pay for a multitude of other government services that way.

I want to be very clear that my stance is not one of anti-government. It is anti-statism, or anti-centralization. Subsidiarity is not anti-government, but (to put it rather simply and incompletely) it holds that governments (local and federal) should be properly ordered to the good of the community it serves. The federal government, in the U.S. system, has certain tasks and duties, especially national security. The police and the libraries in my community are not run by the federal government, but are run by the city of Eugene, Lane county, or the State of Oregon (in the case, for example, of the highway patrol). If we were to use the same model of regulation and federal government involvement that is taken in the health care legislation, my local police and library would be essentially run by bureaucracies in Washington, D.C. There is, of course, a certain variance to how this could/will work, and that is why I earlier mentioned the public school system (K-12). It is not fully run by the federal government, but is heavily guided and regulated by the federal government, and more and more so as time goes on.

I am not against taxes. I am happy to pay taxes for local law enforcement and for libraries, both of which must, in the end, be responsible to local tax payers. But history and current reality shows that bureaucracies the furthest removed from the people they control also are the least accountable to those whose lives they affect. Statism, in the end, thrives on removing more and more control from the individual, the family, and the local community, and placing that control in the hands of technocrats, "experts," and bureaucrats who are not motivated by the needs of particular people and situations, but by economic and political factors, as well as the desire to implement a "plan," usually based in a faulty notion of rights and human nature (i.e., socialism and forms thereof).

The fact is, the U.S. has been moving down the statist road, with some variance, for about a hundred years or so. Income taxes did not exist (if I remember correctly) until the end of the 1800s. The federal government was amazingly small in the late 19th century. Some will argue that, hey, the growth of the federal government is just part of the modern world. Well, indeed it is: the modern secular state thrives on centralized planning, statism, and the undermining of familial and local control, all of which, I am convinced, is contrary to a Catholic understanding of the rights of families and the principles of both solidarity and subsidiarity.

There is more that can be said, but that's all the time I have for now. Thanks!

[Randy]

Brian,

I don't really think the US bishops would disagree with the article you pasted. You seem to concede that the status quo could and should be improved upon in terms of giving the poor better care. That is the key point the bishops would not want to lose in all this.

I am a Canadian and I don't think subsidiarity is incompatible with the system we have. We have a single payer per province not one for the whole country. That brings things closer to home. Even inside my province we have 9 health regions that have the purpose of making the system more responsive to local concerns. I do think it works.

I have a child with Down's Syndrome who has required much more care that I could have ever afforded. So I do see the advantages. The care can be done at a personal level and the costs can still be shared among a large group. Yes, there still will be cases where the value of human life will be expressed in terms of dollars and sense and not everyone will agree on the answers. My experience so far has been that society is willing to spend very generously on my little guy. I am grateful for that.

[Carl E. Olson]

Another piece on health care and subsidiarity worth reading is this 2009 article by Robert J. Mylod for the Acton Institute. Here is a particularly interesting point:

How did this system develop in the bastion of the free world? How did it become “progressively disorganized” and go into “decline”? Two trends are responsible for anesthetizing health care. First, Medicare legislation for seniors and Medicaid legislation for the indigent and uninsurable created the illusion of free health care. Second, employers, particularly large employers, began and continue to pay for all or most of employee health care insurance. Employees do pay for some of the insurance through a “co-pay” procedure; but they typically do not share in the decision-making process concerning coverage. Insurance coverage paid by the employer was (and is) not taxable income to the employee. Thus, there was little incentive to use the system prudently. Most consumers’ sense of medical costs atrophied.

In other words, as people have become further removed from an informed understanding of health care costs--due in large part to federal involvement--they increasingly fail to take responsibility for things (in this case, insurance and/or paying for medical treatment) they should be responsible for. It is another example of how federal programs of entitlement (in this case, via Medicaid and Medicare) eventually turn people into dependents of the State. Throw in the fact that most Americans are educated in public schools that laud the growing role and control of the federal government (ah, I really miss those American history classes!), and it's hardly surprising that we are where we are. In fact, I am actually most surprised by how many Americans are upset about this latest federal, um, expansion; I suspect some in D.C. are also a bit taken aback by the rebellious attitude of their subjec--er, constituents.

