Just Not Enough: A Physician’s Perspective on Justice and the ACA

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Author Jim Wright

Justice or Freedom? In the debate over healthcare reform, it comes down to this: do we aim for a system based on justice – equal access through redistribution of funds and regulation of services – or do we continue to favor freedom – giving patients and doctors unfettered access to an array of diagnostic and treatment options, financed through various private companies?

Our dilemma is uniquely American; we’re one of the wealthiest countries in the world, and yet we’re almost the only industrialized country that does not provide healthcare for its citizens. We pride ourselves on a rich Christian heritage, and yet many of our brothers and sisters live in poverty due to unaffordable healthcare. On the other hand, for those that can afford it, our healthcare system is both the world’s envy and the world’s destination for high quality, cutting edge, and lifesaving care, and it’s that way precisely because we emphasize freedom of choice and entrepreneurship in our healthcare system. We have built a healthcare system powered by freedom, and yet justice calls us to reform.


My experience as a physician, working with both America’s multi-payer and single-payer systems, has led me to the realization that the multi-payer/private insurance system is unsustainable – in a large part because it costs so much money just to get paid.

Among the industrialized world, America is unique in its emphasis on autonomy and freedom. The patient autonomy that underlies our current healthcare system is the same autonomy that powered the modern bioethics movement. Freedom is our great blessing, and from its birth, America has guarded that freedom fiercely. A healthcare system that is more just and equitable, however, by necessity, will impinge on freedom and autonomy. In order to spend healthcare dollars wisely, those managing the funds must divert them towards treatments and tests that have the best chance of improving the health of the populace and away from those treatments that show no benefit. The more control a governing body has over expenditures, the more likely it will be at odds with an individual’s choices. One may want that MRI for his headaches, but if his symptoms don’t meet criteria, it’s not covered. Another may want a mammogram at age 40. If the studies show no benefit in mammograms for any age, sorry, not covered. This is a shock to us; it smacks of paternalism and big government.

vrachi-ubiycy._ugolovno-medicinskaya_praktika_0But the alternative to government control has been no (or very little) control, and our emphasis on autonomy and freedom has proven to be very expensive indeed. Worst of all, the freedom we subsidize doesn’t even buy us better health. We spend eight percentage points of GDP over the average industrialized country, and yet are not even in the top 20 in terms of life expectancy.

Freedom is expensive, but that doesn’t mean America will respond to calls for justice. Justice, some say, means opposing freedom. It means government intrusion, 2 months to get an MRI, 6 months to see a neurosurgeon. Justice is a tough sell in the marketplaces of freedom.

It’s not as if the principles of fairness and moral obligation to the poor haven’t driven healthcare reform in the past. The moral imperative to care for the elderly and chronically disabled prompted the formation of Medicare in the 60s. Medicare has become an incredibly popular program despite being a nationalized healthcare plan with a single payer. But Medicare was a relatively easy sell: the elderly had little choice. They needed healthcare, but about half couldn’t afford it. With Medicare, private insurers had no interest in providing coverage and therefore no interest in fighting against the establishment of a nationalized plan.


Justice or freedom – which will be the driving force behind healthcare reform? Actually, I predict it will be neither.

However, while the US was able to achieve a general national consensus on the moral obligation to care for the elderly – a demographic that most of us expect to one day be a part of – we have balked at extending coverage to others who cannot afford adequate health care. While the Presbyterian Church (U.S.A.) has admirably supported it, a single-payer system – essentially bringing everyone under the Medicare umbrella – is simply not something that reverberates with enough of the country.

money1Justice or freedom – which will be the driving force behind healthcare reform? Actually, I predict it will be neither. In the end, the one thing that will force us to relinquish some of the freedom inherent in our current system will not be appeals to cover one underserved group or the other. The real driving force will simply be money. My experience as a physician, working with both America’s multi-payer and single-payer systems, has led me to the realization that the multi-payer/private insurance system is unsustainable – in a large part because it costs so much money just to get paid.

As a primary care physician, I know the burden imposed by the vast array of private insurance companies: their different requirements for submitting bills, their restrictions, their networks of approved hospitals and doctors (“Not on our panel? Sorry, we can’t pay you, but here’s the 3-month application process and the hours you’ll spend talking to people so that we could (maybe) pay you next time. Is there anything else I can help you with today?”). For any business, a basic rule of survival is to get paid for what you do – as quickly and as effortlessly as possible. Private insurance ignores this essential rule. You have one job, insurance company, one job – pay for the care I provide. It seems pretty straightforward, but I have to hire an extra full-time employee just to get you to do it! A full-time employee to get me on your panel, to figure out where and how to send the bill, to make sure a check comes and then argue with you when it doesn’t.


