Over the past three weeks, we have seen a firestorm concerning the question of whether not contraceptive methods approved by the FDA are or are not properly a matter of healthcare. Over the past three weeks, we have seen amazing unity within the Catholic community in response to a clear over-reach by the Administration. (A few months ago, I wrote on this disconnect between the administration’s understanding of religious groups and religious identity and the understanding of Catholic identity behind all Catholic social services.) Over the past few weeks, we have seen an escalation in rhetoric from left and right (so prevalent that I would not even know where to begin singling out particular examples). In all of this, the debates have largely centered on religious freedom and reproductive rights – and at the center of the debate on the compromise: MONEY. What has been largely missing from the conversation? Health, Preventative Healthcare, and Health Equity for Women (as well as children and men)
Now I wish to be crystal clear – this is not a post about Contraception or whether or not contraception is properly “healthcare.” I am a Catholic moral theologian whose specialty is social ethics (including social aspects of medical ethics) and I wish to make a case for preventative healthcare and the provision of preventative care without co-pays.
According to HHS briefing, “Fifty-Four Million Additional Americans Are Receiving Preventive Services Coverage Without Cost-Sharing Under The Affordable Care Act”
While some plans already covered these services, millions of Americans were previously in health plans that did not. According to the Kaiser Family Foundation’s Employer Health Benefits Survey in 2011, 31% of all workers were covered by plans that expanded their list of covered preventive services due to the Affordable Care Act.[3] The most recent data from the Census Bureau show that 173 million Americans ages 0 to 64 currently have private coverage.[4] Putting these facts together, we estimate that approximately 54 million Americans received expanded coverage of at least some preventive services due to the Affordable Care Act in 2011.[5]
And according to today’s Health Financial Times:
The report on private health insurance coverage also examined the expansion of free preventive services in minority populations. The results showed that an estimated 6.1 million Latinos, 5.5 million Blacks, 2.7 million Asian Americans and 300,000 Native Americans with private insurance received expanded preventive benefits coverage in 2011 as a result of the new healthcare law.
Unlike other forms of insurance, health insurance involves a basic human need. Where auto, home, and life insurance are chosen to protect individuals (and families) from possible catastrophes, accidents, etc (a risk/benefit analysis); health insurance involves a known and certain reality – every human person will need and use healthcare in their lifetime. Will I need surgery? Perhaps but I may not. But it is a certainty that I will need forms of healthcare in my lifetime. Since we are dealing with basic human needs, human dignity and the interdependence of the human family, it is my contention that preventative care is essential to a public health approach that takes seriously that access to medical care and an adequate standard of living is a basic human right
The Universal Declaration of Human Rights (1948) states:
Article 25.(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
In Pacem in terris (often considered the Catholic declaration of human rights), Pope John XXIII echoes this commitment
Beginning our discussion of the rights of the human person, we see that everyone has the right to life, to bodily integrity, and to the means which are suitable for the proper development of life; these are primarily food, clothing, shelter, rest, medical care, and finally the necessary social services.
Therefore a human being also has the right to security in cases of sickness, inability to work, widowhood, old age, unemployment, or in any other case in which one is deprived of the means of subsistence through no fault of one’s own.
Both Catholic social teaching and the international human rights tradition recognize that access to medical care and an adequate standard of living is crucial to the protection of human dignity.
For some time now, the medical community, public health workers and human rights workers have recognized that accomplishing this requires more than treatment of diseases once they occur – it requires preventative healthcare.
So what is preventative health? According to healthcare.gov:
For example, depending on your age, you may have access — at no cost — to preventive services such as:
- Blood pressure, diabetes, and cholesterol tests
- Many cancer screenings, including mammograms and colonoscopies
- Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use
- Routine vaccinations against diseases such as measles, polio, or meningitis
- Flu and pneumonia shots
- Counseling, screening, and vaccines to ensure healthy pregnancies
- Regular well-baby and well-child visits, from birth to age 21
Nowhere is preventative care more essential than in the child health. In particular, well-baby and well-child visits as well as specific care: vaccines, developmental screenings, observations of physical development are all necessary for the well being of individual children, public health and early detection for treatable conditions. These are all a matter of basic human needs, they are guaranteed (not a matter of catastrophic illness) and for low income families with insurance copayments can be excessively burdensome. (without insurance, all non-emergent healthcare is basically out of reach) Quite simply, it is a matter of human dignity and the common good that preventative healthcare for all children be available. (This is integral to the unquestionable commitment of Catholic social teaching and the United States Conference of Catholic Bishops to universal access. –and in order for access to be real – it must be realizable and usable).
