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The Limits of Subsidiarity Print E-mail
By Peter Brown   
Saturday, 14 April 2012

Whatever the fate of Obamacare, there is no escaping the fact that the great American health care debate is far from over. The debate has been at times so fierce that it has even spilled over into theology, where partisans on either side are armed with cudgels called, respectively, “subsidiarity” and “solidarity. In recent weeks, we’ve even seen these two Catholic terms, unfamiliar to most Americans, applied to support or to condemn Paul Ryan’s budget proposals for the entire country.

In broad outline, “Subsidiarists” are people who are fearful or hostile to the state provision of social welfare – preferring that charity be dispensed at lower levels of society: communities and families. “Solidarists,” by contrast, believe that society as a whole is often the best administrator of social welfare, and prefer that things such as health insurance be run by the state.  

For the moment, it seems as though the subsidiarists have the upper hand, but the question is by no means settled. For the last several hundred years, not only in the United States but in all advanced societies, the trend has been very much away from “subsidiarity” as welfare states of various forms have sprouted. Let’s take a sober look at why this is so. 

Subsidiarists speak kindly of social arrangements as they were in the old days, when communities consisted of people who knew and cared for one another and extended families. Why, in this view, should Catholics support a distant, impersonal, bureaucratic welfare state, when for most of Church history Catholics subsisted by taking care of one another? Close to this view – increasingly common in the age of Obama – is that programs such as Medicare, Medicaid, Social Security were adopted by historical accident, or worse, as some sort of progressive plot to subvert communities and families by making them dependent on the state. 

In his core conviction, the subsidiarist is not wrong. People did use to care for each other more and without state provision. The original risk-pooling arrangement in the West was the feudal society – with  peasants and lords combining resources to take care of the sick and the dying. That system worked adequately, though it was always vulnerable to systemic risks: Crop failures, famines, wars, droughts, and pandemics where many people were affected simultaneously could not be insured against. Despite this, civilization managed to survive.  

With the emergence of modern capitalism, the feudal system collapsed. The provision of social welfare was replaced largely by guilds, trade unions, and – increasingly – friendly societies. For a membership fee and active participation, friendly societies would visit sick members while underwriting doctor bills and funeral expenses. Over time, many of them arranged for long-term support for the disabled as well. 

These societies also practiced solidarity, with regular member meetings imbued with a specifically religious flavor – prayers, Bible readings, and fellowship. The Knights of Columbus was originally set up along the friendly society model. The arrangement seemed a subsidiarist theologian’s dream. People taking care of one another in families and communities in Christian charity. What was not to like?


               Nursing nuns: Does the work they did in centuries past teach us anything today?
 

What happened in a word was modernity. The friendly societies actually began collapsing well before the emergence of the modern welfare state. Understanding why they did so is crucial to seeing why they will probably not return. One problem was the vast improvement in medical care. When the work of a doctor is largely limited to amputating sick limbs, dispensing pain killers, and other (often useless) home remedies, patients are left largely to get better on their own, or not. 

A small community could provide for the health care that was available in 1870. It was much harder in 1910. It would be impossible today with the cost of care for, say, cancer or heart disease easily running into the hundreds of thousands of dollars. If subsdiarists really want the 1870 community model , then the tradeoff is accepting 1870’s health care. Any takers? 

Another thing that killed the friendly societies was the other modern capitalist phenomenon: social mobility. With people increasingly moving from farm to city and from city to city, the social solidarity that made the societies work fell apart. Solidarity is in fact an absolutely necessary (though not sufficient) condition for subsidiarist arrangements to work. And solidarity simply does not hold up well in a dynamic labor market. Want to move to Texas to accept that great job offer? Then someone needs to take care of grandpa and the disabled cousin back home. 

The final blow to the societies was a capitalist innovation for dealing with risk: privately underwritten insurance. Insurance companies recognized both the rising cost of medical care and the social mobility; they could offer better rates to younger, healthier, more mobile people. This left the friendly societies with the older, sicker and less mobile.  We know how that ends. 

But what would replace the friendly societies after the world wars and the Great Depression delivered the coup de grace? There was really no one left but the state and some private insurance beset by the same adverse selection problems that killed the societies. As the adverse selection problems inherent in private insurance have grown, the state has assumed an ever greater role. Subsidiarists have not yet come up with a modern model that better manages risk.

Consequently, we have a health care system that is not very subsidiarist – or solidarist. The only solidarity is the ersatz solidarity of both employer provided health insurance and the elderly voting bloc marching under the paradoxical banner: “Keep government off my medicare.”

I do not know what the ideal health care system would look like. But I do know that theological terms such as “subsidiarity” and “solidarity” of themselves provide relatively little insight into where we should go. There are great dangers in turning power over to the state, but also in leaving people in modern societies without practical recourse. On this issue as many others, the complexity of the modern age defies simplistic theological sloganeering.

 
Peter Brown is completing a doctorate in Biblical Studies at the Catholic University of America.

 
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written by Michael Paterson-Seymour, April 14, 2012
Those nostalgic for the pre-modern model of social care often overlook the vast accumulation of capital that parish churches, religious orders, guilds and similar institutions had built up over the centuries. In France, for example, at the time of the Revolution in 1789, these institutions received about a quarter of the rental income of the kingdom, if one includes the dîne, or tithe, usually calculated as a fifth of the rental income of the land, the remainder being the rents of land owned by these institutions themselves. At the Revolution, the dîne was abolished and the church lands declared the goods of the Nation. Small wonder that the old forms of social provision collapsed.

What happened was that the dine was replaced by taxes payable to the commune, which was obliged to assume the welfare functions performed by the church. As this left the poorest areas with the lowest taxes and the greatest demand for welfare, subsidies from central government became inevitable.
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written by Gary Seaton, April 14, 2012
Mr. Brown. Good article. For an informed view of how the tension between solidarity and subsidiarity in American healthcare might be addressed, I recommend the work of James Capretta.
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written by Manfred, April 14, 2012
Perhaps it is not a theological question at all. Catholic hospitals are being sold to "healthcare systems" throughout the U.S. as they can no longer bear the costs, even with State and Federal financial support, due to the large number of people who choose not to own private insurance, but avail themselves of the hospitals'emergency rooms when illness or accidents strike. These systems then introduce contraception, abortifacients, tubal ligations, abortion and euthanasia as means of, let's be frank, "pest control" in order to limit the number of indigent people knocking on the emergency room door. The problem is what any society can do to alleviate the financial pressure continually imposed upon it by the endemic unemployable underclass.
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written by Lauri Friesen, April 14, 2012
I found this article entirely unhelpful and even unfair to Catholics who are opposed to "Obamacare". Mr. Brown has it exactly backwards when he simplistically defines a conflict between "subsidiarists" and "solidarists", then pronounces that there is no solution, given this very complex world we live in. In fact, our modern world is no more complex than human life and society have always been. The big difference is only that people have been largely successful in setting themselves free of any recognition of the "common good" or responsibility for others spiritual and material well-being.

