Health Policy — Paradigm Lost

May-June 2001


Mr. Brown is director, government relations, in the Catholic Health Association's Washington, DC, office.

In Book III of his 17th century epic poem Paradise Lost, Milton calls on the celestial light to counter the "ever during dark" of his own blindness. He then describes how Adam and Eve are led by the serpent down the proverbial garden path to their fate. You could say that Adam and Eve had their paradigms mixed up, looking to the wrong beast and the wrong tree for guidance. Knowing the right paradigm — the right model, gauge, touchstone, or principle for a certain situation or issue — helps enormously in understanding how to address that issue.

What does all this have to do with health care? One of the challenges of addressing the problem of the lack of health coverage in the United States (42.6 million individuals were uninsured in 1999)1 is finding the right paradigm for health care. Should health care be compared to primary education — a right that society is obligated to provide free of charge? Is it like a college education, in which government plays a much smaller role in funding? Or is it comparable to automobile insurance, for which drivers are required to have coverage but receive no government help in paying for it?

Past presidents and administrations have struggled with these questions, but consensus has eluded them time and again. This lack of success should not absolve the new president and Congress — the first of the 21st century — from revisiting what has become a blight on the nation's conscience. The fact that so many Americans lack health coverage ought to trouble each of us deeply. After all, health coverage is the ticket to adequate health care, and health care is often the ticket to educational and economic opportunity.

Let us explore several paradigms to see how health care might compare in terms of the need and societal benefit as well as the means used by government to ensure that these human needs are met.

Whether caves, huts, or mansions, shelter is one of the most basic needs of humankind — giving families protection against natural elements and man-made mischief. The plight of today's homeless demonstrates how important this need is. Yet what does the U.S. government do to ensure that all individuals have adequate housing? The most costly housing element in the federal budget is the tax deduction for home mortgages, accounting for $63 billion in fiscal year 2001. After that, a panoply of federal tax benefits and spending programs for low-income housing assists families in purchasing a home or renting an apartment. State and local funds assist as well, but these measures combined certainly do not guarantee housing, which can cost a family one third or more of its monthly income.

Social Security and Medicare
Although not available until an individual reaches age 62 or becomes disabled, Social Security provides virtually all individuals in this country a modest retirement income that is then often supplemented by other means. It is the quintessential universal protection program recognizing the government's role in providing all individuals a basic level of support. Medicare is similar in its design and intent, giving 39 million Americans basic health coverage yet leaving insurance gaps (e.g., prescription drugs) to be filled by other private or public programs. Funding for these two programs is entirely federal and substantial, with dedicated payroll taxes funneled directly into trust funds. It is more of an entitlement that any other federal program today.

Elementary and High School
Primary and secondary education is both a right and a responsibility in the United States. A combined effort by local, state, and federal governments ensures that all children — even those who are not in the country legally — have a free, public education. At the same time, parents are required to enroll their children in school. American ideals hold that education is the gateway to opportunity, and the country is willing to invest in this equalizer. Of course, millions of families choose to pay thousands of dollars each year to enroll their children in private schools or after-school classes.

The government's approach to college education today differs from that of the past. State and local public colleges abound, and their tuition is usually substantially less than that of private universities. Although Pell grants and other tuition subsidies by federal and state governments help low-income students afford the cost of higher education, it is not free or guaranteed. In the past decade some states have taken steps to pay a greater share of tuition and establish more open access to state colleges and universities for high school students who meet a minimum grade requirement, but these measures are far from universal.

Automobile Insurance
Many parents of teenagers have reminded us that driving is a privilege, not a right. In that vein, government has not taken significant steps over the past decades to help drivers afford the costs of car insurance. In fact, most local governments require that drivers possess automobile insurance as a condition of getting behind the wheel — but then stop there. Yet one could make a good argument for why driving, and thus having car insurance, is essential if an individual is to participate in the work force, gain income for his or her family, and enjoy the freedom of American life.

With these existing paradigms, where does health care for every American fit in? First, we know from experience that although a health insurance card does not always ensure access to adequate care, adequate access cannot be achieved without insurance coverage. This fact is increasingly true as health costs rise and pressures on safety net providers become greater.

Second, the health insurance market cannot work without substantial participation by the federal government. The fact that the majority of working people have employer-based insurance hides the reality that those most difficult to insure — the elderly, disabled, and low-income — depend on the federal government to fill substantial gaps. In fact, health spending for these "gap" populations is larger than for other groups.

Third, health coverage is a national issue. Although the provision of care is almost always local, the system underlying that care — insurance markets and companies, employers, professional standards, quality safeguards — is increasingly national. And the cost of health care is growing rapidly across the country. Last year Hewitt Associates projected an average increase of 10 to 13 percent in 2001, on top of the 9.4 percent increase in 2000.2

Given the high costs, national interest, and essential nature of health care coverage, it constitutes its own paradigm. Health coverage is like education in that a democratic state relies on a healthy citizenry to preserve opportunity and move forward. Health coverage is akin to automobile insurance in that my coverage helps you and vice versa; in fact, the system depends on it. And, although universal coverage need not be exactly like the current Medicare or Social Security systems, health insurance must be a federal guarantee that families can count on from birth to death.

More than 300 years after Milton and two millennia after Adam and Eve, we know well that paradise is regained only through resistance to temptation. The temptation in our story is to fob off health coverage to a paradigm that simply doesn't fit. Saying that health insurance is a personal responsibility with only a limited effort on government's part to guarantee that coverage is tempting — but we know differently. The fruits of this knowledge will hopefully one day lead down the serpentine path toward a more just health care system for all.


  1. United States Department of Commerce. Current Population Survey. Washington, DC, General Printing Office, 1999.
  2. Hewitt and Associates, LLC. Health Care Expectations: Future Strategy and Direction. February, 2001.


Copyright © 2001 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Health Policy - Paradigm Lost

Copyright © 2001 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.