Now I began with children because it is easier to clearly see the role of preventative healthcare and a quick glance at a well-baby/well-child schedule will demonstrate that it is regular and frequent not a rare occurrence. So – we turn to the situation of women’s health. Just as it is important that the debate over contraception does not become an attack on the preventative health care provisions as a whole (a slippery reality creeping in as the focus turns to money and “free services” ) We also must not lose sight of women’s health equity and preventative care. Thus, it is important to remember that well-woman visits, mammograms, domestic violence counseling, breastfeeding counseling, gestational diabetes screening are all examples of preventative care for women as well. (A point reiterated by Michael Sean Winter’s recent article “The Politics of the Accommodation”)
A debate about whether or not contraception is properly preventative healthcare is a debate about contraception – it is not a debate about preventative health care, as such. The issue concerning who counts as a religious group for religious exemptions within US laws is an issue concerning religious freedom and the Constitution – it is not a debate about preventative healthcare. Preventative healthcare is geared to the overall well being and dignity of persons. We have long rejected the idea that healthcare is simply a matter of treating existing diseases; it is a matter of caring for persons and communities. As this debate continues, we must be very careful and make sure that significant achievements in access to preventative care and overall public health are not lost in heated rhetoric on all sides.
Meghan,
Thanks for this. I wholeheartedly agree with what you say about preventative health care. Continuing in this direction, I would also love the federal government to consider food as a part of health care. I would love to see the federal government craft a food policy that is based less on the political influence of certain industries (sadly, the food pyramid is misleading at best) and more on nutritional science. I wish they would promote through marketing and policy these foods and make them widely accessible.
It would also seem that promoting and making healthful food accessible would be even more cost-effective than preventive care.
So yes, I very much agree with you that our current definition of healthcare is excessively narrow.
Katie and Meghan – I think you’re right. When it comes to preventative health care, oughtn’t we be doing much more about food supply – and helping people learning how to cook it well – and facilitating exercise via adding sidewalks and so on in places where few sidewalks exist….
This is a great and thoughtful post – I really appreciate your reasoned voice and your thoughts about what constitutes preventative care.
As for the addition of food by Katie and the ways that we can help people learn to use the food, brilliant.
There is so much heat and so little light going around on this topic right now… as you know. As is so often the case, my Catholic friends that are further to the left have decided that the Church truly has eaten my brain. And equally, my Catholic friends on the right think I lack the vigor to fight for what is right.
Thanks for all you do out here.
Meghan, I found this post very thought-provoking… it actually kept me awake at night!
This isn’t really my area, and I think somehow I am not understanding the issues at hand when one makes a case for the preventative healthcare and the provision of preventative care without co-pays. Don’t misunderstand me as saying that I’m opposed to preventative healthcare; the part that confuses me is why it should be without co-pays, in contrast to other medical care. Access to medical care (preventative or otherwise) is certainly a human right, but why the bias in favor of preventative health care when it comes to out-of-pocket costs?
Our dental insurance has great preventative coverage. All cleanings and exams, x-rays included, are free of charge. So far, so good. But when a routine exam detected my husband’s gingivitis problem, things got a little tougher. Of course, we were happy to have an explanation for his on-going discomfort, and we were convinced by the dentist’s insistence that it must be treated immediately to prevent gum recession and to maintain the integrity of the teeth; thanks to the free exam, we knew all this, and we realized that getting it treated was undoubtedly a dental necessity, of highest health importance. Yay for free preventative care! Now, knowing this was a necessary dental treatment (rather than cosmetic), we initially assumed that insurance would cover the deep-cleaning, deposit of antibiotics, and whatnot. So we were surprised that our out-of-pocket cost was $900, and, as if to add insult to injury, the dental insurance paid a total of $8, i.e. $2 per quadrant. As a family of five on one professor’s salary, we just don’t regularly have room in our monthly budget for a gingivitis treatment. And we’re not even considered part of the insured, but poor, lower-class!
