[Dialogue] 4/05/12, Spong: The Health Care Debate: Is it Possible to Reach Conclusions that are Satisfactory?

[Ellie Stock]

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The Health Care Debate: Is It Possible to Reach Conclusions That Are Satisfactory?
The argument before the Supreme Court as to whether the Federal government can mandate health insurance for all citizens represents a fascinating dance around shifting realities.  It is an argument that totters between the values inherent in an interdependent society and those cherished by an individualistic society.  The reality is, however, that in an ever-shrinking world, individuals are of necessity interdependent.  There is no such thing as pure individualism in an interdependent world.  Individuals sacrifice their individual desires to the corporate well being every time we stop at a red light, drive on the assigned side of the road or accept the fact that we are not allowed to operate an automobile on public roads without insurance. When sidewalks are installed in a neighborhood, property owners are assessed to pay for them whether they want them or not.  The principle of bending the individual will to the corporate well being is well established.  The issue now before the court is not about its reality, but rather about the degree of interdependence that a society can order.  This means that the questions asked by the Justices, which suggest that if health care is mandated so might the eating of broccoli, the requirement of burial insurance and a host of other things that appear to meet universal needs, are diversions and are not really in touch with the issue before that body.  To suggest that healthcare cannot be mandated on the basis of the fact that all of us will sooner or later use healthcare and would be  like mandating the purchase of broccoli because we all eat is “cute,” but it is little more than smoke screening and misses the point rather dramatically.
When I was the Bishop of Newark between 1976 and 2000, I was responsible for a large, church-affiliated, urban hospital in Jersey City.  As a public hospital, supported, as all hospitals are, by taxpayer money, we were mandated to treat any person who came to us for medical assistance whether or not they had insurance.  It was a mandate we accepted as part of our vocation to serve that community’s needs.  No one questioned this policy.  About 40% of our patients were uninsured.  Our emergency room was their primary health care facility.  We staffed it and operated it on a 24-hours a day basis, seven days a week.  We regularly filed reports to the state outlining our costs and applying for tax dollars designated for uncompensated care. We were reimbursed from these tax payer sources, which meant that the public shared our costs.  This repayment, however, was never at the rate that covered our expenses.  This meant that at this hospital we flirted with bankruptcy for each of those 24 years and I learned that the hospital finally filed for bankruptcy protection in January of this year.  If this hospital is ever forced to close because of insolvency, the patient load would simply be transferred to other medical facilities in the area.  People do not stop needing health care because hospitals close.  The fact is, however, that resources in urban areas are far slimmer than they are in the suburbs and all hospitals serving an urban constituency are struggling to keep afloat.  With inadequate payments for uncompensated care, there is no doubt that our costs were and are inflated on those who had insurance.  That was a common practice and without it every urban hospital would have had to close its doors.  Those with health care have thus already been subsidizing those without it.
My point is that if we are to mandate that hospitals be required to treat any patient who shows up on its doorstep then we are also mandating that those costs will ultimately be borne by taxpayers and those who do have health insurance, so the issue before the Court has already been decided.  We have already accepted the principle that health care is a basic right and must be universally offered and paid for by the whole society.
The only alternative to universal mandates is to become a nation in which those without insurance are simply not treated.  Are we prepared to abandon our fellow citizens to that fate? At one public debate involving Republican presidential candidates earlier in the political season that issue was posed and the response of the crowd was to shout “let them die!  Is that the will of this nation or of its highest court? If that were the question before the court or before the electorate, I wonder what the vote would be.