I take exception to his describing "subsidiarists" as fearful of or hostile to government administration of social welfare. It would be more accurate to say that "subsidiarists" believe that government is the most expensive, least caring, and least effective way to administer any social welfare program.

I also think he and the "solidarists" entirely misunderstand what "solidarity" actually means. It is not supporting one large "group" to take care of all the individuals, it is standing together with the marginalized, the isolated, and the ignored in society. It does not mean being able to make your own life better, as long as you can offload your subsidiarity and solidarity responsibilities. It is taking those responsibilities to heart and living them.

Finally, I think there is ample evidence that government administration of social welfare (which is separate from the question of government funding of these programs) leads to individual indifference to the suffering of others, which is what is truly at the bottom of the seemingly intractable problems of our contemporary society.
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written by Louise, April 14, 2012
One thing that we can do to "fix it" is to stop running to the doctor every time we get a hangnail and, especially, to cut out the annual physical exams (At 1:00 PM I went looking for trouble; at 1:03 I found it.) and to stop listening to commercials that promise to cure everything that you didn't know you had.

Before I retired, I learned that Brigham and Women's Hospital was going to conduct a long-term study of women over 55. I attended the informational meeting. Just before we left, the speaker said, "When you come for your appointment, Be Sure To Bring Your Medications" (BSTBYMs). "Hmmph!" I said to myself. "I don't have any mediations. Why would she assume that I do. I think that I look healthy enough."

When I called for an appointment, the woman said, BSTBYMs. I said, "I don't have any medications." "Oh."

When I arrived for my appointment, the receptionist said, "Give your medications to the nurse when you see her." I repeated, "I don't have any medications." "Oh."

When I saw the nurse she said, "Did you bring your medications?" I said, "I don't have any medications." "Oh."

When I saw the doctor doing the research, she said, "Hello. Did you give your medications to the nurse?"

My blood pressure was sky high by this time and I said, "It is obvious that you have already made certain assumptions about women over 55, so I can't see how your study can't be anything but skewed based on your assumptions and presuppositions. Good-bye."

When I related this incidence to a doctor about 15 years later when I did become ill, he told me that most women my age come to him with, on average, seven medications in hand.

I will probably be accused of making unwarranted generalizations, but when I read of busloads of elderly people going to Canada for cheap drugs and stopping at the casinos on the border, surely there is something wrong with this picture, and it is not entirely the system's fault. The people who use and abuse the system must share a large part of the blame. The most efficatious part of preventive medicine is common sense, and for that you don't need a prescription or an MRI.
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written by Mack Hall, April 14, 2012
Mr. Brown is being quite fair; he has written an expository piece, not a persuasive one, and gives the reader historical background, states the problem, and considers possibilities.
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written by petebrown, April 14, 2012
Thanks for the feedback Lauri. Yes I don't deny that there are plenty of valid criticisms of the welfare state. But even conceding all the criticisms you make and recognizing that we could take care of each other more in many more ways than we currently do...in terms of the big things of medical care for the sick and the aged, it is inconceivable to me that any system could be devised which eliminates state involvement. It is more a question of how and how much rather than whether.

And yes, there will inevitably be simplifications as there is only so much that can be said in 700-800 words. But I note that Paul Ryan recently tried to justify his position by appealing to subsidiarity. We can agree with Ryan or not or Obamacare or not....but let's admit that there was nothing subsidiarist about the health care status quo pre Obama...large anonymous government regulated and subsidized risk pools, (even if privately administered) and single payer Medicare for the elderly don't constitute subsidiarity. They are an inevitable result of advanced capitalism and advanced medicine.
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written by Manfred, April 14, 2012
I am sure that the readers know our present system began in the time of WW II when wage and price controls were implemented to hold down inflation.An employer, who could not give a key employee a raise, suggested the employee bring in his health insurance premium and the boss paid it. Soon he was paying for many and "group insurance" was born. The upper limit on those policies was $10,000-today it is Unlimited! There were no MRIs, CAT scans or Bypass surgery in those days. Today we have machines which cost millions of dollars and the cost must be amortized by patients paying each time they use them. We have the best system in the world and people come from socialist countries to have procedures done here. Most people trigger massive amounts of costs with care in their unproductive, i.e, retirement years. When Germany was up against it financially due to war reparations after WW I, Hitler referred to these people as "useless eaters". We are seeing that term, so to speak, in this Country today. It will be interesting to see how things are resolved.
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written by Hen, April 14, 2012
I agree with Lauri Friesen. The USCCB had no right to lobby for Obamacare in my name, by virtue of my baptism.
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written by amanda, April 14, 2012
For someone who should be writing at a doctoral level I can only say your bias is showing! Please don't pass off this persuasive argument as if it were merely attempting to inform. the best thing about your article was that you at least told us your judgement, blatantly, in the second paragraph. As Hagrid would say "cogswallop."
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written by tz, April 14, 2012
The argument that subsidiaritists would require a return to 1870 health care is a straw man. It is a matter of the insurance group instead of being a small or large employer you happen to be at today, being the Fraternal Society (KofC still sells life insurance, why not health insurance with a full tax credit). Most like having one doctor, not whomever the 3rd parties desire, and a Catholic health system could be rebuilt upon that. But not if Government restricts the marketplace. Subsidiarity is a principle - along with solidarity - that may change the form in 2012 over 1870, but it is still a principle.