A healthcare system that is more just and equitable, by necessity, will impinge on freedom and autonomy.

Private insurance and the expense involved in the act of simply getting paid is perhaps the most frustrating thing about being a doctor in the 21st century. That is why I decided, in 2006, to participate solely in the nationalized health system for seniors (a.k.a. Medicare) by practicing only in nursing homes and assisted living centers. Medicare is a single-payer system. You see a patient who is 65 or older, you enter their Medicare number, send a single bill into a single portal and, within 2 weeks, get paid. You don’t have to worry about whether or not you’re on their list of approved doctors. Once you register with Medicare, you’re set.

A+female+doctor+examining+an+elderly+male+patientOf course there are problems with Medicare. But none of these problems are insurmountable. In fact, a number of changes in reducing wasteful spending in nursing homes and hospitals have just started taking effect, and if successful, will cut down on costs as well as improve the health of our elders. Many of the ACA’s critics cite examples of how doctor’s offices are closing to new Medicare patients, but the problem here is private insurance as well. Seniors generally take longer to see. A physician might be able to see 3 younger people in the time it takes to see a single Medicare patient. With the extra staff it takes to collect money for private insurance, one can only afford so many 45-minute visits in a day. However, I have found that with the lower overhead involved in billing through a single-payer system, seeing only Medicare patients becomes an attractive business model. Medicare-only practices like mine can survive mainly because of the single payer system.

The Affordable Care Act is critical because it takes a very important step in healthcare reform – but the step is one towards eventual failure. In this legislation that requires everyone to fit under the same crazy patchwork quilt of our current system, I believe that the cost of subsidizing a private, multi-payer system – the cost of freedom – will finally undergo the scrutiny it deserves. There are not many good things the ACA will do (it won’t even provide universal coverage), but the lack of “affordable care” and the continued increase in the rate of healthcare spending will eventually cause the ACA itself to be reformed.

CMS (Centers for Medicare and Medicaid Services) projects that overall expenditures will continue to increase following the implementation of the ACA, and the rate of that increase will accelerate from 4% per year currently, to 6.5% after full implementation of the ACA. As this rate exceeds that of expected economic growth, it will be obvious that the ACA does nothing to reverse the unsustainable growth in healthcare spending. On the other hand, CMS projects that our nationalized, single-payer system (Medicare) will stabilize or actually see a decrease in its rate of spending growth, even with the flood of baby boomers swelling its ranks. (Center for Medicare and Medicaid Services 2012). My hope is that as the ACA fails, our multi-payer system will fail with it.


My hope is that as the ACA fails, our multi-payer system will fail with it.

born_blind_04Justice or Freedom? If you ask me, our healthcare system will be forged more through practicalities than through principle. I’m reminded of the story from the Gospel of John of the blind man who receives his sight. After he is healed, the man is caught between two camps: was Jesus a sinner or was Jesus something more? The man knew very little about Jesus, he knew very little about how he was healed, but the one thing he did know was his experience, “though I was blind, now I see.”

We in America are currently feeling our way toward real healthcare reform, caught between two camps, some blinded to the waste inherent in a system which favors freedom, others blinded to the difficulty of expecting justice (i.e., government regulation) to affect real change. Passion and principle have their proponents, but as we realize that the ACA is not the panacea, I believe it will be cold hard realities that will bring us to a clearer vision of a just healthcare system – one that that delivers us from the injustices and waste inherent in a multi-payer system.


AUTHOR BIO: Jim Wright, MD, PhD, MATS is a physician and theologian. His medical practice is focused solely on long term care and skilled nursing facilities. He received his MD and PhD from VCU School of Medicine in 1995 and completed a residency in Family Practice in 1998. He holds a Masters of Arts in Theological Studies from Union Presbyterian Seminary and a Certificate in Bioethics from Loyola University, Chicago. He writes regularly for the Faith and Values section of the Richmond Times Dispatch and is currently writing a book addressing the theological, medical, and ethical implications of dementia. He lives in Goochland with his wife, Jennie, who is an amazing Palliative Care Physician for Bon Secours Health System ,and 4 awesome children. You can contact him at [email protected] or read his blog at http://godlifedementia.blogspot.com/

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