This
situation offends the conscience of Southern California’s
Jewish and Christian communities. Deeply held convictions—grounded
in the shared Jewish and Christian scriptures, the Talmud,
and the New Testament—lead us to denounce the
inequities within America’s fragmented health
care coverage system.
As
people of faith, we believe that:
A.
The life of every human being, created in the image
of God, is uniquely precious and worthy of being safeguarded.
Human
beings are created in the image of God. Thus, human
lives have an extraordinarily high value. In Genesis
we read, “God created man in the image of himself,
in the image of God he created him, male and female
he created them” (Genesis 1:27). We interpret
this to mean that each and every human being represents
a unique reflection of God and that each human life
is sacred and uniquely precious.
In
the Jewish tradition, preserving human life and well-being
(pikuach nefesh) is a religious duty of such high order
that it takes precedence over every ritual duty and
almost every other moral obligation (Talmud Bavli, Yoma
82a-83a). In the Christian tradition, Jesus teaches
that a good neighbor is “the one who shows mercy”
to a stranger whose life is endangered (Luke 10:37).
Both faiths recognize a religious duty to come to the
aid of persons whose lives are endangered. We understand
the commandment “Do not stand on the blood of
your fellow” (Leviticus 19:16) to demand not only
that we not stand idly by while a person is bleeding
before our eyes, but, more generally, that we accept
responsibility for preserving human life and well-being
in our society by all appropriate means.
Providing
health care for all persons is one aspect of the duty
to preserve human life. Scripture hints at this duty
by assuming that medical care will be utilized when
needed (Exodus 21:19), and pictures God asking plaintively,
“Is there no balm in Gil’ad? Is there no
physician there? Why then is the health of my people
not restored?” (Jeremiah 8:22). Jesus, throughout
his ministry, healed the sick, going out of his way
to touch those most socially ostracized for their diseases.
Since
each of us and all of us collectively have an obligation
to preserve the life and well-being of every member
of the human community, we must support actions that
ensure that every person has access to health care.
Every person enjoys a right to adequate health care,
regardless of ability to pay for that care. When the
lives and well-being of tens of millions of uninsured
and under-insured people are endangered by lack of access
to health care, we fail in our obligation to safeguard
and uphold the sanctity of human life and we jeopardize
the health of the entire community.
B.
Each of us, as partners with God our Creator, has a
responsibility for stewardship, especially for stewardship
of those resources that protect the well-being of human
lives.
From
the first moment of the creation of humanity, God has
charged us with the responsibility to be stewards of
creation. This charge is reflected in both Genesis creation
stories. In the first, humanity is commanded to “fill
the earth and conquer it, and rule over” all that
live upon it (Gen. 1:26). In the second, the first human
is placed in the Garden of Eden “to work it and
to keep it” (Gen. 2:15). We understand these stories
to place upon humanity as a whole—and each human
being individually—a responsibility to nurture
and protect all of creation. Because of the unique preciousness
of human life, this responsibility reaches its highest
level in the stewardship of resources that could enhance
the well-being of every person. We are called to be
wise stewards of our health care resources.
Without
a doubt, the American health care sector produces cutting
edge medical research and—for those with access—provides
an unequalled capacity to diagnose and treat illness.
However, this success should not blind us to the system’s
failures. It fails to be a good steward of our nation’s
health care resources when Americans spend two to three
times as much per person as other industrialized countries,
yet overall health outcomes are worse.
In
2002, the US spent approximately $5000 per person for
health care. This would be money well spent if we were
buying compassionate, effective, timely preventive and
curative health care for every man, woman and child,
fulfilling our expressed belief that the life of every
person is equally valued. Instead, every day, millions
of people are suffering and dying because they cannot
get the health care they need. Close to 44 million people
in the US lack health insurance, and many more are underinsured
or unreliably insured. For many, health care is delayed
as long as possible, and when finally obtained, it is
often poor quality care.
