The outcome of the battle to repeal and replace the Affordable Care Act (ACA) will go a long way toward determining just what kind of nation we have become.  The late Senator Hubert Humphrey of Minnesota observed “that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”

The Congressional Budget Office reports that the Republican plan on the table to replace the ACA, known as the American Health Care Act (AHCA), would lead to 14 million fewer Americans with health insurance by 2018 and 24 million fewer by 2026.  If the bill passes tomorrow there will be no doubt what kind of nation we have become and how well our government fares on its moral test.  In my opinion only a morally-bankrupt government would do what the AHCA is likely to do to those citizens in the shadows of life.

I believe that the debate over this bill also is exposing a religious divide in this country that to date has not received a lot of attention in the mainstream news media – the widening gulf between the Christian right, especially evangelical Protestants, and other Christians.  The stark reality is that critical support for repealing the ACA and replacing it with a program that will make life harder for the poor and chronically ill is coming from evangelical Protestants.

In recent weeks the bill proposing the AHCA has gone from bad to worse under pressure from Republicans in the so-called “Freedom Caucus” of the House of Representatives.  For them the provisions of the bill as initially drafted were too generous with federal money and the support of health care by the federal government needed to be reduced even further.

The most dramatic change to the bill involves replacing the current formulas for the federal funding of Medicaid with block grants.  Although this change is being portrayed by Republicans as bestowing “flexibility” on the states the reality is much different:  It will put the squeeze on states that now rely upon the expansion of Medicaid funding under the ACA to provide health care to their poorest citizens.  States will have the “flexibility” to try to do more with less.

It will not only be the less affluent states and their citizens that get hurt.  The universal health care program introduced in Massachusetts by Governor Mitt Romney in 2006 that pre-dated the ACA employed a structure similar to the ACA, requiring everyone to purchase insurance and subsidizing those who couldn’t afford to do so.  The funding for the subsidies, however, came largely from the federal government in the form of additional Medicaid funds that were made available to Massachusetts.  A reduction in Medicaid funding by the federal government would require Massachusetts to find other sources for funding to reinstate its own version of universal health care; poorer states could be left high and dry.  In the rush to pass a bill – any bill – repealing the ACA some of the most important questions regarding how health care for our poorest citizens apparently will be left unanswered.

I never had any doubt that the “wonderful” replacement for the ACA promised by President Trump would not be so wonderful for the states.  The temptation to duck the tough fiscal and policy decisions by pushing those decisions down to state governments simply was too great, and that appears to be what congressional Republicans are doing.

If there was an obvious, “wonderful” replacement for the ACA there never would have been the ACA in the first place.  The ACA was an imperfect compromise that falls somewhere between a single-payer system like Medicare and an open, voluntary private insurance market.  Coming up with a program that makes health care available to anyone who needs it but is not either a single-payer insurance program such as Medicare or a government-run health care program like the one run by the Veterans Administration is not going to be easy.

The task is simple enough to describe:  Creation of a health care system that makes adequate health care available to persons who cannot afford to pay for it out of pocket and for whom private health care insurance is too expensive or completely unavailable because of preexisting conditions.  Accomplishing that task is another matter.

If you want a system based entirely on the private insurance market you have to come up with a method to spread the insurance risk:  You either have to require healthy persons to participate or the government will have to subsidize the private insurers for insuring the sickest persons.  Without a mandate or a subsidy for covering the highest risk persons the private health care insurance market cannot provide insurance at a reasonable price, if at all.

The AHCA will retain the provision of the ACA that prohibits insurers from denying coverage to persons with preexisting conditions.  Therein lies the rub.  The private insurance market works great if all of the insureds are reasonably healthy or at least don’t suffer from catastrophically-expensive medical conditions.  It doesn’t work at all if insurers have to raise rates too high in order to pay for the sickest insureds.  That tends to price both sick and healthy people out of the market and is why private insurers came up with the exclusion for preexisting conditions in the first place.

On the other hand, the ACHA will get rid of the mandate that everyone must purchase insurance and Republicans were not going adopt to a single-payer system.  So how does that work without driving up premiums?  Without the mandate younger and healthier people will choose not to purchase health care insurance especially as it becomes more expensive, even if faced with the possibility that they may not be able to purchase it after becoming ill.  Maybe someone can explain to me how making coverage available to people with preexisting conditions but also eliminating the mandate that requires everyone to purchase insurance can be done without providing massive governmental subsidies to prop up the private insurance market.  Unless something changes in the bill it will be up to the states to figure out a way to pay for the health care for people forced out of the private health care insurance market by rising premiums.

