David Craig's Health Care as a Social Good serves as a superb addition to debates over health care reform in the United States (U.S.). Building on interviews with leaders of religiously affiliated nonprofit providers as well as religious activists, Craig demonstrates a thorough grasp of the complexities of the health care system as he maps out the competing moral values and priorities that animate disputes over the proper way forward. Published just as key aspects of the Affordable Care Act (ACA) took effect, the book begins with a balanced overview of rival visions of health care as either a market-driven private choice, as a government-backed public right, or as an employer-sponsored private benefit. The provisions in the ACA, however, which reinforce and strengthen a hybrid public-private partnership, do not fit neatly into just one of these paradigms. And Craig is convinced that “the path to reform in the United States must build on the current mixed structure of private health insurers, nonprofit, for-profit, and public providers, and public funding of Medicare, Medicaid, and subsidies for mandated individual coverage” (17).
Despite his clear support for the ACA, Craig also contends that improving the quality and accessibility of health care in the long term will require a broad transformation of the national discourse. Effective, lasting reform will only take root if and when Americans learn to view health care through the lens of solidarity more than personal rights, and accept health care as a “social good” that is shared and paid for together “through extensive and coordinated social investment” (86). Without such a transformation, Craig presciently asserts, the reform efforts embodied in the ACA will lack political legitimacy and likely fail.
It is important to note that Craig carefully differentiates a “social good” from a “public good.” Whereas the latter calls to mind governmental programs and oversight, a broad array of public and private initiatives help to maintain necessary social goods like health care. This distinction is crucial for Craig's argument. Given the “culturally insurmountable” political obstacles for a single-payer national health plan in the “land of liberty” (205), for instance, he is convinced that a comprehensive government-centered solution will never attract the necessary public support. At the same time, thoroughgoing market-based models promise more than they can actually deliver. He persuasively contends that purely market-driven reforms would selectively steer resources towards the most profitable policyholders and services (177). And in light of these realities and critiques, the most promising pathway forward, according to Craig, requires extensive public-private coordination and a basic commitment to health care solidarity, both of which were modeled to a significant extent in Massachusetts’ Chapter 58 and then in the ACA.
That said, Craig notes the formidable, persistent opposition to the ACA since it was passed in 2010. But he is hopeful that more Americans eventually will support such reform efforts if they can be made to see the “shared moral commitments and civic spaces already operating within US health care” (17). Here, Craig calls attention not only to the role of religious providers, but also to a number of “hidden structures of solidarity” that are built into the U.S. health care system, including the “relatively high insurance premiums paid by young and healthy people,” and the “shifting of uncompensated care losses onto private insurers” (177). As with government-sponsored programs like Medicare, Medicaid, and publically funded research, these non-governmental social structures help to mitigate the unfair distribution of burdens and privileges in U.S. health care delivery.
Ultimately, however, Craig insists that religious voices represent the most important potential contributor to an increased sense of solidarity in U.S. health care, and Health Care as a Social Good shines a bright spotlight on the religious values and arguments at play in health care debates. Though Craig contrasts religious conservatives’ “ethics of life centered in family and congregations” with religious liberals’ “ethics of living abundantly out of a covenant or common good,” he is keen to emphasize the “potential for common ground” between these two groups (62). In particular, religious conservatives’ emphases on charity and on loving their neighbors distinguish them from thoroughly secular proponents of reform who appeal solely to market competition. And for Craig, the shared commitment to social solidarity on the part of religious believers offers an opening for dialogue and for the needed prioritization of the social good over personal rights in our national discourse. Moreover, he points to the significant support that the Greater Boston Interfaith Organization lent to Massachusetts’ Chapter 58, and maintains that similar interfaith efforts are necessary on the national level in order to “foster the active solidarity for national health care reform that secular liberal and economic arguments have not produced” (20).
A brief review cannot do justice to the intricacies of Craig's analysis in Health Care as a Social Good. Suffice it to say his well-articulated positions are not easily dismissed, and pose important challenges to proponents of market-based reforms, advocates of single-payer solutions, and secular activists who call for greater restrictions on religious nonprofit providers.
The weakest link in Craig's argument arguably involves his optimism regarding the potential transformation of the national conversation surrounding health care. As the presidential election of 2016 amply demonstrated, deep political polarization characterizes the U.S. electorate. These entrenched divisions will hamper attempts to cultivate a widespread sense of solidarity into the foreseeable future and will stymie the type of reasoned political discourse necessary for further progress. Despite these challenges, readers from across the ideological spectrum will benefit from Craig's incisive analysis of the competing values that various parties bring to the health care conversation. His fair and well-informed argumentation models the type of civil dialogue that is sorely lacking in public debates.