Economists
have established a ratio between national wealth and
health expenditures. As we might expect, populations
in wealthier nations are healthier. Also, among industrialized
countries, there is a predictable relationship between
Gross Domestic Product (GDP) and expenditures on health
care. The US is the exception. Instead of spending modestly
more per person than countries such as Australia, Japan,
the United Kingdom and Germany, we spend much more.
We spend two to three times as much as other industrialized
countries, almost 15% of our GDP. About half of these
expenditures are paid for by public money.
Many
factors contribute to the wasteful way that American
health care dollars are spent. Three of the largest
factors are:
Administrative
costs. In government health care in the U.S., administrative
costs for programs such as Medicare and the VA health
system are in the range of 3% to 5%, comparable to those
of health care in other industrialized countries. Administrative
costs of HMOs in the U.S., on the other hand, average
around 12%, while administrative costs for traditional
non-group health insurers are often an astonishing 30%
or even higher. Overall, the paperwork burden in the
U.S. is enormous—due mostly to the multiplicity
of billing agents and payers and because patients frequently,
and often involuntarily, must change insurers or providers.
Adding to the inefficiency is the surprisingly limited
use of automated medical record systems.
Pharmaceuticals. In the U.S., drugs are enormously expensive
and vastly overused. In part, this is because Americans
have been led to believe that there will always be a
pill (or shot, spray or cream) that can solve their
medical need. Advertising causes patients to demand
the latest drug, which is often only marginally more
effective than older and less expensive drugs but has
a much higher profit margin. In addition, we pay up
to ten times as much for exactly the same drug as in
other countries because our relatively small and competing
purchasers are unable to negotiate lower prices. In
the U.S., drug companies charge what the market will
bear because they can.
Medical technologies. Expensive medical technologies
undeniably save lives and relieve suffering, but access
is uneven: inadequate in some communities and redundant
in others. Hospitals and private specialty clinics compete
for well-insured patients by advertising that they offer
the latest in medical technology. Worse yet, for a variety
of reasons—patient demand, doctors’ reluctance
to deny hope, or institutional efforts to stretch profit
margins—expensive medical technologies are often
used when they are not needed and cannot help. A recent
study estimated that 30% of all health care dollars
in the U.S. were spent on inappropriate care.
These
three factors are the direct result of a health care
system that is a for-profit, competitive enterprise.
Insurance companies and pharmaceutical companies must
prioritize maximizing the return to their shareholders.
Hospitals and clinics must compete with other providers
to survive, even if that competition leads them to inefficient
and wasteful practices. Private, for-profit health providers
have proved that they cannot be wise stewards of our
nation’s health care resources. But there are
other factors that disproportionately drive up the cost
of health care in this country. Our failure as a society
to prioritize health causes additional inefficiencies
and waste of our health care resources:
Failure
to Provide Preventive Care. Although almost everyone
agrees that timely preventive care, including immunizations,
regular physicals, healthful changes in the environment
and better individual choices, would significantly reduce
health care costs and improve the quality of people’s
lives, there are limited incentives for prevention.
Individuals are poorly informed about what they can
do to protect their health, especially those who lack
a regular source of health care. Rushed providers have
time to focus only on acute problems. Frequently changing
insurers and providers leaves no financial motivation
to make the long-term investment in health promotion
and disease prevention, leaving patients with uneven
care. Furthermore, as a nation we are moving away from
creating a healthy environment and lowering work-related
risks. All these conditions increase the number of patients
who develop serious illnesses that are expensive to
treat.
Emergency Rooms. Increasingly hospital emergency rooms
are being used by the uninsured as a source of primary
care because they have no place else to turn and emergency
rooms by law cannot turn anyone away. This practice
wastes resources because emergency room care is the
most expensive cost center in the health care system.
When patients present themselves to ER, the condition
has usually reached an acute stage requiring more expensive
intervention. After patients leave, ER physicians have
no way to ensure follow up care. This results in primary
care provided by the ER that is effective only in the
short term, for which the uninsured person returns again
for the same condition.