There are reports that President Trump and the House leadership have agreed with conservative Republicans at the last minute to remove from the bill the requirement that insurance policies include specified “essential health benefits” in order to secure the votes necessary to pass the bill.  The requirement is a holdover from the ACA and requires policies to cover services including maternity care, prescription drugs, and mental health treatment.  Eliminating one or more of the essential health benefits will reduce costs, but it will do so at the expense of comprehensive health care coverage.

A “wonderful” byproduct of our federal system is that allows legislators in Washington to claim credit for policies and programs without the concomitant responsibility to pay for them.  During the great wave of social policy and environmental legislation in the second half of the last century the concept of the “unfunded mandate” became anathema to state and local governments.  My prediction at this point is that Republicans in congress want to claim credit for adhering to the principle that everyone who requires health care should be able to obtain it without coming up with a realistic way to pay for it.  Maybe the Republicans simply are hoping that the 2018 mid-term elections will come and go before the scheme collapses.

The ACA may have been an imperfect compromise, but it was the product of an important goal upon which a sufficient number of the members of Congress agreed at the time of its enactment in 2010:  That goal was the provision of adequate health care to all those in the country who need it and it was based on the principle that all citizens of the United States are entitled to adequate health care regardless of their ability to pay for it.  The ACA did not change the hodgepodge of programs that constitute our “system” of health care but it did plug major gaps in the system by making health care insurance affordable for the working poor and available to those with pre-existing conditions for whom coverage had been denied in the past.

For many of us the enactment of the ACA was a milestone both in policy and in morality.  It ended a long period of time when the United States stood virtually alone among developed countries in treating health care as a privilege rather than a right.  Most right-thinking Americans viewed that as a stain on our reputation that had to be removed; citizens of this country were suffering and dying in unacceptable numbers because of inadequate health care.  Treating health care as a right recognizes that health care is a basic human need, like nutrition and shelter; a self-respecting society would no sooner allow a person to die of from an untreated illness than it would allow a person to starve or die from exposure.

What I am saying is that the policy of our government toward health care is as much, if not more, a moral issue as it is a political or economic one.  Do we believe in universal health care or don’t we?  Like it or not when we talk about moral issues in this country we have to talk about religion, and in this case we have to talk about evangelical Protestants, especially white evangelical Protestants.

There no longer is any doubt that we are fighting a war with President Trump and Steve Bannon for the soul of this country.  What happens in Congress with the proposed repeal and replacement of the ACA will be a major battle in that war.  There are very good reasons for avoiding arguments about the propriety of someone else’s religious beliefs but things have gone way too far to worry about hurt feelings.  Religious values, like all other values, inform our beliefs about the role of government, including the role of government in helping the poor.

In my case, before giving the matter much attention I had the naïve assumption for many years that all true Christians found it troubling that the United States stood virtually alone among developed countries in not providing adequate health care to each one of its citizens who needed it without regard to the ability of a citizen to pay for that care.  I found the absence of universal health care in the United States particularly baffling in light of the fact that the United States has by far the greatest number of people professing to be Christians in the world, with about 60% of the population claiming to be members of the congregation of a Christian church.

My assumption undoubtedly was based on the fact that I grew up attending a Lutheran Church in which pastors and Sunday school teachers emphasized that Christians had an unqualified duty to care for the poor and less fortunate.   As it turns out, my assumption was not entirely correct – some Christians are much more troubled by absence of universal health care than others.

Well before the most recent presidential campaign began affecting the results polls showed that opposition to the ACA was considerably higher among evangelical Protestants than among any other religious group, with white evangelical Protestants being the most opposed.  A poll taken before the Supreme Court ruling on the ACA in 2012 showed that a majority (52%) of white evangelical Protestants favored the Supreme Court overturning the ACA while only 36% of all Roman Catholics and 44% of all mainline Protestants were in favor of overturning it.

That is a significant difference, particularly between Catholics and evangelical Protestants.  What explains the difference?