Without the universal mandate, the price of health insurance for everyone would rise substantially, which means that those who have health insurance will continue to subsidize those who do not.  Without the mandate insurance companies, for their own economic well being, would have to cancel insurance for high risk patients and those with pre-existing conditions.  Without the mandate, many hospitals serving the poor would be forced to close and both the quality and the availability of health care for all could be diminished.  So the questions before the court are far more complex than the public seems yet to understand.  Does the well being of the society trump the rights of the individual?  Is this a battle, as conservatives suggest, between the expanding power of the federal government and the freedom of the individual?  If the government can require health care what further government mandates will follow?  If population growth begins to exhaust the resources necessary to sustain life for everyone, will the government have a right to limit population?  Is there any other power besides the federal government that is capable of forcing that decision on the whole society?  When we focus on the issues beneath the political oratory, we discover that the definition of what this nation is and will be is before the highest court of this land. Until universal health care is established, it will continue to be the subject of rancorous and divisive debate.
In an article published in the Journal of American Medical Associations in March of 2012, Dr. David Naylor and Ms. Karline Naylor proposed seven proactive principles for health care reform in America.  They are realistic, but they also make it clear that some of the problems we face will never be solved by political rhetoric.
Their first principle was to recognize that there is no perfect health care system.  Every system balances availability against affordability and quality.  In the year 2009, Canada spent 11.4 % of its GNP on health care while the United States spent 17.4%, but no measurable superiority in terms of satisfaction by health care recipients was revealed.
The second principle was that every nation must recognize that it must adapt health care to its own constituency, but there is wisdom in adopting things that have worked well in other nations without the ideological bias that so often accompanies the health care debate.  Americans who like to demonize Canada’s health care system, for example, do not realize that the vast majority of Canadian hospitals are privately owned and that most Canadian physicians work as private practitioners.  Canadian commentators regularly ignore America’s superb clinical care and advanced use of information technology.  Both have something to gain from the other.
Third, in designing national health care programs, simplicity always trumps complexity. The more changes a program initiates the greater the risk of unintended consequences.  Canada built its system on a single payer premise that had been developed in the Canadian provinces and adapted it to its national constituency.  The originating bill was over 14 pages long.  Compare that with the Affordable Health Care Act now before the Supreme Court that, which when passed by the Congress and signed by the President, was close to 2000 pages long.
Fourth, we will all need to face the fact that every health care bill has limits and engages in rationing health care services.  The question is who will make the decision on who gets what care.  In a single payer system, a single authority usually makes that decision.  In the more complex American system, those decisions are made by many people on many different levels.  The myth is that there is no rationing.  In no system are all conditions covered.  It is, however, far more expensive, more difficult and politically more compromised to make it on local levels.
Fifth, every system is designed to achieve fairness and all promise to deliver fairness, but no one is yet able to define what fairness means or to describe how it looks.  When efforts are made to do so, some one is always hurt and the political debate becomes heated and those with vested interests combine with political power to force decisions in their favor.
Sixth, there appears to be little correlation between the amount of spending and the quality of health care that is provided. America’s heath care costs per capita are the highest in the developed world while America’s health care falls far short of being the best for all its citizens by almost every objective statistical measure.
Seventh, micromanagement has been demonstrated not to be optimal whether the system is administered by public or private agencies.  Administrative costs in the United States are far higher than they are in Canada.  Most Canadian health care decisions are made by clinicians, while in the United States, a massive industry to accomplish micromanaging has been developed to “contain costs.”  Perhaps the clinicians are better equipped to do this than the bureaucrats.
The real question that this survey raises is whether our democratic form of government, which seems to have become dysfunctional in recent years, can ever implement a national or universal health care program.  This is an area of life in which every citizen has a significant vested interest and in which other clearly identified constituencies like doctors, lawyers and insurance companies conduct active and well financed lobbying efforts to protect their profits. These are some of the reasons that healthcare seems intractable and remains polarizing.
I am still convinced that a single payer universal national health service is both inevitable and, in the last analysis, the best system for the vast majority of our people.  Before this nation arrives at that, however, we must stagger over the terrain and live with mistakes and shortcomings and the issue will be political red meat for years to come.
~John Shelby Spong
Read the essay online here.