You aren't going to be flown to a national emergency room - there are county hospitals in very rural places for that reason. You have to have health care provided locally. Care other than physical things can't be manufactured in China, and will be difficult to outsource to India, but that is the alternative to subsidiarity. (I can't defend "free market" since trauma is not an event where when it happen you are going to get competitive bids from the nearest 3 ERs).
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written by Achilles, April 14, 2012
Dear Will, I should never have said I agree with you because it appears that we may be at different ends of the spectrum. Obamacare and the ideologies from whence it sprung and those to which it leads are deeply disordered. Sadly though, without Catholics, Obama could not have been elected, and how could have Catholics elected such a person with his character and ideology asks a very important question of our Church. Sins of the fathers are visited upon the sons and the USCCB must take responsibility for the horrendous catechesis that has plagued our country. Now for us Catholics to live the Catholic life we must make very difficult and damaging decisions to make sure we don’t cooperate in the evil that our own Bishops helped bring to our doorstep. Pete Brown’s essay is very interesting though reductionist, but Laurie answers that well. What about the family? All answers from govt are calculations, not neccessary evils only apparent remedies.
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written by Mouse, April 14, 2012
Interesting article! There is indeed more to this issue than we might all like to admit, given that we all have our strong opinions on the matter.

Some say that the govt shouldn't be doing charity, we should directly do it locally/from the churches. But they forget that when the govt wasn't involved, many people did not do their charitable duty, and as a result, there were many impoverished and sick souls who got no help! People today don't realize the utterly miserable poverty in which so many souls lived, especially after the industrial revolution, or in places like Russia where they were reduced to a harsh and unprotected serfdom. We can't look at the past with rose-colored glasses.

At the same time, I don't want the govt doing everything. And in today's anti-life environment, government run healthcare is a recipe for abortion and euthanasia. Problem is, so is the dominance of all healthcare by profit-driven companies, which includes many that officially call themselves non-profit but which in fact operate as for-profits. There is no evidence whatsoever that national and multinational healthcare companies/insurance companies will be any more compassionate than will the government. And we have no voting/lobbying power over those private companies at all, really. They do what they want and basically tell us we just have to suck it up. It stinks.

Personally I think that we Catholics may have to start a pro-life underground medical network some day. That's a wild idea, but imagine what it will be like when the hospital, insurer and govt all refuse care to you or your parents or children for x y or z reason. We're already seeing cases like this. We need souls to prepare now to help those who are rejected as not worth helping.

I don't have an answer either, as it seems danger lurks on every side.
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written by DDPGH, April 14, 2012
This opinion piece is simply defeatist. God-given human purpose is not fundamentally changed, even in modern times. Subsidiarity and solidarity remain essential principles of truely human society. What may have changed for some, however, is the enduring will to pursue the good and to find modern ways to live these principles.
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written by duke, April 14, 2012
All Paul Ryan is talking about is the desirable direction of govt policy. Surely from where we are it is helpful to consider decentralizing some of the functions now performed through Washington. It seems quite unlikely that too much shifting of responsibilities toward states, localities, voluntary organizations and families will occur in the near future. Lets try some focus on subsidiarity and see how it works.
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written by petebrown, April 14, 2012
Thanks Amanda...it's nice to get a strong reaction. And I'm pretty sure you've broken new ground by quoting Harry Potter on these pages.

TZ...you make a good point. The KofC sells life insurance...and indeed many of the friendly societies that survived morphed into insurance companies. Life insurance is a very differnt kind of product...if it pays out at all it's a specific indemnity. Why don't they do health care? For one I bet the average member age is well north of 50. Any idea what a family policy would cost for a 50+ year old without alot of younger people to even out the risk pool? Well over $1000 a month for even scaled down coverage. ANd much more than that for some of the members if you allowed K of C to underwrite to charge more for the ones at a much higher risk. It certainly wouldn't be better than what a K of C member could get through his job (assuming he has one). WHich proves I think that the huge improvements we've seen in health care and the higher costs that these have brought are not a red herring....they are the very heart of the issue. It would be no problem for K of C to sell health insurance if all it meant was a few death bed visits from a physician and the cost of the funeral, which was basically what was available in 1870. But, rightly, we tend to want more than that from medical care.
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written by Lauri Friesen, April 14, 2012
Mr. Brown, you say that "in terms of the big things of medical care for the sick and the aged, it is inconceivable to me that any system could be devised which eliminates state involvement. It is more a question of how and how much rather than whether." I will assume that you mean chronic conditions, such as diabetes, and catastrophic illnesses, such as cancer, to be the "big things" of medical care. And on those subjects, I would agree that the majority of individuals and their families do not have the financial means to deal with these things unaided. However, there is a huge difference between the state providing the medical care and the state providing funding for medical care. Why does it have to be the state which provides all medical care? There is much evidence that this only leads to ever more cumbersome bureaucracies that eat up a disproportionate share of the money, demand ever larger shares of tax revenue, make undemocratic decisions about what constitutes eligible procedures, treatments, etc., and just basically never have enough of anything.

I would not say that what came before Obamacare in anyway constituted subsidiarity or solidarity. What is needed now, though, is a public debate about statism v. subsidiarity and which will be more effective, compassionate, and responsive in delivering health care.
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written by Brian English, April 14, 2012
"it is inconceivable to me that any system could be devised which eliminates state involvement. It is more a question of how and how much rather than whether."

What are you talking about? Do you realize that Medicare and Medicaid only came into existence in 1965? Medicare and Medicaid, along with the linking of health insurance with employment, have been the major causes of the problems we now face. And your answer is more government involvement? Insanity.

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written by Sue, April 14, 2012
Why has the practice of medicine gotten so expensive? If it were like computers, it should have become much, much cheaper by now. It is not, because insurance has taken over, and so inefficiencies and bloat has crept in. Whenever a third party pays, and the patient doesn't see the bill or have motivation to correct it, the provider can make a killing. This also, by the way, allows bad medicine to happen; for instance look at all of the suicides from antidepressant overprescription. When you give the doctor the insurance card, he can charge up whatever he likes and you have little motivation or expertise to protest.

This is not to say most doctors are venal - but they are tied up by the system of payment and tort system, and because of the corruption of the pharmaceutical industry, doctors don't have access to good medical data all the time.

Now throw in Obamacare, and you've got a -fourth- party - the government. If the regime is a welfare-dependency regime, you are viewed as a mouth to feed, and your care will be provided accordingly. So much for the "doctor-patient" relationship.

