Claiming an entity as a right requires clear thinking about who possesses a claim to something while defining who must fulfill this obligation. We can clearly agree on responsibility to care for our neighbor and yet not promote federal dominion over doctors and nurses.

Some mistakenly quote Pope John XXIII‘s 1963 Encyclical Letter Pacem In Terris (Peace on Earth) discussing “the right to live… the right to bodily integrity and to the means necessary for the proper development of life, particularly food, clothing, shelter, medical care, rest, and, finally, the necessary social services (11).” In this context, the Holy Father speaks of health care as a natural right, with corresponding responsibilities, not as a direct obligation of the state. Nowhere in Pacem In Terris is government assigned accountability for food, clothing, shelter or health care.

Archbishop Charles J. Chaput recently reiterated the Church’s understanding of health care as a right. “At a minimum, it certainly is the duty of a just society. If we see ourselves as a civilized people, then we have an obligation to serve the basic medical needs of all people, including the poor, the elderly and the disabled to the best of our ability.” Yet, there are options for society to meet this duty apart from the federal government.

In a May 2008 address to the Pontifical Academy of Social Sciences, Pope Benedict XVI guided us in correct understanding and action:

“The four fundamental principles of Catholic social teaching: dignity of the human person, the common good, subsidiarity and solidarity…offer a framework for viewing and addressing the imperatives facing mankind at the dawn of the 21st century…The heart of the matter is how solidarity and subsidiarity can work together in the pursuit of the common good in a way that not only respects human dignity, but allows it to flourish.”

Respecting these four principles can help this country achieve consensus without increasing reliance upon Washington.

The first principle, Respect for Dignity of the Human Person, is prerequisite. Health care reform is meaningless without it. Life must be safeguarded from conception to natural death. Tax dollars must not subsidize abortion or euthanasia. This principle must apply on both ends of the stethoscope, respecting both patient and provider. Health-care professionals must be able to follow their conscience in prescribing and providing treatment.

We share a duty in the United States to nearly 50 million uninsured, and millions more who are precariously insured, to reform health care. Human dignity also predicates responsibility to care for oneself and one’s family. Many medical problems arise from personal decisions affecting health, and medical resources are over-consumed when perceived as free. Therefore, reform must not abrogate personal responsibility for decisions which affect health, nor financial participation in consumption of medical goods and services.

Pope John XXIII was clear on this as well. “Every basic human right draws its authoritative force from the natural law, which confers it and attaches to it its respective duty. Hence, to claim one’s rights and ignore one’s duties, or only half fulfill them, is like building a house with one hand and tearing it down with the other. (30)”

The second principle, the Common Good, requires us to promote “those conditions of social life” that allow people “access to their own fulfillment.” Impending Medicare insolvency and the inability of strained state budgets to cover more Medicaid patients requires re-evaluation, and not expansion, of government responsibility. Moving forward with incremental improvements that are achievable with consensus is more prudential than comprehensive, and unaffordable, legislation without bipartisan agreement and popular approval.

Policy changes could approach more universal coverage without tremendous additional cost. Tax and insurance market reforms could increase premium affordability and policy portability. National coverage mandates, instead, will hinder insurance affordability. Defensive medical practices, particularly in emergency rooms and critical care circumstances, result in unnecessary expense and compromise compassionate care.

The third principle, Subsidiarity, emphasizes providing care by those closest to persons in need. A community of a higher order in society should not assume tasks belonging to a community of lower order and deprive it of its authority. As Pope Benedict XVI wrote in his 2005 encyclical Deus Caritas Est, “We do not need a State which regulates and controls everything, but a State which, in accordance with the principles of subsidiarity, generously acknowledges and supports initiatives arising from the different social forces and combines spontaneity with closeness to those in need.”

This principle argues for strengthening and protecting the doctor-patient relationship. Individuals and families with health savings accounts would be better able to prioritize health care resource allocation through the marketplace, rather than distant bureaucrats assigning mandated benefits. Educating patients about costs, outcomes, and quality of medical goods and services will improve resource allocation, rather than rationing by appointed advisory panels. The fourth principle, Solidarity, obliges us to maintain a preferential option for poor and vulnerable. Our results will be judged by how we have fulfilled our duty, in the spirit of loving our neighbor, feeding the poor, and caring for the sick. (Mt 25:40).