The current inadequacies and inequities in American
health care coverage have economic as well as human
costs. While, as people of faith, we are most concerned
about the human welfare aspects, we also share a concern
about the economic implications. The Institute of Medicine
estimates that the economic value in healthy years of
life that would be achieved by extending health insurance
coverage to everyone in the U.S. would, under almost
any set of assumptions, exceed the cost of providing
coverage to those who currently lack it. Further, if
the wasteful factors described above were eliminated
or reduced, we could probably achieve universal coverage
for less money than we currently spend, allowing more
resources to flow to education, environmental protection,
increased rates of saving, or other worthy pursuits.
This
report recognizes that there are excellent models of
private, non-profit medical care that are affordable
to most working people. However, we also conclude that
the best steward of health care rights and resources
is the government. In a democracy, only a governmental
structure responsible to its elected representatives
can guarantee public policies that enable quality health
care to all of society.
C.
As people of faith, we are called to pursue
justice, to practice love and compassion, and to advocate
for the well-being of the poor and marginalized.
From
the beginning of human communities where people worshiped
God, we have been charged with the responsibility to
create a just society: “Justice, justice shall
you pursue” (Deut. 16:20). We are particularly
commanded to actively concern ourselves with the welfare
of the economically vulnerable. Isaiah chastises those
who believe their highest religious obligations to be
the rituals of their tradition, and reminds us that
the highest duties are to care for one another, including
“to share your bread with the hungry, and bring
the poor that are cast out to your house…”
(Isaiah 58:7).
Those
who hold wealth are commanded to share with those who
do not in the biblical injunctions not to reap the corners
of the fields or gather the gleanings of the harvests
or to gather single grapes, but to leave these for the
poor and the stranger (Lev. 19:9-10). In the Jewish
tradition, this is not a matter of charity—the
portion we are commanded to share actually belongs to
the poor rather than to the “owner” (Mishnah
Peah 7:5). In the Christian tradition, Jesus taught
that caring for the poor and the sick is the equivalent
of caring for God: “‘Lord, when did we see
you hungry and feed you, or thirsty and give you something
to drink? When did we see you a stranger and invite
you in, or needing clothes and clothe you? When did
we see you sick…and go to visit you?’ The
King will reply, ‘I tell you the truth, whatever
you did for one of the least of these brothers of mine,
you did for me’” (Matthew 25:37-40).
In
both faith traditions we are called to have special
concern for the stranger. The earliest attempts to define
holiness called upon the faithful to protect those who
are not like them: “And if a stranger lives with
you in your land, you shall not wrong him. The stranger
that lives with you shall be to you as the native among
you, and you shall love him as yourself, for you were
strangers in the land of Egypt” (Leviticus 19:33-34).
In the Christian tradition, the Good Samaritan models
mercy to the stranger by stopping to help and providing
for his care (Luke 10:25-37). Much of Jesus’ ministry
was to society’s outcasts, including his healing
ministry to the lepers.
Thus,
we have a high religious obligation to ensure that everyone
in our society, especially the economically vulnerable
and socially marginal, is treated with both justice
and compassion. To deny health care—which preserves
life—to people because they cannot afford to pay
for it or because they are among the marginalized in
society—people of color or immigrants—is
repugnant not only to our understanding of the sanctity
of human life, but also to our sense of justice and
compassion, and to our obligation to safeguard the well-being
of the most vulnerable in our society.
Most
Americans, whether or not they are members of faith
communities, are shocked when they understand the extent
of inequities in health care access in this country.
Poverty, language and cultural isolation, geography,
and racial bias all create severe barriers to timely,
affordable, safe, quality care. These barriers can only
be addressed as part of a larger process of reducing
disparities in our society. However, lack of health
insurance is specific to the health sector. The uninsured
population in the U.S. is huge, diverse and growing.
It is easier to be uninsured than many think. Eight
in ten live in working families. People lack insurance
for reasons such as:
Their
employer does not offer health insurance, or they don’t
qualify because they haven’t worked long enough,
or they only work part time.