The march of socialism, and nothing else, has morphed the "Angels of the Battlefield" (nursing nuns of the Civil War) into the "Angels of the Death Panel" (think Sister Obamacare Carol Keehan and her fellow femin-nun-ists).

I agree with Louise and those who protest the USCCB shilling for Obamacare. If USCCB wants to promote solidarity, it can innovate a Catholic care system that imitates the Amish, who are incidentally exempt from Obamacare because they don't buy into the "insurance" concept. Smart Amish!

We _can_ turn the clock back to a time when Catholics and families took care of each other. We might have to stay closer to home and not galivant the globe, but ironically the internet will help with that. We might have to watch our diets, our lifestyles, and our knee-jerk impulse to run-to-the-doctor to avoid big-ticket care (there are several bumps and lumps I ignored this year which healed themselves, but I'm sure would have been thoroughly drilled down by a doctor who knew I had insurance coverage and had to cover himself legally).

And we might have women finally come home to take care of young and old - that will solve a lot of other problems with the family, as well. The success of homeschooling might just be paralleled with a certain amount of home nursing!

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written by Aaron, April 14, 2012
This is, essentially, a pointless waste of bandwidth. The author, unfortunately, pulls an "either/or" with subsidiarity and solidarity, while ignoring that the terms are "both/and". Solidarity refers to the fraternal love that we must share with our fellow man under the command, "Love thy neighbor as yourself". It is solidarity that enables us to even conceive of subsidiarity. Subsidiarity, as the Church's Magesterium emphatically teaches, is the most effective (and dignity affirming) way of meeting human needs, but it is based on the concept of solidarity.

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written by Aaron, April 14, 2012
@ Mouse:

The government DOESN'T do charity. It never has. It can't. Charity is the willful donation of time, talent, and treasure to aid in those less fortunate out of love for them. Passing laws that compel or coerce me to give of my hard-earned money to some "program" that I don't agree with, or is inefficient, is not charity. When government gets involved with the poor, or sick, or some other disenfranchised group, it does so only out of self-preservation. Otto von Bismarck did not provide unemployment compensation to Germans because he cared about them, but because he wanted to shut the socialists up...and it worked.
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written by Devra, April 15, 2012
This is a fascinating article. I am skeptical of those who assume that families and other intermediate associations would step up to take care of their own adequately if government would just "get out of the way." But I also wonder if it's really necessary to have large, distant, impersonal organizations step in to provide modern medical care. Recent family medical problems have convinced me of the almost inconceivable inefficiency of standard hospital practices--they're so expensive that only enormous, distant parties can possibly pay for them partly because they really are complex and incredible, like MRI machines, but also partly because hospitals are so incredibly spendthrift--at least that's true of U of Michigan, which is practically the only flush organization in the state, with all its government money. I wonder, too, if the entrepreneurial spirit will produce more than we might expect in the way of home care, travelling nurses, machines that allow people to give themselves certain medical treatments (infusions, injections, tests) in their homes. I've always loved the way the Church takes the best of "solidarity" and the best of "subsidiarity," when everyone else seems to be setting up a dichotomy--they neglect one and misunderstand the other. Anyway, I hope you'll be writing more about this.
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written by Anil Wang, April 15, 2012
Subsiduarity does not mean eliminating all consolidation. It simply means that decisions need to be kept at the level most appropriate to them and not at any level higher. So care of children should be by the family and not the state. A police force, cannot be done at the family level (without causing anarchy), but it can be done at the municipal and state level.

WRT health care, cancer treatment can definely have solidarity, but the bulk of health care does not need it so it can be done at a lower level. Subsidarity demands that it be done at this lower level. Obama"care" fundamentally violates subsidarity.
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written by Manfred, April 15, 2012
What an incredible discussion and yet so typically "Catholic". Someone getting a Ph.D. in Biblical studies is writing on this arcane subject? Where is the mention of 26 States suing the Federal Gov't on this issue? How about a mention of Belmont Abbey, EWTN and Alabama also suing the Gov't on this issue. Where are some of the points made before the SCOTUS and the responses from the Justices? I have been marketing and servicing group health insurance for over forty years and I know the subject very well. I have taken courses on PPACA (aka Obamacare).
Sue: Smart Amish? They leave school at age fourteen! There are no Amish doctors (or lawyers,accountants,theologians, etc.).They show up at the emergency room door just as is done in urban or rural areas with the hope that their care won't cost more than a few thousand dollars (cash). This is a very complex subject being discussed by amateurs. The USCCB has been told they have until August, 2013 instead of August, 2012 to get their hospitals, colleges, etc. organized as the Gov't wishes, but then they get on line just as everybody else has to. Look up Kulturkampf and read how Bismarck drove many Catholic religious orders out of Germany (many to the U.S.) in the 1870s. The U.S. Gov't is at war with the Catholic way of life and the naifs who manage/populate the Church are just beginning to realize it.
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written by Other Joe, April 15, 2012
I worked in the medical field for many years. I offer a few observations in the interest of re-centering some of the rhetorical explorations. The cost of developing new medical equipment and drugs is made artificially high by the demands of the FDA. The demands are bureaucratic in the extreme, to the extent that they were attempting to make developers of new products provide a paper trail of their thoughts! They reasoned that bad design starts with a bad concept and it does. The failure was in imagining that bad thoughts could be eliminated with the proper protocol. It is laughable idiocy that costs you (the reader) big money. The FDA also controls who may buy medical equipment. Say it cost 5 million to develop a medical sensor that can be used by eye doctors. That money includes the engineering staff, the quality control staff, the financial staff, the cost of heat and light and working space, the sales staff, the bureaucratic interface (every step in the process has to be documented and the documentation has to be documented) the technicians and so on. Not every eye doctor will buy the sensor and there is competition, so say the market for the sensor is 5,000 eye doctors in the US. Each doctor will have to spend a thousand dollars for the sensor to cover development costs before the cost of making it, selling it, shipping it, stocking it, advertising it and providing tech help and repair for it is paid for. Actually he is going to pay closer to $3000.00 for the sensor because of distribution. If he has 300 patients, and 100 of them might benefit from the sensor, he will have to charge each one $30.00 for a scan to cover his expenses, so make that $50.00 - except that he has to pay an individual to handle the paperwork load to get reimbursed so make that $100.00 and add $10 more to cover the liability insurance payment because a nurse in Indiana once poked out a patient's eye and the manufacturer was sued for $5 million. The government sets the usual fee for using the sensor! Most people don't know that. The sensor is not perfect because nothing is perfect. The doctor uses it to make an educated guess about what is happening with the patient - a diagnosis. In other words, the doctor does not provide health care as if it was a commodity (there is no such thing) the doctor makes judgments based on experience, intelligence, training, in a small window in time. Being human, the doctor is sometimes wrong. Notice that good doctors are wrong less, but all doctors are wrong sometimes. The doctor pays $100,000 a year for liability insurance. The government sets the limits for what patients can sue to recover after what a lawyer may determine is a fault in the diagnostic process. In other words behind every single expense is the government which then uses the problem of expense to take more control over the process. The way the FDA rules on new medical sensors biases the process toward what already exists, because the FDA knows nothing about medical technology and must rely on existing manufacturers to set standards which they do to benefit the products they already make. By the way the cost of the parts in the hypothetical sensor mentioned above is typically under $10. If the sensor could be sold OTC, it would cost about the same as a cheap digital watch - but nobody wants that because then patients would monitor their own health. Some would get it wrong and hurt themselves so it can't be allowed. But then some are eating themselves to death, drinking and driving, shooting up drugs and indulging in various deadly sins - and for them, we can't have cheap sensors. The reason computers are cheaper every year, but medical expenses go up faster than inflation is government in action.
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written by Frank, April 15, 2012
When the government particularly the US Government spends 50 to 80 cents on every dollar collected through taxes on bureaucratic overhead and not to those in true need for which the dollars through force of law were collected, then something is truly amiss and will remain so until there is some constructive rethink about the social gospel and the secular application of social justice.