Neighbors who become sick or injured within our borders cannot be left out of the health care reform equation. Doctors and hospitals are required by law and conscience to care for those who come to emergency rooms. The debate over immigration reform has no place at a patient’s bedside. Those with chronic disease are particularly vulnerable and vigilance must be maintained to ensure their safety net. Yet again, this does not mean state expansion. Government can play a role by facilitating the activity of charitable organizations in health care, but the primary obligation falls on all of us to be generous with our time, talents, and treasure. There will always be a place for charity in care for the sick and dying.

We ought to agree on the right to health care as a moral duty, but not as a federal responsibility. Supporters of this deeply flawed bill should contemplate these universal principles.

Despite good intentions, many reform proposals increase the role of government, place additional burdens on business, and interfere with medical decision making between the patient and doctor. Yet, without substantial health care reform, the United States will suffer from a greater financial disaster than is anticipated in the current crisis, and will unconscionably burden our children and grandchildren with debt and inflation. The PCA represents a more promising approach.

Our government is already responsible for 50 percent of health care spending. It has failed to control spending and promote quality. The Medicare trust fund will be insolvent by 2017 (Part A or hospital insurance). The combination of aging baby boomers and increasingly expensive treatments has led to medical spending exceeding the growth in our Gross Domestic Product year after year. This cannot continue. Yet many reform proposals advocate expanding Medicare, Medicaid, or new public health care programs, when our government is already fiscally failing to handle half of America’s health care.

As those of us who live in Michigan know all too well, job-providing businesses are having trouble competing in global markets when competitors are not handicapped with similar benefit package requirements. Where will jobs come from if employers have to bear greater responsibility for health care expenses, as many reform proposals suggest? Furthermore, we have also learned we would rather have health insurance obtained outside the workplace, so that when businesses close or move, or we become unable to work, our health insurance is not jeopardized. Anyone who has lost a job and learned how much COBRA insurance costs—without a paycheck—understands the value of affordable and portable health insurance.

Furthermore, many reform proposals interfere with the doctor-patient relationship. The heavy hand of government is already leading to shortages of physicians, particularly in primary care specialties. Michigan is likely to be short-handed by 6,000 physicians by 2020. Three-quarters of health care spending and two-thirds of deaths are due to chronic conditions such as diabetic, heart, and lung disease. Preventive medicine and patient responsibility for personal decisions affecting health care can make a tremendous difference in health and health care spending. Rules, regulations, and bureaucracy contribute to patients’ losing both their greatest ally in understanding complex medical issues and their best advocate in promoting a healthy lifestyle.

The PCA will enhance patient and family ability to afford health care insurance and incentivize healthier lifestyles. As the name suggests, patients will have freedom of choice for health care insurance. This proposal would more justly allocate the current $300 billion tax subsidy for employer provided health care. In addition, it would surpass other options in fulfilling our social responsibility to the poor and vulnerable.

Sixty percent of working Americans obtain health care insurance through their employer. Both employee and employer benefit from a significant tax break, whether they realize it or not. Wages are lower when employees receive health care benefits, whether they realize it or not, too.

The 40 percent of workers who pay out of pocket understand that they pay dearly for health insurance. These individuals may resent that they are paying taxes to subsidize those receiving the $300 billion federal tax subsidy for employer based health care, particularly when those making more money get a bigger tax break.

People who take care of themselves with healthy diet, regular exercise, and avoidance of harmful habits are probably over-insured. Most workers would be better off if they received the tax break themselves, received a bigger paycheck, and could purchase lower cost insurance directly. This would certainly be fairer for those paying taxes but missing out on the tax break.

The PCA replaces the unfair ‘at work’ tax subsidy to give people an ‘at home’ tax break for health care expenses. For those who need help affording insurance there will be assistance in the form of refundable tax credits for individuals and families. State insurance exchanges are proposed to increase competitive pressures on insurance companies, which often possess monopolistic power, and ensure people with chronic illness receive help.

The PCA is not only fiscally responsible, it also fulfills our social responsibilities.

Human dignity is respected when we fulfill our duty to improve access to health care through reforms that increase affordability and quality of care. Personal responsibility is promoted by enabling patients and families to assume greater responsibility for their health care. Immigrants and Native Americans’ needs are considered in this plan. Veterans who sometimes may be better served outside the Veteran’s Health Administration are provided this opportunity.

