Why Ryan's AHCA Can't Save Health Care

The plan recently released by Republican leaders of Congress to replace Obamacare is a poor substitute. The new plan, American Health Care Act, attempts to walk a line of appeasing those who have found something desirable in the ACA, or Obamacare, while also pushing the system further into the milieu of free markets and personal responsibility. A move that will not succeed in doing what Obamacare was intended to do - stabilize the health care market and make it affordable for all.

Prior to the passage of the ACA, health institutions were facing major financial stability problems. At the heart of the problem is the fact that such institutions do not refuse treatment, particularly emergency care, to anyone on the basis of ability to pay. As a result, those least well off and unable to afford health insurance or even regular visits to a clinic aimed at preventative care, put off seeking any medical attention until they are unable to function normally and require emergency care. This form of care is generally the most expensive treatment compared to other visits with medical professionals. These hospitals would get what they could from their patients to cover the costs for this care, but those that attract large numbers of patients without the ability to pay incur large deficits. In order to cover these deficits, hospitals structured prices such that they were essentially operating as insurance providers themselves. Those with insurance or the ability to pay were charged at rates much higher than the cost of the treatments they were receiving. This additional revenue could be used to cover the expenses from emergency care.

However, people with the greatest ability to pay for the care they receive are also more likely to have health insurance, and insurance companies are not particularly inclined to pay more than they feel they should. As such many hospitals were still operating at deficits. The profitable customers were simply being outnumbered by the non-profitable ones.

Part of Obamacare's intent was to fix this crisis in hospital budgets, primarily by providing insurance to those who previously were unable to pay their hospital bills. This allows the hospitals to still get paid for the services they are providing, regardless of who they are providing them to. Secondarily, it should transfer the resources used from emergency care to more standard general and preventative care that cost both the patient and the caregivers far less. Though on this second mechanism, I would expect the effects to take some time to be seen as behaviors will not change over night. Together, these mechanisms should lower the overall cost of health care services and thus health insurance premiums.

These goals are only feasible by bringing more money into the pool, that is more healthy people who will use little of what they are paying in an average year need to contribute. Obamacare does this through the individual mandate. Everyone has to have health insurance or else pay a fee at the end of the year when they file their taxes The revenues generated from this fee are also applied to medical care and subsidies so even if you choose to go uninsured, you still contribute to the pool. The more healthy people contribute, the smaller the burden on those who need care. That is essentially the idea behind health insurance in the first place.

Ryan's AHCA fails to provide any real incentive to get more money into insurance pools. Instead of the individual mandate, the new plan allows for higher punitive rates for a year on those who choose to go without coverage and then sign up or those who allow a lapse in their coverage. Such a rule does not incentivize anyone who may struggle to afford premiums to do so. Instead, such people will return to the way things were prior to Obamacare; they will go uninsured and visit the emergency room when things are bad. Couple this with the change from subsidized insurance plans to tax credits based on age, Republicare is sure to cause a shift back to the way things were with the poor unable to afford adequate health care and hospitals paying the price for their emergency care.

If our health care institutions are to survive, we must come up with a way to support them and the services they provide. The AHCA will not do that. Even the ACA may not be able to accomplish this goal as it currently stands. Changes need to be made to our health support system, but they must be ones that ensure its viability rather than sign its death certificate.

The United States: A Christian Nation?

     Over the Christmas weekend, I had a conversation with my Dad about whether the United States was founded as a Christian Nation. He suggested the fact that those who signed the Declaration of Independence and helped build the government that followed were Christians provides evidence that it was meant to be a Christian Nation. My response was that had they intended for the country to be a Christian State, they would have made that clearer in writing. Since this is not made explicit in our founding documents (Declaration of Independence, Constitution, and Bill of Rights), that was not their intention.

      This week I found some quotes from four of our founders inscribed on plaques outside a local bookstore.

      I was pretty surprised to find them, especially the one from Jefferson.* They really got me thinking about what it would mean for the US to be a Christian Nation and how that would affect someone like me who does not identify as a Christian. Would church attendance be mandatory? Would being a member of a congregation be a requirement for public office? To be able to vote? Would the ten commandments be national law? What about the other laws of Moses as written in Deuteronomy and Leviticus? Would all schools be run by the church, dedicating time each day to prayer and bible study? Would sex education and all forms of birth control be illegal? Would records of baptism and confirmation be required forms of identification the way driver's licenses and birth certificates are now? Would one need approval from church leaders to start a business or run for office?

