It's time to take our medicine: An interview with Sister Carol Keehan, D.C.
Health care reform is about more than reducing insurance premiums, says this Catholic health care executive. It’s about caring for the sick.
On March 5, 2009, Sister Carol Keehan, a Daughter of Charity and president of the Catholic Health Association (CHA), which represents more than 600 Catholic hospitals and medical facilities, participated in a White House roundtable on health care reform. The gathering included members of Congress, journalists, and invited interested parties, such as Keehan.
"When we came together, you got that sense that we really have to get this done," says Keehan, a 35-year veteran of Catholic health care as both a nurse and an administrator.
A year of rough-and-tumble politics took the shine off that early gathering. "I don't know if it was other issues or just that we can only stay positive so long in Washington," she says. "There has been a lot of fear-mongering and deliberate misinformation, and so people were frightened."
Keehan pitched a Catholic case for health care reform on Capitol Hill right up until its passage in March. But CHA's support of the final legislation was not without controversy: Her endorsement of the reform bill on March 15 was followed the next day by a U.S. bishops' conference statement rejecting it. At issue was whether restrictions in the final bill are sufficient to maintain the ban on federal funding of abortion.
"The legislation is not going to fund abortions," Keehan says. "Still, we need to carefully review its provisions, its safeguards, and its implementation."
Why should Catholics support comprehensive health care reform?
Because everybody needs it. If you are poor and uninsured, you desperately need it. If you're a working person, you need it because your wages have been depressed for at least the last decade and your insurance premiums, your out-of-pocket expenses, and deductibles have all gone up.
We have 18,000 unnecessary deaths a year because of people not being able to get the care they need due to lack of insurance, according to the Institute of Medicine; a more recent Harvard study put that number at 45,000. Right now about 18 percent of a family's income goes just to health care expenses, and it's slated to go up to 24 percent.
If you're concerned about the nation's economy, we are moving today from spending 16 percent of our gross domestic product on health care to 17.3 percent. The industrialized nations we compete with spend 8 to 9 percent, and they have better health outcomes than we do.
There was a study released last year of cancer survivors. It found that four out of every 10 have spent every cent they had to get to where they are. One out of every 10 survivors no longer has a roof over their heads because they've spent all their assets. Seventy percent of the personal bankruptcies in this country last year were because of medical expenses. We can't ask people to live like that.
For us as Catholics it's very hard to be pro-life when we don't give care to many mothers who are pregnant or when we don't provide pediatric care and well-baby care and sick-baby care to children. We have 9 million uninsured children in this country. That's not pro-life.
Where have you seen the need for reform in your own work?
I could give you a million examples. There's the pregnant woman who comes to the emergency room ready to deliver who hasn't had an ounce of prenatal care. Or maybe she is not ready to deliver but is toxic because her blood pressure is out of control. This is a mother who has never, ever had any kind of maternity care, any kind of counseling.
Or there's the woman who has a tumor so large it is actually coming through her breast. She knows she doesn't have the money to afford chemotherapy so doesn't do anything.
We see elderly people in the emergency room who don't take their medicine because they were waiting for their Social Security check. We see people with ulcers on their legs that have become grotesquely infected, which could have been easily addressed much sooner if we simply had access to them.
Then there are people who try to use home remedies when they have symptoms that make most people go straight to the doctor. A classic would be blood in the urine. Often people who don't have coverage will just drink a lot of fluids, or maybe somebody told them cranberry juice was good. By the time they come into the emergency room, they've got a bladder cancer that's eaten into the wall of the bladder and may even be in the intestines.
By then it is imposssible to cure their cancer; they're not even going to be reasonably comfortable for the rest of their lives. They're going to be utterly miserable.
If from a Catholic perspective we say these are people in the image and likeness of God, then we ought to be pushing to get them treated as if they're made in that image.
What are some components of an ideal health care system from a Catholic perspective?
An ideal health care system would first of all provide everybody with high quality care. It would reach out to everyone, it would focus on preventive care, and it would give special attention to the vulnerable. It would be transparent, so people would know what they were getting, and it would be financially responsible. Clearly care must be available for everyone from the moment of conception until the moment of natural death.
Additionally, the goal is for everybody, regardless of income, to have the dignity of being able to choose a provider that will treat them with respect.
When you need to get health care for your children, you shouldn't have to come looking for charity. It's a point of pride for parents to be able to support their children and get them what they need.
A majority of Americans favor elements of health care reform, but large numbers remain opposed to the actual legislation. Why do you think that is?
I think the misinformation and fear-mongering have been unbelievable.