Market-oriented changes to improve the allocation of $2.4 trillion in annual health care spending can advance the common good more effectively than can increased third party decision making. Mandates, often prompted by special interest lobbying efforts rather than patient demand, have increased the cost of insurance beyond affordability for many citizens. More mandates mean more expensive health insurance, and fewer people able to buy it.

The poor and vulnerable would benefit more from subsidized access to the health care market-place than from expanding government health care authority. Medicaid reimbursement for doctors and hospitals does not cover the cost of providing care. As a result, patients on Medicaid have difficulty with access to providers and rely on costly emergency rooms for care. The safety net for those with chronic disease can be maintained at the state level by insurers of last resort.

Facilitating health care by those closest to those in need, rather than government or employer, begins with the family and doctor-patient relationship. Churches, community organizations, and employee associations should be helped to care for their members rather than higher, and less personal, levels of society.

But, as the language of the PCA warns, expanding the reach of government would create a health care system displaying “the compassion of the IRS, the efficiency of the post office, and the incompetence of Katrina.” The proposed PCA bill will instead empower patients, with the helping hand of their doctors. It prescribes reform with financial responsibility and without bankrupting our children and grandchildren. Finally, the PCA would fulfill our social responsibility to those in need while increasing the competitive ability of American business. This is the right prescription for health care reform.

But this prescription could be worse than the disease. A better solution would be portable or personal health insurance, which would allow people to choose their own plan and keep it — and their doctors — when they change jobs. Under this system, employers would offer wages and salaries that are sufficient for their employees to purchase portable benefits — and attract good people to their workforces.

Today, 60 percent of workers receive health insurance as an employer-provided benefit. Many people see it as an attractive perk. But there is a dark side to this arrangement. What happens when jobs are threatened, an increasingly likely prospect during the current downturn? People may lose their health benefits, face expensive ‘continuation of benefit’ coverage, or lose insurance altogether, in addition to being without a paycheck. Thousands of unemployed Americans can attest to this “double jeopardy” vulnerability.

Some people feel tethered to their employers to maintain benefits for themselves or their families. Many employees suffer in silence in miserable job circumstances. This health insurance serfdom is an affront to human dignity, and denies many workers the opportunity to improve their livelihoods.

The 40 percent of workers who do not receive medical benefits unjustly subsidize those who do. The U.S. government forgoes $250 billion in tax revenue per year for employer provided health care. The tax benefit is regressive: Those in higher tax brackets benefit the most from health insurance provided as an untaxed perquisite. Those who obtain health insurance outside the workplace often cannot deduct their medical expenses. Thus, the latter’s taxes subsidize health care for nearly everyone else.

Employer-provided health care interferes with competitive market forces and affordability. Younger and healthier workers are often over-insured. Employer-paid premiums may be double what is necessary for adequate coverage.

Under our current system, health benefits are often perceived as an entitlement rather than a scarce good, subject to the law of supply and demand. Third-party payment for medical care promotes resource over-utilization. With a portable plan, with more accountability, those financially participating more directly as consumers of health care services and products are likely to be more careful about how they purchase health care services.

Employers usually offer a very limited selection of health care plans. More competition by insurance companies eager to expand their customer base would increase pressure to improve quality and lower cost.

As we have learned in Michigan, employee benefit mandates handicap American firms’ competitive ability in the global marketplace. Auto companies were thriving when their competition was domestic and all manufacturers were equally bearing benefit costs. But the business expense playing field is no longer level with domestic firms competing against overseas firms that are often not required to cover employee health care. Furthermore, struggling to control employee health distracts employers from their primary mission of providing goods and services — and jobs.

In addition, with portable health benefits obtained outside the workplace, the national economy would benefit from a more mobile workforce. Workers would be more likely to pursue satisfactory jobs or better opportunities. Productivity could be enhanced.

If economics argues against employer-provided health coverage, a critical question remains: Can decreasing employee medical benefits be considered moral?

Pope John Paul II in the 1981 encyclical Laborem Exercens indicated, “Besides wages, various social benefits intended to ensure the life and health of workers and their families play a part here. The expenses involved in health care, especially in the case of accidents at work, demand that medical assistance should be easily available for workers, and that as far as possible it should be cheap or even free of charge. ” This appears to obligate employers considerably.

However, the same papal letter also warns that unemployment “in all cases is an evil, and … when it reaches a certain level, can become a real social disaster.” When mandatory benefits jeopardize firm survival, they do not serve the good of employees or society.