Certainly many white evangelicals recognized the same flaws in the ACA that everyone else did, but that would not explain the difference.  Exit polls taken after the election showed that 80% of white evangelicals voted for Donald Trump, but that support generally was attributed to anti-abortion sentiment and, to a lesser extent, on the opposition to gay marriage.  The ACA is “abortion neutral” – it had to be in order to get through Congress.  Some policies available under the ACA exchanges pay for elective abortions but they are not required to do so because abortion is not one of the ten “essential health benefits” under the ACA and no federal tax credits or subsidies may be used to pay for abortions under the Hyde Amendment.  The provision of insurance coverage to same-sex couples was a matter of other law, not the ACA.

There is something else going on and that something else has to do with theology and disparate views on what the duty of Christian charity encompasses.  Evangelical Protestants tend to have a more constrained view of the duty of Christian charity than other denominations.  I hasten to add that such a statement suffers from the weakness inherent in all generalizations in that there are evangelical Protestants who have an expansive view of the duty to help others and who are among the most generous people in the world.  My observation has to do with institutional beliefs, not individual behavior, and there simply is no doubt that evangelical Protestantism puts less emphasis on “good works” than, for example, Roman Catholicism.

One of the most quoted and debated passages in the New Testament is Matthew 25: 31-46, known as “the Judgment of the Nations” and sometimes referred to as the parable of the sheep and the goats, even though it is not actually a parable.  I won’t quote all of it, but this is from verses 35 through 40 in the New American Standard Bible and begins with Jesus describing God as God addresses the righteous (the “sheep”):

“‘For I was hungry, and you gave Me something to eat; I was thirsty, and you gave Me something to drink; I was a stranger, and you invited Me in; naked, and you clothed Me; I was sick, and you visited Me; I was in prison, and you came to Me.’  Then the righteous will answer Him, ‘Lord, when did we see You hungry, and feed You, or thirsty, and give You something to drink?  And when did we see You a stranger, and invite You in, or naked, and clothe You? When did we see You sick, or in prison, and come to You?’  The King will answer and say to them, ‘Truly I say to you, to the extent that you did it to one of these brothers of Mine, even the least of them, you did it to Me.’”

God tells the sheep that they will be given eternal life.  In the remainder of the passage God speaks to the “goats” – those who did not feed or clothe the least of his brothers – and tells them that they will be consigned to eternal punishment.

There are two debates that spring from the passage.  The first debate is the extent to which Jesus was stating that good works – rather than grace alone – are required for salvation.  The second is the question of whom Jesus meant by his reference to “these brothers of Mine.”

I have absolutely no credentials as a biblical scholar but when you review the literature on the passage you can see that the arguments seem to follow denominational lines, with Roman Catholics at one end of the spectrum and evangelical Protestants at the other.  Interpretation of the Judgment of Nations is sort of a litmus test for evaluating a Christian’s view on his or duty to help the less fortunate.

Pope Francis leaves no doubt about what he believes is the proper construction of the Judgment of Nations, the parable of the Good Samaritan, and similar passages:

“Let us ask ourselves: is our faith fertile? Does it produce good works? Or is it rather sterile, and so more dead than alive? Do I make neighbors, or do I just pass by?” Francis asked during an Angelus address last year, adding that these questions would be good to ask ourselves often, since in the end “we will be judged on the works of mercy.”

In the same address he warned against a narrow interpretation of a Christian’s duty, cautioning that Christians must not “catalogue others to decide who is my neighbor and who isn’t” and should adopt the same attitude as the Good Samaritan toward the people that they meet who need help, “even if they are a stranger or even hostile.”

Evangelical Protestant theologians tend toward the less expansive view of to whom Jesus was referring as “these brothers of Mine,” arguing that in the Judgment of Nations Jesus was referring only to his disciples and other missionaries who suffered because of their work and that Jesus was not imploring his followers to help just anyone.  They also caution against reading into the passage any suggestion that a Christian needs to earn his or her way into heaven as contrary to the principle that salvation comes from grace alone.  There is a subtle but definite lack of emphasis on “good works” as these writers focus on the priority to be given to the expansion of the church and the salvation of souls.  There is an insular, self-absorbed quality to the theology that I personally find unacceptable – in the words of Pope Francis, more dead than alive.

Donald Trump would not have won the election but for an unholy alliance between the Christian right and the alt-right.  As part of the deal the Christian right gets the potential opportunity to take away the right of women to terminate pregnancies within the limits set forth in Roe v. Wade and the right of same-sex couples to marry.  The alt-right gets to promote a white nationalist agenda that includes suppressing immigration in general and the immigration of Muslims in particular.  It looks like the poor just get forgotten.

March 23, 2017