People agree they don't want the insurance companies to be able to raise premiums dramatically when they've had the policy for four years and suddenly have cancer and need the care. They don't want insurance companies to deny coverage because of preexisting conditions, which include things like pregnancy, domestic violence, or even an infant's cleft palate.
Everyone wants incentives for preventive care, such as mammograms and colonoscopies and other screenings, and limits on out-of-pocket costs. But when you put a stack of 2,000 pages on the table, everybody gets nervous.
The most egregious example of the fear-mongering was the nonsense about death panels. Everybody who has any experience with health care knows sometimes people don't have good advance directives about end-of-life care. Family members or the physician feel obligated to do everything they can, instead of allowing a patient to die in peace with good pain control and emotional and spiritual support.
People want to be able to say that they want pain control, they want their family around, and they don't want to be tied down with tubes and IVs. So a group of people who were in health care encouraged their representative to include a provision to pay a physician once every five years to walk through an advance directive with a person if the patient wanted to do it.
It was a perfectly legitimate and eminently desirable proposal that got turned into the fiction of bureaucrats telling you that you ought to die, that you've lived long enough and shouldn't use so much of the nation's money, that we shouldn't spend so much money on old people or people in the last six months of their lives. Even if it isn't true, it scares people.
Why can't we just legislate separately the things everyone agrees on, such as not denying coverage to people with pre-existing conditions?
We have a very dysfunctional health care system, which we have allowed to get more and more dysfunctional over the past 60 years. That's why health care reform has to be comprehensive. I would not call the legislation that finally passed completely comprehensive because it leaves a lot of gaps, but it is a good first step.
Fewer and fewer people are getting insurance because it has become so expensive. Some people would love to be able to have insurance and pay for it; others are young and think they are invincible and would rather pay off college loans or buy the car of their dreams. Besides, nobody gets a thrill out of paying a health insurance bill.
But the insurance market doesn't work unless you have almost everybody in it. Insurance is based on the idea that only about 10 or 15 percent of the people will use it in any significant way in a year, but everybody will pay into it. It's sort of like fire insurance: If everybody who had fire insurance had a fire every year, the cost would go way up. The reason you can keep fire insurance affordable is we all have it. Most of us will never use it, but it's really good to know you have it in case you need it.
The same is true with health insurance, so from that perspective you've got to have a comprehensive solution. We have tried to do a piecemeal approach with programs to expand coverage to poor children, for example. That helps, but it still leaves their parents without any health insurance.
Medicaid helps cover the very poor, but it still leaves a lot of working poor without coverage. A lot of employers have had to resort to plans with $1,000 deductibles, which for many people means only if they get cancer or heart disease will they get care because they only make minimum wage and can barely cover food and rent, much less a deductible.
How do you respond to those who wanted to table the whole thing?
How do you say "we're going to table it" to a family struggling to keep insurance, to a family that's been turned down for insurance because they have a preexisting condition, to a parent or to a person who cannot get chemotherapy because they can't afford the large deductible, or to a person who can't find a chemotherapy provider to take Medicaid because it pays so poorly? We have so much suffering.
But we aren't going forward naively thinking we fixed this whole thing or that this particular package of reforms takes care of the problem. But the measures being put into place by the reform are good first steps.
We couldn't afford to forgo the good and wait for the perfect. If we had waited for perfect legislation, a lot of people would suffer for many more years.
Even at best only 32 million of the 47 million Americans who don't have any health insurance now will get it over the first 10 years. That still leaves 16 million uninsured, and it still leaves immigrants not covered. We've got to continue to address that.
How do you respond to the criticism that Catholic hospitals support health care reform because they stand to benefit financially?
I would say it's a fairly cynical way of looking at it, not borne out by the history of Catholic health care in this nation.
A community needs psychiatry, it needs neonatal intensive care, it needs palliative care, emergency rooms, the kinds of services that don't pay for themselves. Those services are more often found in Catholic hospitals than in any other kind of hospital.
Those of us in Catholic health care also have a tradition of being good businesspeople. The religious sisters who went before us in this country built the largest, most successful not-for-profit health care system the world has ever known. It is an untold story because it just grew up in every community.
Our history has its troubles, just like any other group, but by and large we have sought out the services a community needs and found a way to get them there. We have done outreach to the poor and brought technology to communities before anyone could say there was a good return on the investment.
It seems the biggest issue in the Catholic debate has been the question of federal funding for abortion. How was this handled in the reform?
There is a piece of legislation called the Hyde Amendment that gets reauthorized every year. It says none of the funds appropriated in the federal budget-and none of the funds in any trust fund related to it-shall be expended for abortion, and none shall be expended on coverage that includes abortion.