Furthermore, John Paul explains that his exhortation “is not a brief treatise on economics or politics. It is a matter of highlighting the deontological and moral aspect. The key problem of social ethics in this case is that of just remuneration for work done.” Since benefits represent foregone wages, it would appear that pay sufficient to obtain medical insurance would fulfill an employer’s duty to workers. This obligation is consistent with income providing for means to food, clothing, and shelter.

We ought to love our neighbor, feed the poor, clothe the naked, and care for the sick. All of us are called to service, with a preferential consideration for the poor and underserved (Mt 25:40). This duty is not confined to the workplace. Communities, churches, trade organizations, and affiliation groups can coordinate health care benefits for members. Corporate human resources departments should not be viewed as the main source of support for Americans’ health care. The iniquitous government subsidy for employer-based health care could be redirected to help those without access to affordable health care, by virtue of poverty or chronic disease.

The prevalent perception of employer responsibility for health care certainly cannot be changed overnight. However, we ought to obtain a second opinion before increasing the role of employers in medical care, a move likely to further sicken our economy and harm the common good.

United States health care spending is escalating faster than growth in our gross domestic product. This trend, mixed with technological advancement and an aging population distribution, is unsustainable. Our government finances approximately 50 percent of health care spending. The Centers for Medicare and Medicaid Services reported medical spending was more than 16 percent of GDP in 2007. In 10 years it is projected to exceed $4 trillion and comprise nearly 20 percent of GDP. The Medicare trust fund is expected to become insolvent by 2019. As a result, Medicare and Medicaid control prices to restrain spending. Market forces are foregone. Price controls lead to shortages. Quality of care deteriorates, and you have difficulty getting to talk to a nurse or doctor.

This week Congress is debating further cuts to Medicare reimbursement superimposed on annual inflationary erosion of fee schedules. Physicians’ office rent, employee, and other overhead costs continue to increase. They are relying upon answering machines rather than nurses to triage phone calls. Subsequently, access to care is further jeopardized for many Americans. Increasing overhead and liability concerns, in the face of declining reimbursement, lead physicians to decrease availability for the indigent and uninsured. Only half the nation’s doctors are accepting new Medicaid patients because reimbursement is insufficient to cover the costs and inherent risks of providing care. Michigan, where I practice, is expected to face a 12 percent doctor shortage by 2020. National studies reach similar conclusions regarding physician shortfalls. Graduating medical students, with debt up to $200,000, are rationally less likely to consider careers in lower paying primary care specialties.

Medicare price controls and byzantine bureaucracy have resulted in a misallocation of health care resources. Primary care shortage is a perverse outcome. Over two-thirds of health care expenses are influenced by behavioral factors. Two-thirds of US citizens are overweight, twenty percent smoke tobacco, and alcohol consumption is epidemic. (www.cdc.gov/nccdphp) People need their internists, family physicians and pediatricians. They are the most qualified to help patients with preventative health care and chronic disease management. These primary care coaches can help them with expensive health problems potentially under personal control, yet primary care residency positions remain vacant, and emergency rooms are overcrowded.

Some argue that medical care demand is inelastic, the quantity of care demanded is not sufficiently influenced by prices, and increasing consumer responsibility for payment will not curb health care spending. However, much of health care is not emergent. Many patients are sophisticated enough to become informed health care consumers, as they are for other goods and service. Prices effectively allocate scarce resources. Half of the United States population spends very little on health care, while five percent of the population consumes almost half of the total amount. There is opportunity for a more just allocation of the $2 trillion dollars spent, annually, on health care in the United States. The RAND Health Insurance Experiment, completed in 1982, identified considerable price elasticity, wherein some personal financial responsibility for health care did not significantly affect quality of care. (www.rand.org)

Galen institute founder Grace-Marie Turner, (www.galen.org), at this year’s Acton University, prioritized three social justice principles for health care reform: human dignity, subsidiarity, and charity. As humans created in the image of God, we have the responsibility to care for our health. Secondly, care of the poor, vulnerable, and those unable to care for themselves ought to occur at a level of society closest to those in need. Government should be the provider of last resort, not the first. Finally, charity must be sustainable: resources are not unlimited and so in health care as in every other form of charity, it is important to match the available assistance with genuine need.