Bishop Spong will be appearing at St. Peter's Episcopal Church in Morristown, NJ on Good Friday, April 6th.
http://www.stpetersmorristown.org/ 

10:00  am   Children's Stations of the Cross
12:00  pm   Good Friday three hours
   to             The Rt. Revd. John S. Spong
3:00   pm    Meditations on John's Story of
                   the Cross





Question & Answer
Chris, a Lutheran pastor from Clemson, SC, writes:
Question:
You have said that there is no mention of the Virgin Birth prior until the ninth decade when Matthew wrote the first account of the miraculous Nativity.  You also say that there is no reference to a miracle associated with Jesus prior to the gospel of Mark.  How can you make these statements since they violate Lutheran doctrine of the Word?
Answer:
Dear Chris, 

I admire many things about Martin Luther, but I have a contemporary understanding of biblical scholarship, so seeing Luther as a scripture scholar is not one of them. 

In Luther’s time, there was a general assumption that the gospels were eyewitness accounts and that they reflected the things that happened in Jesus’ life accurately.  Today we know that is not so.  The gospels were not written until 40-70 years after the crucifixion.  The material included in the gospels circulated in oral transmissions, probably in the life of the synagogue for two to three generations before being written down.  In that time, the memory of Jesus was shaped by the Hebrew Scriptures, which were applied to him in an interpretive fashion as if these were predictions fulfilled by Jesus.  Actually, it was the other way around.  The memory of Jesus was altered to fit his life into these scriptural and messianic expectations.  Even the earliest story of the crucifixion found in Mark 14:17-15:47 is not an eye witness account, but a story that interpreted the crucifixion according to the Hebrew Scriptures that were written 400-600 years earlier than the life of Jesus.  Mark’s story of the crucifixion is based primarily on Psalm 22 and Isaiah 53. 

Second, the gospels were originally written in Greek, a language that neither Jesus nor his disciples spoke or wrote.  It is simply not so to suggest that these second and third generation people were writing remembered history.  They were developing interpretive models for understanding Jesus based on their knowledge of the Hebrew Scriptures. 

We also now know the approximate dates of the writings of Paul and the various gospels. Luther did not have that knowledge available to him or to his generation.  We can line the various books of the New Testament up in the order of their writing and see how the story grew from Paul, who wrote between 51-64 to John who wrote between 95-100. 

When you search Paul, you find no hint of a miraculous birth story.  He says of Jesus, he was born of a woman (like every human being) and he was born under the law (like every Jew). 

Mark, the first gospel written in the early 70’s CE, says that God entered Jesus at his baptism and he portrays the mother of Jesus as thinking he was mentally disturbed and seeking to have him taken away (see Mark chapters 3 and 6).  There is no way Mark could have written that if he had heard or accepted virgin birth myths. 

The Virgin Birth story is introduced by Matthew about 82-85 CE.  He bases it on a text from Isaiah (7:14) which he mistranslates either by ignorance or by design.  Matthew says that Isaiah writes, “Behold, a virgin will conceive” but what Isaiah really says is, “Behold, a woman is with child.”  That is quite a difference. Luke writing in the late 80’s or early 90’s (88-92) tells a story of the miraculous birth of Jesus, but it disagrees substantially with many things in Matthew’s version.  The Fourth Gospel drops the Virgin Birth completely, replacing it with a hymn to the Word and on two occasions this gospel simply refers to Jesus as “the son of Joseph.”  (See chapters one and six).  These are simply facts. 

In regard to miracles, Paul never refers to a miracle that Jesus performed.  The Q source, which is regarded by some scholars as earlier than Mark (I am not one who agrees with this, but that is not germane to this issue), makes no mention of any miracles.  The gospel of Thomas that some biblical scholars date earlier than Mark (I do not), but I include it to complete the survey of the data since there are no miracles in Thomas. 

When the miracles do appear in Mark, they fall into three categories, nature miracles, healing miracles and raising the dead miracles.  They tend to reflect three Old Testament sources. The Moses-Joshua cycles where nature miracles were plentiful; the Elijah-Elisha cycle that features nature miracles but adds one healing miracle and two raising of the dead narratives.  These accounts find significant echoes in the miracles associated with Jesus. Matthew and Luke copy Mark and expand Mark including adding some new miracle stories.  When John writes he turns the miracles into interpretive signs and none of the “signs” in John seem to be the retelling of things that actually happened. 

The third Old Testament source of the miracles is in Isaiah 35 where the prophet describes the inbreaking of the Kingdom of God.  It will be accompanied, Isaiah says, by having the blind see, the deaf hear, the lame walk and the mute sing. Jesus, interpreted as the life in whom the Kingdom of God breaks into human history, is made to perform all these signs. 

No, neither miracles nor the Virgin Birth are original parts of the Jesus tradition and a simple study of scriptures makes that obvious. 

Thanks for your question and best wishes in your ministry. 

~John Shelby Spong





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