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.