      While some might rejoice at affirmative answers to any of these questions, I would be concerned by them. A yes to any of them places a limitation upon individual's freedom, a principle I see as quintessential to the character of America. It bothers me now that many, in the name of religious principles and ideologies, insist on curtailing people's freedoms. Nor do I think it right that those who wish to express their belief are asked to be silent. The beauty of this country was supposed to be that each could worship, or not, according to his or her own beliefs. That there would not be any coercion to adopt particular beliefs or customs. The government and its agents would be able to protect all individual's rights and freedoms equally, which are inherent to our nature and not the privilege of our class, stature, beliefs, or position in the eyes of God.

      So what should I make of these quotes that seem to suggest otherwise? Do they provided the evidence I have been missing that the US was in fact founded as a Christian Nation? Delving further into history suggests no. These quotes were selected for their usefulness in supporting the claim, but they are not the whole picture. Once revealed, I think it is rather clear these quotes either reflect the speaker's personal beliefs and not necessarily the position of the State or were minority opinions that cannot be accredited to the State either.

      The Adams quote connects religion to morality. From that connection I get a sense that Adams sees religion as being the source of morals for individuals. The concern he expresses here is that a population that is not religious is not moral, and an immoral people cannot have their rights protected equally in the manner the Constitution sets in place. But I think it very telling that Adams says the Constitution is for a “religious people.” He does not say Christian here. He leaves it open with his terminology. Religion as a source of morals is true for all religions and not merely Christianity. Adams recognizes that religions teach many of the same moral lessons – don't steal, don't murder, don't lie. These basic moral precepts are what the Constitution takes for granted. As long as the population holds these moral beliefs, regardless of their motivation and reasons for holding them or the deity they worship, the Constitution, and therefore the government, will function as intended.

      In opposition to my understanding of the quote, many read Adams's terminology to mean Christian, and it is not just with this quote. Many take our early political figures' comments on religion to mean Christianity. They argue the fact that since they were Christians, and that the majority of the population was also Christian, they were only referring to their own religion. I don't buy that argument. I believe the founders were smarter than that and more precise in their language. Had they wanted to restrict beliefs to forms of Christianity, they would have said such.

      Here the Patrick Henry quote is relevant, as his statement is making the very point I am arguing against, but he did so as a founding father and not as a modern revisionist. I caution against taking his position as a stand in for others of the era generally or about the United States as we know it. In the first case, Henry was part of a minority who voted against the ratification of the Constitution, demonstrating he had issues with the legal framework this country would end up with. What he believed about the country and how it should be does not necessarily agree with what was actually passed by representatives of the various states. He thought the Constitution lacked protections for citizens that would later be spelled out in the Bill of Rights, which includes the establishment and free exercise clause of the first amendment--the opposite of declaring the nation singularly Christian. Additionally, this quote is dated 1765, 11 years before the Declaration of Independence and 22 years before the Constitution was approved by those present at the Constitutional Convention where it was drafted. His comment can thus not accurately describe the country we have today as it predates the laws which define it.

      Instead of looking at a single figure such as Patrick Henry, regardless of how pivotal a role he played in encouraging the revolution and enumerating our rights, who claimed the US was Christian, we should look at the collection of documents our founding fathers wrote or passed in Congress in order to get a sense of their collective intentions.

      In a letter to a Jewish community in Newport, Rhode Island, then President Washington wrote that our country was based on the equality of natural rights for all people. Different groups are not merely tolerated by those from a more privileged class but enjoy the same rights as citizens. The government disallows the bigotry and persecution that many had experienced under Anglican English rule. Had he felt these rights were limited to Christians, he would not have made them so clear when writing to a non-Christian group. He makes it apparent they were just as much citizens as any other group in the country.

      In the Virginia Statute for Religious Freedom, a work he was particularly proud of, Jefferson enumerates a number of ways in which governmental coercion to support or follow a specific religion or denomination is tyrannical and corruptive of both the individual and the organization. He also felt such acts were antithetical to the natural rights which the country was based on. He makes it clear that one should be free to use one's own mental faculties to judge the truth of spiritual claims and come to one's own understanding of the divine. What ever one chooses to believe should not preclude civic participation, whether this is voting or holding public office. As such the statute prevents compulsory support or attendance of any religious institution as well as religious persecution.

      At no point throughout the law does Jefferson invoke Christianity. He consistently speaks of religion. He does reference “Almighty God,” though I find that phrase to be as vague as 'religion.' In no way is he playing favorites here. Nor do I believe the establishment clause of the first amendment, which was influenced by this statute even if much briefer, does. Religious belief is a highly personal matter which the State recognizes as such. We are free to decide for ourselves what to believe and those beliefs do not disallow us from being a full citizen of this country able to hold property, vote, petition our representatives, or run to become one.