It's one of the easiest and most of the time painful efforts to write a cheque to the Government. Write the cheque, attach to return and mail before the deadline. OK, I've done my duty for the year and thrown my obligated money at the problem so now I'm absolved from further effort to my neighbor and go about my daily business until next year. My reading of the Gospels over many years thoroughly convinces me that Christ wanted everyone of us to give more than just money, we are required to give of ourselves; our time, our abilities, and yes a portion of our money. "Social Justice" under the current definition and application of its secular adherents and a few too many Catholics as well is stuck and will remain stuck in the antagonistic paradigm of constantly throwing more and more and more money at the problem. The "War on Poverty" begun in the 1960's through the "benevolence" of LBJ has spent over 35 TRILLION dollars and no victory over this war in not even in sight. Insanity, that thing done over and over again while hoping for a different outcome? Are we not called to bloom where planted or replanted? The sense of community while dormant is not dead. It will reappear once enough of us reassume that mantle of obligation and tell government to reduce its efforts in an area of which it has failed through its largesse.
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written by ann, April 15, 2012
I agree with those on this thread who nix the either or pessimism in this article. The problem is that the health care industry is too big and too greedy. There are alternatives and they are not difficult to implement. Do not say simplistic. It will take time to implement, but it is not simplistic because it is subject to "tweaking".s

How to get the greed of the insurance companies out of the mix?

Non-profit health insurance entities like BCBS used to be.No shareholder profits or huge CEO salaries.

How get greed of health care providers out of the mix?

Encourage the schools to accept as many students as they can who are entering medicine as a vocation of service to others rather that to their own ego and pocketbook.

How get greed out of hospitals?

Nonprofits established as providers of service with no shareholders or overpaid CEOS.

How get the greed out of big pharma?

Tax breaks for manufacturers of quality generics, trust bust the big pharmaceutical companies which buy up generic manufacturers and shut them down to establish a monopoly. Allow for purchase by individuals from Canada or Mexico without penalty.

How pay for it?

Tax credits to the purcheser of insurance coverages and medicines. (For those who may have forgotten, tax credits come right off your tax bill or you get a rebate if you do not have a tax bill large enough to off set the credit)

How manage it?

As locally as possible.


Why?

Because I have been an HMO recipient and a private insurance member and now Medicare and HMOs and Medicare are terrible in too many ways to articulate. I have also worked in the healthcare industry. And get rid of the word industry in association with health care.


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written by Michael DePietro, April 15, 2012
I do not think Mr. Brown understands what subsidiarity means. It does not mean that charity should be dispensed at the level of families and communities. Since he gets the definition wrong the rest of the essay becomes a non sequitor. The actual definition is the idea that a central authority should have a subsidiary function, performing only those tasks which cannot be performed effectively at a more immediate or local level. The concept is applicable in the fields of government, political science, cybernetics, management, military. This principal has the beauty of being empirically testable. For example the American military has found that giving lower ranking officers greater decision making authority missions can be more successfully carried out ( as compared with the military experiences of those countries which leave a greater percentage of decisions higher in the chain of command). In terms of social welfare programs, it is pretty obvious in terms of their empirical success the large bloated federal programs favored by the Catholic left have been a disaster. If I was some demonic entity that detested the poor and wished to grind them further into poverty I would simply follow the policies recommended by the USCCB committee on Peace and Justice. Lets just try looking at one fact, prior to 1965 the poverty rate in the United States was rapidly decreasing, post 1965 and the implementation of the liberal "great society programs" the rate of decline ceased and has floated around 12-14% ever since. This suggests that at best these programs do not work, but more likely they are not just neutral but detrimental, since the obliterated the decline in poverty that was already underway. In fact modern capitalism has done more to obliterate poverty and human want than any other system devised by man, that is why the poor in the United States are in fact wealthy compared to the middle class in places like India. The least wealthy 5% of people in the United States are wealthier than the wealthiest 5% in India. For those who would like to see the details read Branko Milanovic's book "The Have's and Have Nots". In any case what Catholicism teaches and what god commands is that we care about the each other, and seek to alleviate human misery, including poverty. This includes of course personal alms giving. In terms of public policy it mandates actually looking at the policies that work ( what are the actual causes of poverty and what things are associated with less of it.) The problem with the folks who like to throw around words like "solidarity" is that they do not seem to actually care if the policies they promote actually do anything to lower the rates of poverty and human misery. To the extent they do not, what they are doing is simply moral posturing. I am not a believer in subsidiarity because it is ideologically sound. I am a believer because the empirical data supports it, and more importantly in terms of economics the empirical evidence does not support the social welfare state.
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written by petebrown, April 15, 2012
Well I'm glad my piece touched off an interesting discussion. Yes Lauri, I think the debate is really about finance of the cost of medical care not govt. owning all the hospitals and employing all the professionals. So I think we're not as far apart on the issue as I thought before.