I’m sure medical insurance is not an exact parallel, but I can think of several families I know that have real medical issues – problems that are not solved (or even really improved) by free preventative care. For example, one friend whose child has diabetes spends $200 per month in treatment. Another friend has a son with spina bifida, and he has to see a few different specialists for that and related problems; not to mention the cost of wheelchair and building a ramp for their house. In neither of these cases does free preventative care make much material difference.
You use well-visits for children as an example of where we see the benefit of preventative care. Vaccines are a great example because they so clearly bring positive results to society at large. Perhaps that is why here in Jersey I constantly see flyers advertising free vaccines sponsored by local governments, clinics, etc. (largely geared toward those WITHOUT any insurance- a good example of how there preventative care can be available to the uninsured). It makes sense to me that these should be provided free of cost because of the advantages for public health, as well as the individual. Regarding well-visits in general, however, again, I can’t understand why these should be free of cost in contrast to sick-visits, emergency room visits, or extended hospital stays. As I said, I have friends really bogged down by medical bills, but I have never heard them complain about the burden of making a $10 or $20 co-pay for a well-visit.
I have three kids under the age of five, so I’ve gone to my share of well-visits, and I admit those co-pays are a bit annoying. But I would much rather put out a $10 or $20 co-pay and know that when/if a serious emergency occurs, my insurance will be there to cover the expenses for me. Moreover, (vaccines aside because they don’t have to be in the context of an office visit) the multitude of well-visits I’ve taken my kids to have not “prevented” any illness or injury.
Also, when I look at some of the things listed on preventative services provided free of charge, such as blood pressure, diabetes, cholesterol tests, cancer screenings, again I have mixed feelings. A free test is great; early detection of these problems is great (just as with free dental cleanings and exams). But let’s be clear that these screenings to do not actually prevent diabetes, high blood pressure, or colon cancer. A free exam is great…but then what? For those who don’t have any problems, they go their merry way and are glad to have saved the cash for the exam (which we now know they didn’t really need). But for those where problems are detected, they now have serious medical expenses to face. $20 is really neither here nor there when they now face the expenses of blood pressure or cholesterol medicine, insulin treatment, chemotherapy, surgery, etc.
When we shift the focus to women’s health, there is certainly a need to prioritize access to preventative services like those you list. But, again, is a $10 or $20 co-pay really what’s preventing women from getting that care they need? And if a health problem is identified, such as breast cancer or an STD, shouldn’t we make sure that the cost of necessary treatment doesn’t prohibit women from getting what they need? Maybe free preventative care can get women in the door who wouldn’t otherwise come (though even that will likely need some community health counseling), but for those who are poor, will it assure their ability to fight illness? Good prenatal care is likewise essential, but a lack of co-pay there does very little to help an impoverished individual with 10% coinsurance on a hospital delivery (with our second child – a natural (unmedicated) hospital delivery, our coinsurance payment was $1,500!).
Even if we look at this from an economic point of view, wouldn’t it make more sense for people to make co-pays for well-visits, thus saving the insurance company some money they can then put toward helping people who can’t afford medical expenses incurred from injury or illness? It seems that an emphasis on free preventative care turns this equation around. Insurance companies can’t afford to pay expenses for people with dire medical needs because they are spending their money on a multitude of healthy people, whose well-visits and routine exams detect no health problems.
So what am I missing here?
Morrow,
I appreciate your comments and I must say….nothing in what you say strikes me as reason not it have free preventative care but questioning the justice and structure of our health care system as a whole. The data from HHS, CDC etc is that removing the copay drastically increases participation in preventative care especially women who often do prioritize everyone else’s needs over their own when resources are tight. The esti mates are that participation went up 8% last year alone for women’s preventative health. Paying copay for preventative care will not make a difference to the costs of something like diabetes maintenance. The problem is not that insurance companies lack money, they break in record profits as an industry….now the very reality of for profit health insurance itself is something I would question..