      During Adams's time as President, a series of treaties were signed with the powers of the Barbary Coast in hopes of preventing piracy and other disruptions of trade. One such was made with Tripoli and contained the following article:

Article XI

As the government of the United States of America is not in any sense founded on the Christian Religion,-as it has in itself no character of enmity against the laws, religion or tranquility of Musselmen [Muslims],-and as the said States never have entered into any war or act of hostility against any Mehomitan [Mohammed] nation, it is declared by the parties that no pretext arising from religious opinions shall ever produce an interruption of the harmony existing between the two countries.

      This line makes it explicitly clear that the United States is not a Christian nation. Had there been an objection to stating so in a treaty governing the nation's international relations, I think it likely for us to find objections to the treaty and in particular this article by those whose approval of it was necessary. Instead we find a full endorsement of the treaty by President Adams. In the Seante, the treaty was unanimously passed by the twenty-three Senators in session of a maximum thirty-two. I am not certain what the nine absent Senators thought of the clause or if any would have decented because of the clause. Regardless, over seventy percent of our Senators at the time thought it unnecessary to comment or reject the treaty and this article. That fact should secure its place as a principle our country holds. That it includes explicit references to Islam shows that the United States has not historically been one to find fault with it or its followers. Such a fear is a modern one that has a reasonable cause, though it has spread beyond a reasonable scope.

      As I see it, the modern claim that the US is a Christian Nation is one born out of fear. That fear is predicated on the shrinking size of the Christian population and what they believe their diminishing numbers means for the country's moral grounding. The primary cause of the decline is fewer young people are adopting the beliefs of their parents. Many associate this change or loss of faith as also a loss of morals. They associate religion, as I suggest Adams did, as essential to morality. They believe godlessness is at the heart of all wrong doing and thus the source of any and all ills facing the country. If fewer people are believers, then fewer people will be moral. Acts that they deem sinful will and have become common place. To the extent they believe God holds the attitude of the Old Testament, such immoral behavior will bring His wrath akin to the destruction of Sodom and Gomorrah.

      A lesser cause of the decline in the proportion of Christians in America is the increased presence of other religions, in particular Islam. The religion is still a rather small portion of the population such that most people, especially those in more rural areas, have not interacted with any Muslims. What they do know about Islam comes from national and international events, many of which are tied to violence. While Martin Luther King, Jr. is held in high esteem for his non-violent and Christian approach to achieving civil rights, his peer Malcom X is much more maligned for his seeming endorsement of violence and his Muslim faith. More recently, the terror attacks of September 11^th and the formation of the Islamic State have intractably connected violence and Islam. Such things reinforce people's notion that specifically Christianity is needed for morality and peace.

      I believe this fear is misplaced. Christianity does provide a good moral framework, but it is not the only way people are moral. Nor does its adoption ensure moral behavior. I would argue that Jesus taught everyone fails at times to live up to our moral standards. No matter how pious one is there will be times of moral faltering. Not all wrong doing can thus be blamed on a lack of faith. We cannot cure all of society's ills by merely introducing people to Jesus.

      People may be right to fear a lack of morality within our culture, but they need not link it to religion. I, like Adams, believe that a strong moral foundation is necessary for a country like ours to function. But unlike him I do not believe those morals need grounding in religion. We should all be able to recognize the rights each of us has inherently, that the founders pointed to over and over again in our early laws and charters, without a common deity, or any at all for that matter. It doesn't take belief in God to denounce the immorality of corruption, cronyism, extortion, exploitation, fraud, and theft that bring nations down from the inside. Those are the types of moral failings we should be concerned with and fight against when we vote or petition the government, which we all can do regardless of our spiritual beliefs.

*Concerning the Jefferson quote – I thought it sounded a little off in the context it was placed and was curious about what the original context was. On a whim I opened up a some pictures I took while visiting DC earlier in the year. To my surprise I found the same quote inscribed at Jefferson's Memorial. But this time it was longer and thus provided some of the context I was looking for.

     I think it is fairly clear from the fuller quote, the subject Jefferson is talking about is inequality. In a literal sense it is the inequality between a master and slave, but his push for education at the end suggests he sees the relationship between the common laborer and proprietor as similar if the two are not given equal opportunity to learn. His comments about the justness of God and His inevitable wrath on the unjust are not meant as foundational principles for the nation, but a belief that allowing a wrong to persist, when you know it is wrong, is also wrong and worthy of judgment and punishment. If a Nation is built upon such injustice, it will eventually fall. God is invoked as the source of the inherent equality between men and as well as the deliverer of karmic justice. One need not have a government based on Christianity to hold such values personally or institutionally. I think it is possible to recognize the fundamental equality between each of us without relying on the existence of a supreme being that is ultimately responsible for existence and justice.