You're right Aaron, solidarity and subsidiarity do ideally go hand in hand. Maybe the lead in could have been better expressed. But the larger point is that both subsidiarity and solidarity have been undermined by the workings of capitalism itself, as much as by govt. welfare states. I'm a strong capitalist of course, but we need to be honest about the tradeoffs here.

A couple of you rightly complained about the high cost of medical care. No doubt some of it is due to inefficient state a federal regulations. For instance in many states it is illegal for a dental hygienist to clean a patients teeth unless she works for a dentist. COnsequently it is much more expensive to have teeth cleaned than it would be if we could visit a teeth cleaning clinic in a Walmart or something. And there are many regs like this.

But this is only part of the overall cost picture. Much of medicine is expensive because it is still very labor intensive. It takes just about as many nurses to staff an ICU ward as 30 years ago, and just as many doctors and support staff to do most surgeries. And a doctor can only see one patient at a time and do one surgery at a time. The productivity gains felt in other sectors just haven't been felt so much in medicine yet. And it's only through increased productivity that prices can come down. But doctors, nurses and techs command higher and higher wages than before, mainly because the market demand for their work is growing. No one wants to admit it, but in the future docs and nurses will have to make less because medicare and private insurance will force down wages. But doing so more aggressively than they already are will be very controversial.

I'm glad Manfred mentioned the example of the Amish. Answering that one is another whole article. Stay tuned.
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written by Frank, April 15, 2012
One last comment on the other issue of medicine. Yes it is expensive. The last three years of cancer treatment have taught me that much. Next time, when you whine about medical bills, take the time to consider the malpractice premiums each physician and hospital has to carry for practicing medicine, the performance of staff and quality of diagnostic equipment that comes into question every time a malpractice claim is litigated in court. In half of my life time of 28 years ago, the diagnosis for prostate cancer would have been less than a 50% chance of survivability and more than likely, I would not be here to write this. Yes, there are some physicians out there who should not be practicing medicine. Our faith teaches us only one who was perfect born form a mother without original sin and what did he get for being perfect, nailed to a cross dying an ignominious death. So, I guess there is no escape for the imperfect as well. We thank and praise the physician for saving our lives but wouldn't think more than a minute to sue them for great sums if they make a human error without malice, just a mistake. We rail against "Big Pharma" and forget what it takes to bring a pharmaceutical to market. The scientists from physicians to biochemists to synthetic chemists are highly talented and they don't come cheap. All have spent years in school learning their craft in both classroom, laboratory and publication. It is not uncommon for a pharmaceutical company to have hundreds of millions of dollars in development and testing before the medicine goes to market and begins to return any level of profit. What happens if the pharmaceutical fails after all that investment? It is also lost on many that many popular medicines though expensive also provide the additional dollars to research and develop medicines for small patient populations with rare diseases. Pharmacy patents have limited time before a generic is allowed to come to market. So while we wail and rail against the gouging and abuse that we all like to point to and at times occurs, where would some of us be without that medicine? Surviving cancer has driven home one important point i've lived by for many years...LIFE ITSELF IS RISKY BUSINESS. We all take a risk everyday when we get out of bed and I'll conclude with the famous quote of Ben Franklin, "Those who would trade their freedom and liberty for security are undeserving of either."
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written by petebrown, April 15, 2012
@ Michael Pietro. With respect, I think you are confusing several things. Regarding the many things in the world, yes of course it is better to have decisions made locally. The federal govt.. does not set the price of gasoline or steak or bread or laptops because all the things that go into such prices are diffuse throughout the supply chain and cannot possibly be known to central authorities but only large numbers of disconnected local actors. But is localized decision making always better in every case? Obviously not. Many successful multinational corporations have become so successful by learning to standardize their operations. The local manager of a Mc Donalds has some autonomy of certain aspects of the running of a local restaurant. But McDonalds doesn't let him change the menu even if he thinks his customers might really like tandoori chicken and pad thai this week. Many companies have learned there is an immense value to branding and standardization of a product that can only come through top down decision making. And if you think about it, the Catholic Church standardizes many things from top down decisions in more or less the same way. I'm curious for you to tell us how health care should be financed locally.

You also write "In terms of social welfare programs, it is pretty obvious in terms of their empirical success the large bloated federal programs favored by the Catholic left have been a disaster." I don't know....is it obvious that Medicare and Social Security have been a disaster? What about unemployment insurance? What about SSI for the disabled?

We may have legitimate complaints about how these programs work in practice. They are expensive for instance. And the concern about welfare is moral hazard ie. it promotes the very things it is insuring against. Well that was what welfare reform was all about!

But complaining about the workings of social insurance programs is different from proposing what really could practically replace them if they didn't exist at all.

Most people (including me) have taken the pragmatic step of recognizing the need for their existence while tolerating the inevitable shortcomings.
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written by Sue, April 15, 2012
Yes it's obvious Medicare is a huge item of waste - lots of unnecessary tests and procedures being done. I speak from having worked as an analyst for Medicare programs. Social Security is broke, a failed Ponzi scheme. That doesn't make it any easier to shut them down, however and it doesn't mean there's not meaningful medicine being practiced under Medicare. Families plan for themselves given certain assumptions about what will be available. There would have to be some gradual shift to more local systems.

But it could be provided with less waste if administered at a lower level - at least at the level of each church. And ideally things could move down to parishes and families. And if we have fewer intact families, perhaps that might be a mighty incentive for people to start patching things up.

What if the Catholic Church undertook to provide health care on its own, using only the contributions of its members, like it has provided Catholic education? No more billing the federal government, but then no more having to dance to the piper's tune, either. We could define abortion, contraception, and ivf away as not-health-care.

As for unemployment insurance, yes...that too is a disaster...and disincentive for getting people back to work. Double income families getting double unemployment checks is a huge corruption.

As for welfare reform, that was RINO-Newt style welfare reform in the 90s you're talking about. Real welfare reform would promote marriage, natural families, and adoption and would discourage divorce and single-parenting. Outlaw abortion, and let teen single mothers see the many many married couples who would love to adopt their babies, if only they would give life a chance.