With all due respect, just because you have been lucky that nothing has been found wrong with your children during well visits doesn’t change their function, imoortance or the reality that in part -that’s a matter of luck. And it is only from a relative position of privilege that one would say would $20 really stop someone from getting care? As a professor, I am not wealthy but I am privileged and it is important that we realize that things which are not a major factor for us – are for millions of Americans. When you have to make difficult decisions concerning medical care, food, rent, electricity, etc
I understand your analogy to dental insurance and even the best dental insurance in the us is largely deficient. It does clearly expose the profound inadequacies in the ENTIRE way we structure health care delivery in this country. Still, free preventative healthcare is but one step in the right direction
Meghan,
I am totally with you on the insurance companies making way too much money. I think there’s something to requiring them to pay for preventative care that’s easier than getting them to pay for sick care; anyway, it’s easier to determine what is preventative care than what is necessary medical care for the sick and injured. I just worry that this becomes an excuse for insurance companies to raise premiums while still failing to help cover the costs of people who REALLY NEED medical treatment to maintain a certain quality of life. But if free preventative care is merely a first step in calling insurance companies to accountability, then I’m all for it.
It’s great that removing a copay increases participation, though I’m not sure I’d call 8% drastic. And again, I’d be more interested in knowing what percent of that 8% had problems identified and whether they were able to afford treatment for the problems. But perhaps I do underestimate the expense of $20. I remember that when we were living under the poverty level (admittedly temporarily, as grad students, not the “true” poor), that $20 copay was a big sacrifice, especially since it came as a new and regular expense when we became parents.
As for my family’s “luck” at not finding anything wrong at a well-visit, I think that it’s pretty standard not to find anything wrong. The fact that they are called “well”-visits implies that the child is well. But what I said was that they didn’t “prevent” any illness or injury in my kids, such as those we’ve had in the last few years: severe allergic reaction, gastroenteritis, ear aches, abdominal pain, colds, lice, warts, ezcema, or getting knocked unconscious (our most recent child injury!). Actually, I considered it “lucky” the one time my baby’s being sick coincided with a previously scheduled well-visit… because it saved me the co-pay for a sick visit!
So, again, we’re on the same page here with the injustice of the health care system, and if free preventative care will certainly get them to pick up some of the costs they rightly should be covering, so be it. I just really am sympathetic to those who have serious and expensive medical conditions and can’t get help paying.
Thanks for considering this topic… I’d really been thinking about it a lot since the HHS mandate.
Maria Morrow
Hi Maria…thanks for complicating this for us. Another complicating factor is that while some preventive care saves money, other preventive care does not: http://www.nejm.org/doi/full/10.1056/NEJMp0708558
Maria,
I agree that at the bottom of it all we probably are in very close agreement. And while I do not assume you agree with me here, this is why fundamentally I do not think we wil really deal with the injustice at play in terms of access and distribution without universal healthcare, (but I am upfront about being in favor of a national single payer system).
My point about luck is that particularly with child visits there are a number of markers and things they look for that if caught on time are able to be fixed and if not have lifelong consequences like developmental hip dysphasia.
I will forever be grateful at the luck that my fathers health insurance (from a university) coved me through graduate school as I found myself in the position of needing expensive cutting edge cardiology care….which because of my parents status (as professors) I had access to one of the top cardiac surgeons in the country in NY……we had wonderful conversations on healthcare as he serves as cardiac surgeon for uninsured children in ny and on international trips….and that he fundamentally did not believe we had a hope at justice as long as we have for profit health insurance.
None of this, however, changes the fact that in all the rhetoric about contraception there are some important goods about this health bill – preventative Health and others – need to be kept in perspective too.
Thank you for your article. I just discovered this site and as a person who often works and teaches in the church I am grateful for the content.
i generally work with the very poor. Daily there are people who must have teeth pulled out because they had no access to preventative dental care. When enough of their teeth are missing, eating becomes a problem but caring for and replacing teeth are not part of preventative care. Many middle class people are unaware of how life threatening a tooth decay can be if one develops an abscess and has no antibiotics. Pulling the tooth is then emergency care.
People from the poorest communities sometimes miss even free medical care because they lack the money needed for transportation to the appointment.
Over and over my community has spent some of their very limited funds to put people in motels for a few nights because they are released from hospitals to the streets or shelters where sanitation cannot be guaranteed.
I have listened to families decide whether they should go to an emergency room or chance that their child will get well without care.
I could go on and sometimes do. It just seems to me that the good that comes with providing preventative care and access to medical care for large segments of the population that do not have that care now should somehow override the potential moral negative of providing contraceptives for people who likely will get them one way or another anyway.