[Brian J. Schuettler]

Randy, I don't think the bishops would disagree with the article either. That was not the point. The point was, as Carl stressed elsewhere, that the focus of their attention should have been to a range of social teachings of the Church. By limiting their focus to abortion alone, they gave the democrats the opening needed to get over the top with holdouts via the "exec order ploy".

[Carl E. Olson]

As a follow-up, in support of my last comment, check out these stats from the Heritage Foundation showing the incredible growth of dependence on government over the past fifty years. It's worth noting that the growth only slowed during Reagan's eight years, and was outrightly robust during George W. Bush's eight years. In relation to the discussion about subsidiarity, consider this:

Historically, private individuals and local entities have provided more assistance to needy members of society than they do today. Particularly during the 20th century, government gradually offered more and more services that were previously provided by self-help and mutual-aid organizations.[5] Lower-cost housing is a good example. Mutual-aid, religious, and educational organizations have long aided low-income Americans with limited housing assistance, but after World War II, the federal and state governments began providing the bulk of low-cost housing. Today, the government provides nearly all public-housing assistance.

Health care is another example of this pattern. Before World War II, Americans of modest income typically obtained health care and health insurance through a range of community institutions, some operated by churches and social clubs. That entire health care infrastructure has since been replaced by publicly provided health care insurance, largely through Medicaid and Medicare. Regardless of whether the medical and financial results are better today, the relationship between the people receiving health care assistance and those paying for it has changed fundamentally. Few would dispute that this change has negatively affected the total cost of health care and the politics of the relationships among patients, doctors, and hospitals.

The moral erosion of the 1950s/60s led to the break-up of more and more families, resulting in fragmented communities and a decrease in involvement in churches and other institutions that traditionally offered non-governmental support. The government took on more and more responsibility, which in turn has led (directly or indirectly) to more instances of abortion, births outside of wedlock, divorce, etc., furthering a cycle of dependency. All of which to say, one of the great challenges of trying to apply the principle of subsidiarity is not just in getting people weaned off the federal teat, but helping them see that personal responsibility, traditional morals, and involvement in local, non-government institutions are essential parts of being a good citizen and furthering the common good. That is, needless to say, a daunting task, especially since there is such a huge swath of Americans who cannot conceive of life without the full or partial support of the federal government, not have much incentive to do so.

[Randy]

The other thing that has impacted both health care and education is the decline of vocations. Nuns and brothers provided a ton of health care for next to nothing for a long time. Those orders are all but gone. So we replace them with government programs that overpay for everything. But what is the other choice? To simply not give care or not educate?

Other changes to society have made both health care and education more and more expensive. It does lead to a contraceptive/abortive mentality as kids become more and more expensive and the commitment of society to help parents with these costs is anything but certain.

[LJ]

On Solidarity

A couple of boarding school boys decide one day to play a nasty trick on the head master of the school. An investigation brings a blank wall of silence as to the identity of the perpetrators, even though it is well known among the boys who did the deed.

We’d call that solidarity, wouldn’t we? Seriously, even though those lads have done wrong, we cannot throw them to the mercy of the head master who is known for unusual severity. So what is the result? Everyone gets punished for the sins of the two perps. Is that not comparable to forcing everyone to buy insurance to cover the bad habits and/or negligence of some who might not otherwise buy insurance? Solidarity forever.

Well, let’s ask the WWJD question. The Christian in the group of boys might just stand up and ask to be punished for the crime, even though he was not guilty, to spare the other innocent ones from punishment.

That is true solidarity. The one boy has recognized the humanity of his fellows and is unwilling to see them suffer. So he stands up and volunteers to suffer for them.

How is that so different from the old days in America when Catholics built hospitals without government interference and served the needs of the poor, many of the staff if not all in some cases being Sisters who had committed their lives already in poverty to serve God through service to their fellow human beings?

Let us not confuse Christian solidarity with socialist solidarity. Solidarity is not Christian without free will.

[Kevin C.]

To expand further, LJ, there is no such thing as a virtue without free will. You might even call it 'charity by the sword' to steel a phrase from a friend.