The insurance offered by their employer is unaffordable
given their salary level.
Individual policies are too expensive and/or unavailable
due to a pre-existing condition.
Young adults lose parental coverage when they leave
home or finish college.
Spouses lose family coverage due to divorce, retirement,
or death.
A
small number of the uninsured (approximately 3%) are
healthy and relatively wealthy, and may not suffer any
negative consequences from their lack of health insurance.
For the vast majority of the uninsured, however, the
result is less health care and worse health outcomes.
People without health insurance:
Get
fewer preventive screenings such as mammography and
prostate exams.
Are much less likely to get regular prenatal check-ups.
Are hospitalized more for complications of chronic conditions
such as diabetes, hypertension, pneumonia and ulcers.
Have less access to equipment such as hearing aids and
wheelchairs that allow them to live independently and
with some dignity.
Have later diagnoses for and higher risk of premature
death from cancer, heart disease, diabetes, mental illness
and many other conditions.
The central problem is that health insurance in the
U.S. is voluntary, fragmented, and expensive. This creates
great disparities in access to coverage and health care,
leaving lower-income groups politically isolated in
chronically under-funded health clinics and hospitals,
geographically isolated with no access to timely care,
and/or receiving occasional, uncoordinated care with
real risks of treatment errors.
Medical
debt exacerbates these disparities. One in seven American
families has trouble paying medical bills. Medical bills
were cited as a factor in half of all filings for personal
bankruptcy in 2003. Even for families with health insurance,
the requirement to pay higher shares of increasingly
costly premiums, to take larger deductibles, and to
make bigger co-payments for each visit and prescription
puts them one major illness away from financial insolvency.
Those hardest hit are the working poor (families of
four with annual incomes of $18,400 to $36, 800), 22%
of whom had difficulty paying medical bills last year.
There are health consequences as well as economic ones.
Families carrying significant medical debt tend to delay
seeking needed care. They particularly skip or reduce
purchase of needed medications.
The
problems in California are more severe than they are
nationally, and even worse in Los Angeles County than
elsewhere in California. California’s un-insurance
rate of 21% is one of the highest among large states.
Los Angeles is at the epicenter of the national problem,
with over 2 million residents who are uninsured at some
time during the year, representing 1 in 4 of the county’s
non-elderly population. Furthermore, Latino and Asian/Pacific
Islander people in Los Angeles are even more at risk:
more than three times more likely to be uninsured than
non-Latino whites.
Given
the structural deficit of California’s state budget,
there is a real risk that the already bad situation
will get worse for the 6.6 million uninsured Californians
and a similar number cared for through the MediCal and
Healthy Families programs. In the near future they are
likely to:
Have
less access to affordable, employer provided health
benefits.
Have more difficulty finding providers willing to treat
them (already 56% of MediCal patients report difficulty
finding a doctor). Find the few remaining free clinics
closing, and increasing numbers of emergency rooms closed
or on diversion.
This
report recognizes that the fundamental injustice in
the health care delivery system in the U.S. is due to
a complex set of factors: the multiplicity of insurance
plans, the inability to secure insurance coverage, medical
debt, uneven health care, ethnic or language isolation,
lack of health system access—these are all the
causes of health care injustice. And the situation is
getting worse. The percent of uninsured persons increases
annually as do per capita health care costs. As communities
of faith, we draw upon the teachings of our foundational
scriptures and on our traditions of concern for those
in need to urge our congregations to call upon our legislators
to address this health care crisis, and to insure that
everyone receives timely, affordable, safe, quality
health care. |
In
2003, the Los Angeles Council of Religious Leaders,
representing a broad spectrum of Jewish and Christian
communities in Southern California, convened a Health
Care Task Force, whose charge was to study the crisis
in health care coverage and to suggest remedies appropriate
for these religious groups to support. Over the last
year and a half the task force has met with many of
the stakeholders in this issue—hospital and health
plan executives, health activists, providers, public
health scholars, elected officials, and theologians.
This report represents their conclusions.