Elena,
Thanks for your work with the poor… there’s nothing like someone’s actual experience to contribute to the conversation!
Just to clarify, our discussion here was about people who DO have insurance. I am in no way opposed to preventative dental care free of charge, and it obviously can do a great deal of good, just as can community dental health education. What I dislike so strongly is the huge profit that insurance companies, here represented by dental companies, make by charging premiums that in and of themselves more than cover the “free” preventative care they provide, while they subsequently do not assist substantially in any care beyond the preventative.
If preventative care were being mandated for all people (and not just the insured), I think that might change this debate.
Best,
Maria Morrow
Elena,
Thank you for sharing your experience, it is easy to forget the real long term effects of lack of care especially regular or preventative check ups . You are absolutely right that people completely ignore the role of prev dental care (and you probably have more without dental insurance then medical). I have never been able to figure out why we separate the 2….. It always seemed so odd to me that medical and dental not part of one plan.
Maria,
I really do think we need to have a serious moral debate about the morality of for profit insurance. This isnt about wages for workers, doctors, etc….but the very idea that health insurance companies like Kaiser are for profit corporations is I think unethical. It sets up a system where the basic goal is to pay out as little as possible. And, as I tried to argue in the post is fundamentally different from car or life insurance.
Why is universal healthcare for American citizens so often off limits as part of the conversation? If we had that kind of system fewer people would have to go without basic care. Preventative care would make much more sense to administrators in such a system since the profit motive for costly treatments would be eliminated.
We seem to separate the issue into such tidy pieces. Talk about preventative care but only for those who have insurance – a privilege in the American system where employers provide healthcare but only (of course!) to those they employ. No job – no care. Small company – small insurance pool and more expensive coverage.
I know many people who have insurance but put off timely preventative care because they cannot come up with the co-pay. By the time they get to the doctor, they are really unhealthy and care is expensive. When raising my children I was in that circumstance many times. I switched to Kaiser back then because I discovered I was putting off my own care when I could not meet the yearly deductible. Kaiser, for profit, had a low co-pay that at least allowed me to get care.
Even now, in my area of the country, Kaiser in its attempt to keep costs down offers more preventative care to its members than the church based insurance that I could have chosen! For example; anyone at high risk for foot injuries (diabetics/cardiac patients etc.) gets a free fitting and a free pair of high quality shoes every year! Kaiser cuts down on the risk and cost of amputations and the patient has a better chance of keeping their limbs!
I say take the profit out entirely. That means a very different system.
Elena – I agree with you! Part of how/why its been taken off the table is because of lies, myths and misrepresentation of universal healthcare in Europe and Canada. If you frame the conversation as if Canadian healthcare is “unAmerican” then we don’t have to engage the reality that we spend more and have poorer outcomes….
Hello Meghan – does the current healthcare legislation cover the preventative care practices you mention: well-woman visits, mammograms, domestic violence counseling, breastfeeding counseling, gestational diabetes screening. One of my colleagues, who has spent time in Denmark, asked me recently why the healthcare policy was covering contraception, sterilization, and abortion causing drugs and not pregnancy and delivery.
Yes, all of the preventative care practices I mention are included in the law and new HHS regulations regarding preventative care. I took them from the government list. Moreover, prenatal care is also part of the law and as a result of the law – pregnancy is no longer considered a pre-existing condition.
Hello Meghan, thank you for directing me to the government website. I saw a place where it mentioned the expansion of prenatal care but I could not find the particulars. Could you guide me in this regard? Also, I saw that in the future patients cannot be turned away for pre-existing conditions. In that sense women who are pregnant are still considered to have a pre-existing condition, but they cannot be turned away for their pre-existing condition. Am I understanding that accurately?
pregnancy can no longer be considered a pre-existing condition to either deny coverage or deny insurance plan. so before this law – if an uninsured woman got insurance during her 2nd month of pregnancy the insurance company could deny paying for prenatal care because it was a preexisting condition. Also, they discriminated against women who had had previous pregnancies/deliveries – and they can no longer do that once this law is in full effect. This law also removes the discrimination where women were charged significantly higher premiums simply for being women.
This expands mandated prenatal coverage to the full range of what is recommended (so they can’t deny gestational diabetes testing, etc).