You may think that I'm dreaming, but I'm not the only one! Couples are paying huge prices to undergo IVF, because it is simply too hard to adopt. Get rid of all the obstacles!

Yes, Peter Brown, I'll take your one-way ticket back to Civil War times and take my chances with the medicine. At least babies weren't flushed down the toilet, grannies didn't have to watch their back in the hospitals and children didn't get sterilized or pornified by the government and we didn't have the national debt remaking our posterity into little more than slaves on the government plantation.

Maybe we shouldn't have the half a million dollar hospital stays in America until they get cheap enough for third-worlders to have them, too. That'll happen a lot sooner if the medical field were unleashed to compete in a free market.
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written by JohnF, April 15, 2012
Subsidiarity is not fear or hostility of the state doing anything. It simply states that if a solution can be accomplishesd by a lower level of the state or society, it should be. So the question is: can the solution to healthcare needs be accomplished by a level lower than the Federal Government. The answer is a resounding yes, but is there the will to do it.
JohnF
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written by Bob, April 15, 2012
This is a horribly flawed article. "Subsidiarists" as a term reflective of "people fearful or hostile to state provision of welfare"---how naive, how simplistic, how absurd. And then to suggest by some form of inferential reasoning that social security, medicare, and medicaid are "solidarity" innovations. This makes no sense, makes a mockery of the teaching found in Centessimus (sp) Annus, and conflates political solutions with the brilliant, timeless wisdom of Rerum Novarum and Centismus Annus.
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written by Michael DePietro, April 15, 2012
Peter:
medicare and Social security are obvious disasters, both are approaching bankruptcy. Social security in particular is senseless since if you invested the money you pay in SS taxes your retirement would be significantly greater. As Medicare is bankrupt as well, it reimburses at rates less than cost particularly for hospitals and as such causes cost shifting and market distortions. Moreover since it essentially has set price controls ( It has effectively reduced reimbursement rates for physicians and hospitals and since private insurance often determines its reimbursement rates to the prevailing medicare rate, it has set price controls nationally.) This is inevitably resulting in rationing if via no other reason restricting the number of people willing to enter poorly reimbursing medical fields such as primary care. It has also lead to a system in which patients are discharged from the hospital faster, at times perhaps sooner that is ideal.

Peter you seem make a lot of statements that are not supported by any evidence at all, and when you venture into medicine you are making statements that are simply incorrect. I am a physican ( pulmonary and critical care medicine). Actually physicians and nurses and the whole system is a lot more productive than before. First of all the patient volume is dramatically increased. (In the last 5 years the medical intensive care unit in which I see patients has gone from about 1000 admissions/ year to almost 1700, with the average length of stay dropping, and the mortality rate unchanged, and the acuity ( meaning the severity of illness is increased). So we are seeing more patients, who are sicker, and in fact sicker patients receive a larger number of interventions. Thus we are in fact more productive. There are scales for measuring such things, such as the TISS scale ( therapeutic and intervention scoring system, which you are obviously unaware even exists). As far as your statement about physician incomes increasing because the "demand for their services in increasing", This is incorrect. There are de facto price controls set by the existence of medicare, the incomes of physicians has been declining in real terms since the mid 90s. Salaries for nurses adjusted for inflation have been fairly flat since the early 90s, based on the National Sample Survey of Registered Nurses.

Your last set of comments proves my point. It is no argument at all to say Medicare, SS etc are successes, it is an assertion. The fact that the programs are popular with the public is not a measure of their success because the public is not well informed as to the details of the programs, nor what alternatives to the programs exist. They are also unaware that the programs are resulting in effects that have not been linked in the popular mind to the programs themselves. For example most people do not like being discharged from hospitals faster than previously, and perhaps in a sicker condition, but they are not aware this is a consequence of a truly absurd reimbursement system.

My essential point then remains that many are responding to the idea that a program "sounds good", but have no ideas what the actual details regarding the effects of the program are.
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written by RoderickA, April 16, 2012
Thank you Sue. I appreciate your comments!
RoderickA
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written by rob, April 16, 2012
Subsidarity does not mean eliminating all consolidation. It simply means that decisions need to be kept at the lowest level of organization that will be effective, thus promoting both care and personal responsibility.

As one who lives in Maine, it is hard for me to see how the minimum level of organization for my effective health care must be one that includes people in Alaska.
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written by petebrown, April 16, 2012
@ OK Michael, I appreciate your feedback. I don't deny that there have been no gains in efficiency. Hospitals stays are indeed much shorter than before. Many surgeries are less invasive. And so on But I stand by my assertion that health care remains very labor intensive in comparison to other economic sectors. And I also add that docs and nurses and tech make quite a bit more in the US than in other countries on average. I can't link here but you might do a little reading on the Baumol cost problem which affects all labor intensive industries. These sorts of structural issues are one important driver of costs. Though we can surely agree that govt. subsidies also play a big role.

You've sort of admitted another of my points. Many people use the health care system alot more than before. I think this is for many reasons but mostly because they expect that health care can do much more for them. Ironically we have seen a huge increase in veterinary medicine for much the same reason. Vets can do more for sick dogs than before and can also sell patients on more expensive procedures, to owners who can afford them. There's little distortion from govt. here or from 3rd party payers...its largely just a case of people wanting to spend more money. And society in aggregate people are choosing to spend more on care for themselves even if its through Medicare or 3rd party insurance.

Yes. Soc, Sec medicare and the rest will need some adjustments..Payments will have to be cut, taxes will have to be raised or some combination of the two. But let's be honest and admit if our preferred solution is to scale back or eliminate these programs entirely our position is not rooted in concerns about subsidiarity. It's more just opposition to the concept of social welfare programs. And for the record I agree with many of yours and the others' criticisms of the American welfare state. But I think it is quite a bit harder to imagine what would go in its place if it didn't exist at all. For me it is a necessary evil that comes with accepting the gains of modern capitalism.

Moreover, these programs would be facing the same financial pressures if they were administered by states, cities, or even private firms. So let's have the political debate as we will. But let's stop pretending that Catholic social teaching compels one or another solution.

