For this week's Common Good Forum, we are featuring a piece by Dr. Mary McDonough. McDonough is the author of Can a Health Care Market Be Moral?: A Catholic Vision.
One of my favorite Gospel stories is the healing at the pool of Bethesda (John 5:1-18). Perhaps I love this passage so much because I specialize in bioethics and this story succinctly captures the essence of the health care debate. It goes like this. Jesus is in Jerusalem when he comes upon a pool with five porticoes. Here he sees “a multitude of invalids—blind, lame, paralyzed” who have come to experience the healing power of the water. Next to the pool is a man who has been sick for 38 years. Jesus asks him, “Do you want to be healed?” The man responds, “Sir, I have no man to put me into the pool when the water is stirred up; and while I am making my way, someone else steps down ahead of me.” Jesus replies, “Rise, take up your pallet and walk.” The man is immediately healed.
The story reminds us not only of the desperation and isolation associated with illness, but also of our duty to help the sick access adequate care. The man is all alone; he has no one to help him get into the pool. Not only that, but the strangers around him could assist if they wanted to but instead, they simply choose to ignore him, stepping ahead of the desperate man so they can get to the healing waters themselves. And then: a miracle. Jesus, filled with compassion and mercy, comes to his aid.
The U.S. has several “pool of Bethesda” scenarios of its own. Precisely, 23 of them—the number of states that have opted out of Medicaid expansion. The Medicaid program originally came into existence as part of President Johnson’s “Great Society.” Administered by the states under federal guidelines, Medicaid is the nation’s chief public health insurance program for the poor and the single largest source of health coverage in the U.S. When the Affordable Care Act (ACA) was passed it required states to expand Medicaid eligibility so more people could have access to medical care. The expansion was targeted at adults living in poverty, people who have limited access to employer coverage, and those who cannot afford to purchase coverage on their own. Under the new law, those with incomes at or below 138 percent of the Federal Poverty Level (about $16,105 for an individual in 2014) can enroll in Medicaid. The federal government agreed to pay 100 percent of the costs associated with the expansion for 3 years, gradually declining to 90 percent in 2020.
But in 2012, the Supreme Court intervened. They ruled that states may opt out of Medicaid expansion. Since the decision, 23 states have done so. Why? Many state governors and legislators simply do not support public entitlement programs; others want the ACA to fail. Some are worried that Washington will not continue to cover the federal government’s share of the costs after 2020. The problem with this logic, however, is that by refusing to accept Medicaid expansion states are not only turning down federal money that could boost their economies and save hospitals millions of dollars in uncompensated medical bills, they are also creating enormous gaps in health care coverage. Without the expansion, millions of people do not qualify for Medicaid because their income exceeds their state’s eligibility cutoff, yet they also do not earn enough to buy insurance through the ACA.
Approximately 8 million people are without insurance because their states opted out. Most of them are employed either part-time or full-time but still live below the poverty level. In Texas alone, the largest state opting out, over 2 million people will be without health insurance. Minorities, particularly Black Americans, are disproportionately affected because of the racial and ethnic composition of states not expanding their Medicaid programs.
Access to Medicaid matters. In 2012, a group of Harvard researchers studied how Medicaid expansion affected the health of adults. Their findings, published in the New England Journal of Medicine, concluded: “our results offer new evidence that the expansion of Medicaid coverage may reduce mortality among adults, particularly those between the ages of 35 and 64 years, minorities, and those living in poorer areas.” In a January 30, 2014 post for Health Affairs, a leading health policy journal, another group of doctors summarized their study which analyzed the health impacts of citizens in Medicaid opt-out states. This study found that Medicaid expansion would have resulted in “240,700 fewer individuals suffering catastrophic medical expenditures….422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64.” The most shocking conclusion they reached, though, is that between 7,115 and 17,104 people have died because their states refused to expand Medicaid.
To make matters even worse, the Supreme Court recently announced they have decided to hear yet another case involving the ACA. King v. Burwell challenges the health law’s subsidies for low- and middle-income Americans who live in states that did not set up their own health insurance exchanges. Plaintiffs in the case argue that the text of the law allows for subsidies only in states that are running their own marketplaces so people in states relying on the HealthCare.gov federal exchange should not get subsidies. Health care experts speculate if the Court finds for the plaintiffs, insurance premiums will spiral out of control. In an amicus brief filed in support of the ACA, several economic scholars argue if the court disallows the subsidies the health care act will be completely undermined noting that “the best available economic modeling demonstrates that, without these subsidies, average premiums would double and an estimated 6.5 million fewer Americans would have health insurance.”
In their iconic document, Economic Justice For All, the U.S. Catholic bishops clearly define justice by how a society treats its poor and vulnerable. If we, as a nation, continue to allow large numbers of people to remain uninsured, we risk condemning the poor to the status of what liberation theologian Gustavo Gutiérrez describes as “nonpersons, the ‘in-significant ones,’ the ones that don’t count either for the rest of society, and, far too frequently, for the Christian churches.”
We must answer injustice with justice. We need to make a choice. Are we going to mimic the people at the pool of Bethesda by simply stepping over the poor and the sick, leaving them to fend for themselves? Or, are we going to emulate Jesus and immerse them into the healing waters of our health care system?