What that really means is that government employees' health plans cannot include abortion coverage because the federal government is paying for that coverage, although all of the plans can pay for abortion for the life of the mother, rape, and incest. That's also true for the armed services and Medicaid, although 17 states cover abortion for Medicaid recipients with separate state money.
The Stupak Amendment, which was part of the original plan that passed the House of Representatives last year, reflected the federal employees' plan: A person who buys coverage with a federal subsidy couldn't have abortion coverage in the plan and couldn't buy a separate plan with his or her own money that covered abortion.
But in the bill that passed the Senate last December and passed the House and was signed into law by President Obama in March, if you're buying coverage in the insurance exchange and getting a tax credit to pay for part of it because you have a low income, you can buy a separate plan that covers abortion with your own money. The plan is so separate that you even have to write two checks every month, with the second check going to a separate fund that has to be audited every year.
Why did the U.S. bishops and other pro-life leaders oppose the final legislation's approach to abortion?
Many people are uncomfortable with it because it will allow more people to be in plans that cover abortion, even though no federal dollars are used. That is not a happy thought.
On the other hand, it is also not a happy thought that women who are at 300 percent of the poverty level and below have abortions at four times the rate of women in any other socioeconomic group. We haven't found ways to reach out to those women.
I'm tortured by these kinds of issues because it can take forever for poor pregnant women to find someone to validate that they're eligible for Medicaid and get them into a maternity program, which is certainly a pro-life tool.
Is there reason to believe that if those women had access to health care that they might not have abortions?
I think there is. If you have two children already, and you're pregnant and you have no insurance and can barely afford to keep those two children fed and clothed, that's hard enough. Now you're going to have a mammoth bill because pregnancy is expensive and then you've got the ongoing expenses of another child, never mind the fact that you're going to have to be off work, if you have a job. Insurance coverage would go a long way toward easing some of that burden.
Considering the difficulty surrounding abortion and other medical interventions that conflict with Catholic teaching, would it be better if Catholic hospitals didn't need public funds?
From the start, we in Catholic health care have always been not only good members of our church but good citizens of our country, and so we've always worked with government as partners to reach out to our fellow citizens. We haven't said all government is bad, and we haven't said government has no responsibility for the poor.
If you read the history of why Catholic hospitals are in this or that city, many times it was because elected representatives went to the bishop or to the motherhouse of a women's religious community and asked them to come and run a hospital in that place.
The charter for the hospital that I ran in Washington for 15 years, Providence Hospital, was signed by Abraham Lincoln because Washington is a federal city. The finance committee for that hospital was the House Ways and Means Committee. The sisters would walk into Congress, go to Ways and Means, and get their annual budget, so we've got a long history of engagement.
The Ursuline Sisters established the first Catholic hospital in this country in New Orleans. After the Louisiana Purchase that transferred the territory from France to the United States, they were petrified because they didn't know what it would mean. President Thomas Jefferson visited them, and they still have his handwritten letter in which he promised never to interfere with their work and pledged to help them.
I think the ideal is that we work together, because in many ways we have the opportunity to inform the government about the needs of people and about what works and doesn't work for the people the government is called to serve.
We've been accepting Medicaid for a long, long time, and I can tell you you're never going to get rich by taking care of poor people, not in my lifetime anyway. We have an obligation to our fellow citizens to make our government what it ought to be, and you don't do that by walking away.
Is there a Catholic argument for health care reform that goes beyond the merely practical and economic?
I think there is a moral and gospel-based argument for health reform, though it's not the easiest one to make in the nation's capital. It boils down to the common good and to solidarity.
We Catholics have a tradition that if you're sick, we ask what we can do for you, not how much we do have to do for you.
The truth of the matter is, when people are sick, they should have the best care possible. There is so much anxiety and stress associated with suffering and illness that people need a health system, caregivers, and a church that asks what we can do and how we can help make things better for sick people and their families.
I recently gave a talk about solidarity as the moral foundation for health reform. It is a different way to look at the issue. We tend to focus on what is in a piece of legislation and what it means for us. Are we going to get more than we have to give?
That's one way to look at it, and certainly most of us are our own favorite charity. But we need to remember that we're called to a gospel view of life. We're in this together and should make sure this is good for all of us.
That's different from asking what I am going to get from it and what it's going to cost me. The solidarity perspective says I'm not happy that I can get health care when others can't, because we're all part of the family of God.
This article appeared in the May 2010 issue of U.S. Catholic (Vol. 75, No. 5, pages 18-23).