Cheers
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written by Michael DePietro, April 16, 2012
Peter you say
"But let's stop pretending that Catholic social teaching compels one or another solution." Yes! Indeed. I think what Conservative Catholics would argue is that indeed particular economic policies are not compelled by social teaching one way or another.
Given this fact then the social issues, ie the right to life issues should trump other concerns. We currently have a political party that favors abortion on demand throughtout all 9 months of pregnancy, abortion defined as an "unspeakable crime" by Vatican II. It is then obviously immoral to vote for someone who favors unspeakable crime and this is not offset by someone being more or less in tune with the Church's social teaching since as you point out we should stop pretending that Catholic social teaching compels one or another solution. This kind of pretense is what the left has been doing in order to justify voting for pro-abortion liberals. I agree they should stop.
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written by petebrown, April 16, 2012
On that we agree Michael. I think you're reading waaaay too much into my piece if you think I'm urging support for one or another political party. My main point was that Conservative Catholics should be realistic that the welfare state in one form or another is probably here to stay, and that we should seek to apply our principles and apply Catholic social teachings with that assumption in mind.

Thanks for the stimulating discussion!
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written by Sue, April 16, 2012
"My main point was that Conservative Catholics should be realistic that the welfare state in one form or another is probably here to stay, and that we should seek to apply our principles and apply Catholic social teachings with that assumption in mind.

Thanks for the stimulating discussion!"

Not so fast, Pete Brown...you have threatened to unload yet another article on the Amish...please don't act as if the vigorous and logical opposition to this present contentions yet been effectively rebutted and all that's left is to politely pack up.

In fact, Catholic social teaching *does* compel opposition to socialism. Read Rerum Novarum, and don't miss the fact that while Leo XIII critiques faults of capitalism, he in no uncertain terms damns socialism. And please don't miss the fact that most of the flaws that have been attributed to capitalism of the last century have been in fact crony corporatism, in bed with government and plutocrats, masquerading as free-market capitalism. We Conservative Catholics hold no brief for the Bush Republicrats who "had to abandon the free market principles in order to save the free market. Also note that it was the confusion-sowing CINO liberals, like Hesburgh, and the Rockefeller Republicans who have manufactured the social side of our current crisis. Whether it's economics or social issues, we true conservatives are on the correct (and Catholic) side of things. "

You choose well the setting of the Civil War and Catholic nuns' sacrifice, for a comparison point in history. In fact, Sister Obamacare Keehan and her liberal femi-nun-ist orders "Leadership Conference of Women Religious" major contribution of late has been to produce a promotional documentary on the importance of nuns to America. The extent they rely on 1800s and early 1900s is not even funny. Once the 60s hit, and sexual liberation evacuated so many orders, little happened in these orders beyond kumbaya. I shrank to view the website of the order that taught in my 1960s era elementary school - instead of habits, they flaunt clown-suits. Instead of the intellectual clarity I was bequeathed in their teaching, and the even greater precision that I see my own parents received, they are mired in slap-happy happy-talk.

Liberal nuns sold their birthright of sacrificial sisterhood history for a mess of pottage...as I say, they are the "Angels of the Death Panels". They are benefiting off the reflected glory of their forebears and trying to milk all the borrowed public respect for nuns while providing none of the benefits or sacrifice those nuns gave.

(Thank goodness, of course, for the new Catholic orders, who have nothing to do with LCWR!)

Similarly, the present day technocrats are living off the borrowed image of the country doctor while prying into every bodily orifice and plying technocratic euthanasia like zombies.

Please recognize that you have not effectively answered the arguments of your commenters before you sign off to write your article on the Amish, else it will be just as likely to miss the points your interlocutors have been making.
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written by Mark H, April 16, 2012
The article leave a lot to be desired. First, Catholics have abdicated our own personal responsibility to the poor to the government. We only have to look at the giving levels at all Catholic churches. Catholics are at the low end of giving. When I (the youth minister) are in the top third of the giving at any Catholic church, we have a problem with giving. Second, most Catholic churches do not have a vibrant ministry to the poor. I am talking about a full time staff member who is dedicated to the widow, single mother, and poor. A staff member who knows the stories of every person in the parish as well as the needy in the surrounding community. I can think of only one parish who has such a staff member and that job was slimmed down a couple of years ago. Why can't parishes hire a nurse to treat the poor and elderly? Why can't churches set-up ministry to the home bound? Most churches are doing little so we end up turning to the state. The Catholic church was the first ones to do foster care. We were the first ones to help pregnant mothers. We were the first ones to help the sick and elderly. We have abdicated our personal responsibility. How many people reading this are giving 10% of their income to God? I doubt there is a single one. Yet, if every Catholic gave God 10%, we would be a force to reckon with in the USA. When we give over to the state christian charity, we lose. This is the key thing: We are not a humanitarian organization. We exist to evangelize. We exist to lead people to Jesus. When we hand over charity to the state, we lose out on our opportunity to lead the needy to Jesus. 'The poor will always be with us'. The poor need the gospel as much as the middle class and the rich. Helping the poor is our chance to share Christ.
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written by Troy Jones, April 17, 2012
Too often these terms are discussed as if they are mutually exclusive instead of complimentary. Subsidiary does not have to mean by private people. Similarly, solidarity does not have to mean the federal government. We do have state governments in the United States of America.

I am convinced it is this either/or arguing about everything is why we have no middle road in American politics.
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written by James Stagg, April 17, 2012
I find this article incredibly ignorant of the causes and solutions for the correction of healthcare in the US, and, for that matter, in the world. The careless tossing about of terms which the author tries to rigidly define is not productive to a positive dialogue about what is wrong and what is right in the matter of government-controlled healthcare....especially when we see the disasters encountered with such policies in other countries.

We must start with personal responsibility. That can be encouraged in many ways, and Paul Ryan's yeoman work in this area is paramount. To foster a system of irresponsibility, as has been done with federal welfare programs, and then expect otherwise responsible people to pay for the irresponsibility of many is ludicrous. To waste the resources (tax collections)of government on frivolous pursuits of more administration and aid, while failing to police those handouts already authorized is criminal....not "uncharitable", but criminal.

There are many ways in which healthcare can be saved and even improved in this country if reasonable men and women will decide to provide reasonable solutions. Obamacare is not reasonable; it is a huge joke meant to increase government employment, taxation and government control of lives. Paul Ryan's plans are not the zenith of perfection either, but negative articles like this stack up barriers to constructive work that needs to be done to find real solutions.

Stay out of politics, Peter, and stick with Biblical Studies.

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