A few years ago, as Obamacare was being put in place, Republican governor John Kasich of Ohio suggested that the Christian obligation to assist the poor was a reason for expanding Medicaid in the state. Catholic social teaching does indeed make clear that the state has a role in assisting the needy, but only—in line with the principle of subsidiarity—when there is no other way it can be done. Is that the case with providing access to health care?
Subsidiarity is hardly just a sectarian principle. Even though hardly an American politician ever mentions it, it is a basic principle of social ethics—part of the natural law. As Pope Pius XI famously stated it in his encyclical Quadragesimo Anno, it is at the same time “an injustice,” “a grave evil” and “a disturbance of right order to transfer to the larger and higher collectivity functions which can be performed and provided for by lesser and subordinate bodies” (#79). In other words, when something can be done in the private realm—starting with the family and also including private associations, whether for-profit or non-profit—it is a moral imperative that it be done there. It is only when the evidence shows that something is truly needed in the first place and that it cannot be done privately that it is justified bringing it into the governmental realm. If so justified, it must then be shown that it cannot be done at the governmental levels closest to the people before it can go to the higher and more distant levels. In other words, while there is a moral obligation to assist the needy, it can be immoral if it’s done in a way that involves government when it’s not necessary.
It’s also not just a question of morality, but of practicality. When the attempt is made to do all sorts of things from the center, they can’t be done adequately or efficiently. As I’m fond of telling my students, it’s a good thing that the federal government isn’t in charge of trash collection in communities all over the country because it probably wouldn’t get done. In the encyclical Centesimus Annus, Pope St. John Paul II ran down a whole list of the troublesome results of the welfare state: the loss of human initiative, massive increases in public spending, and less concern with those being served than with “bureaucratic ways” (#48). In Europe we now witness national economies being crippled because of bloated public social welfare spending and a host of problems—including terrorism—resulting from easy immigration motivated in part by trying to get more people to tax to sustain the welfare states.
It’s curious that such a prominent American liberal intellectual as Alan Wolfe in his book The Future of Liberalism would say that it’s better for the needy to be taken care of by a government bureaucracy than private charitable organizations, which he says would be kind of “groveling.” He should have consulted John Paul before saying that and, for that matter, just observed how government bureaucracies treat people—with the additional fact that they have the full force of law to club people with. He might also have noted how when the elderly have turned to Medicaid for nursing home assistance, the state readily seizes any lingering assets they may have upon their deaths. Perish the thought of even any tidbits going to their offspring. Could anyone envision a private charity doing that?
The massive increases in public spending that John Paul alluded to raise a related problem that also has moral implications: the high taxation needed to sustain it. Pope Leo XIII’s admonition in the encyclical Rerum Novarum should be remembered: the state acts unjustly when it takes “more than is fair” from its citizens by taxation, as it is an indirect violation of the right of private property (#47). So, excessive taxation can be immoral. One of the criticisms of Medicaid expansion in Ohio and other states occasioned by Obamacare is the many millions it will add to state budgets—which is likely to mean, sooner or later, higher taxes. Those higher taxes won’t come just from the super-wealthy, of course, but will reach into the working and lower middle classes and will be an additional strain on them.
Do the facts show that aiding the needy on matters like health care mainly requires government? The members of Congress apparently thought that when they enacted Medicaid during LBJ’s Great Society. They simply made that assumption, probably without doing—or even wanting to do—much research about it. As historian Allen J. Matusow has written, however, there is no evidence that since its establishment Medicaid has provided either more access to health care or a better quality of care for the poor than the previous charitable care did. Following from what his predecessor said, Pope Benedict XVI in the encyclical Caritas in Veritate made clear that it is in no way inevitable that centralized, bureaucratic structures are needed to provide social services and assistance. He called on nations to develop a “more devolved and organic system” (#60).
Almost certainly, this especially refers to the non-profit sector—like the old charity-provided health care that Matusow speaks of—but perhaps to some extent even the for-profit sector, since Benedict says the distinctions have blurred in some ways as even certain for-profits now address some social welfare needs (#46). It’s worth noting that one of the consequences of the expansion of government’s social welfare role has been to weaken the non-profit, charitable sector or make even it increasingly dependent on government.
Actually, there is no danger that the poor would not get badly needed care from medical institutions even in the complete absence of Medicaid, since they are required by law to provide it. Many health care institutions don’t even need such legal prodding, however. They have arrangements to reduce the cost of care based on income.
In light of the history of successful charitable care in the U.S., one wonders if instead of proposing the expansion of Medicaid in their states, governors should seek to change state law and use the prestige, persuasive power, and even bully pulpit of their executive offices to encourage the reinvigoration and expansion of non-profit health care institutions and various efforts at charitable care. For that matter, the president ought to push in similar ways for this nationally and by encouraging legislative action to make it more possible. As charitable care would be strengthened and show people anew what it did before the era of Medicaid, Medicaid could actually be gradually wound down and, ultimately, retained only in the health care areas where government involvement is clearly needed.
It is problematical to suggest, as Governor Kasich does about health care, that the Christian obligation to assist the needy should be carried out via government programs. While, to be sure, government is sometimes needed and the obligation may in some cases be one of justice more than charity, to dismiss charity entirely from the picture makes it all seem like a redistribution-of-income scheme. It is hard for people to think they are carrying out a moral obligation to assist others when government gives them no choice and just forces them to pay up through the tax system. The case can certainly be made that, besides helping to avoid the pitfalls spoken of here, charitable institutions are both more effective than government in addressing human needs and—the Alan Wolfes notwithstanding—better at respecting and having concern for the individual than, as Pope John Paul recognized in mentioning “bureaucratic ways,” a distant, impersonal bureaucracy.
Editor’s note: Pictured above is St. Camillo de Lellis saving the sick of the Hospital of the Holy Spirit Sassia during the flooding of the Tiber of 1598, painted by Pierre Hubert Subleyras, c. 1746.