The common good would be better served by market oriented reforms coupled with compassionate subsidization for the poor and vulnerable, rather than by expanding third-party health care. The American Medical Association proposal for health care reform, which incorporates these precepts, is compelling. (www.voicefortheuninsured.org) Tax law changes could more justly allocate the $120 billion federal tax subsidy for employer-provided health care to provide millions with access to health insurance, and improve family security. Insurance industry reform, including measures increasing inter-state competition, could foster premium affordability. People might take better care of themselves with increased incentives for improving personal health and with the help of primary care physicians.

It will take sound economics working in concert with good intentions to bring about real health care reform that provides more and better access to the people who need it. Government expansion and price controls won’t take us toward that goal.

As a hand surgeon who treats many traumatic injuries, Moore's portrayal of a patient who amputated his middle fingertip captured my interest. He depicted this uninsured man as required to pay $23,000 to have his finger "saved." Moore lost considerable credibility here. Most hand surgeons would never consider micro-surgically replanting this table saw injury at the finger nail base. Rather, this unfortunate injury would have been comfortably and safely treated — without reattachment of the severed bit of finger — in an office procedure room for $1,000 or less.

In Sicko, Moore consistently equated lack of insurance with inability to obtain care. In Grand Rapids, Mich., where I practice, a sign on the front door of Blodgett hospital, in English and Spanish, indicates patients will not be turned away for lack of ability to pay. This is policy across the United States.

We hear a lot about the nearly 50 million Americans without health insurance. However, approximately half of them are insured six months later with new jobs, suggesting more of a problem with our employer based health care system than with affordability.

Moore harshly criticizes the U.S. government. Yet he is arguing for a centrally controlled allocation of health care resources. Who does he want to run health care in this country? Medical resources are not unlimited. The combination of aging demographics, technological advances and unconstrained consumption within our third party payment system has led to an unsustainable trajectory of ever increasing spending. It is already clear that price controls have created strong disincentives to debt-burdened students considering careers in primary care. Yet Sicko gives market oriented solutions no consideration.

Three individuals with ailments after admirably serving in New York rescue and recovery efforts after September 11, 2001, were transparently used in Sicko to promote Moore's agenda. This manipulation was as revolting as the stories of individuals egregiously denied care by insurance companies. Transported to Cuba, the three 9-11 patients were shown to Cuban doctors who (while cameras were rolling) appeared more than happy to provide care and subsidized prescriptions. This contrasted with a California hospital denying care to a child with a severe infection and a sick, elderly woman dropped off by a taxi in front of a rescue mission while still in her hospital gown. The latter two tragic situations were portrayed as illustrative examples of our domestic medical system.

There is no question we need major improvement in U.S. health care. To use a few outrageous anecdotes to argue for a socialized solution, however, is a non-sequitur. Despite ostensibly compassionate intentions on the part of its backers, greater harm would result from centrally planned and controlled health care. Canada and the United Kingdom provide contemporary models: rationing occurs by decree and delay. Even the Canadian Supreme Court, when ruling against Canada's single-payer law prohibiting private payment for health care in 2006, stated, "access to a waiting list is not access to health care … in some cases patients die as a result of waiting lists for public health care … and many patients on non-urgent waiting lists are in pain and cannot fully enjoy any real quality of life."

Pope Benedict XVI wrote in his recent encyclical Deus Caritas Est, "We do not need a State which regulates and controls everything, but a State which, in accordance with the principles of subsidiarity, generously acknowledges and supports initiatives arising from the different social forces and combines spontaneity with closeness to those in need." Moore and his allies would do well to take this exhortation to heart. We now have unsustainable consumption of medical resources, with third party responsibility for health care expenses. A socialized system would increase state dependency and diminish motivation for charity. Greater government bureaucracy would increase inefficiency and waste compared to doctor-patient "two-party" interaction. Socialized medicine violates the social justice principle of subsidiarity by interfering with the family, churches, charitable clinics, and other intermediate organizations attending to those who are most in need.

The common good would be better served with medical insurance purchased, like other insurance, outside the workplace. Tax law changes could help improve insurance portability and affordability. Insurance industry reform, including measures increasing inter-state competition, could decrease premium cost. Greater competition from patients directly paying premiums would lead to stronger demands for quality and less egregious denials of care. With improved alignment of responsibility for personal health choices and medical care consumption, scarce health care resource allocation would improve. There is significant opportunity for recovery. Market oriented reforms, with compassionate consideration for those without means, deserve far greater consideration than Sicko's deceptive solution.