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Is Health Care for the Poor a Requirement of Justice?

It just so happens that as Congress considers dismantling Medicaid as we know it – as well as an end to the law that requires health insurers to cover people with pre-existing conditions – I am preparing to explore the theme of “Good News for the Poor” with my seminary ethics class. One of the things I do with my students is to walk through the New Testament to show them just how continuously and emphatically Christ and the apostles call Christians to take responsibility for the poor. Care for the poor is so central to the kingdom and its justice that it became the basis for an entire office of the church: the diaconate.

I also point my students to the history of theological reflection on poverty in the Christian tradition. In particular, we discuss the general Christian consensus that God gave the earth and its resources to human beings in common and that property rights are always subject to the rights of all human beings to the basic resources necessary for life.

Thus the church father Ambrose argued that the possessions of the church belong to the poor. Thomas Aquinas argued that it is not theft when a starving person takes what she needs from a rich person because every person has a right to have her basic needs met. And John Calvin argued that those who do not share with the poor when they are in need are guilty of theft – and potentially of murder. Basic provisions are not owed to the poor as a matter of charity but as a matter of justice. Indeed, Calvin regularly stated that the poor have a “right” to such resources.

That’s why Calvin took the work of Geneva’s General Hospital so seriously. He believed it was the responsibility of government to provide funds for poor relief and medical care, and that it was the responsibility of the church to care for the poor through the diaconate.

Free stock photo of landscape, mountains, man, love

I’ve written a fair bit on Calvin’s views of poor relief, here on my blog (including on Calvin’s view of the distinct responsibility of government with respect to the poor), for the Gospel Coalition, and for the Calvin Theological Journal.

I realize that Christians differ on just how it is that government should most effectively secure justice for the poor – whether with respect to poverty in general or health care in particular. Neither the church nor its clergy have any authority – let alone expertise – to dictate health care policy to the state. But where I think Christians ought not disagree is that we owe the poor their rights – to basic sustenance and to basic health care – as a matter of justice.

That’s why, for instance, the catechisms of the Reformation (Heidelberg, Westminster) declare that the commandments You shall not murder and You shall not steal require us to care for the needs of the poor. To put it in classic theological terms, it is a requirement of the moral law of God. It is part of the natural law written on our hearts as image-bearers. We are, scripture teaches us, our brothers’ keepers.

If we believe that failing to secure the poor their rights constitutes theft – or even murder – then it goes without saying that it is well within the responsibility of government to protect the poor from such injustice. Indeed, if government can be best evaluated based on how well it protects the poor from injustice – as Calvin thought – than how proposed health laws will affect the poor should be the primary concern of legislators and citizens alike.

Whatever conclusions we come to with respect to particular policy approaches (and we should be humble here), we should be agreed that health care for the poor is not merely a matter of charity. It is a matter of justice. Our representatives should know that this is where the Christian tradition stands.

Who is to blame for the unsustainable expansion of America’s welfare state? – a look at food stamps

Amid all the talk about whether or not President Obama won reelection on the votes of people who simply want handouts from the federal government it is worth paying attention to how America’s safety net actually works. In a fascinating report at National Affairs David J. Armor and Sonia Sousa provide an analysis of just how relief gets to the poor (and not-so-poor) and how it has grown in the past few years. In this post I want to focus in particular on what they say about food aid programs. The major programs in view here are the Supplemental Nutrition Assistance Program, or SNAP (formerly known as food stamps) ($68 billion in 2010), the school lunch and breakfast program ($14 billion) and the Women, Infants, and Children (WIC) program ($6.7 billion).

The baseline point to note is that food aid programs have in fact dramatically grown under President Obama. Armor and Sousa write:

Between 1992 and 2007, spending on food programs did not vary by more than a few billion dollars, after adjusting for inflation. But according to the Congressional Budget Office, spending on food programs rose from $57 billion in 2007 to $95 billion in 2010 (again, adjusted for inflation), an utterly unprecedented increase of 66%….

Between 2000 and 2010, the number of persons receiving food stamps more than doubled, increasing from 17 million to slightly more than 40 million. Real spending more than tripled during this period, rising from $22 billion to $68 billion.

Map: Percentage of People in each county who receive food stamps, June 2009

What are the reasons for the expansion? Obviously the recession has been a big part of it, but the growth of food aid programs outpaces the growth in the number of persons receiving food aid. The main reason for this is President Obama’s 2009 stimulus program, which purposely sought to increase the benefits received per person.

The expansion of the number of people receiving food aid also owes to factors other than simply the recession.

During the recession of the early 1990s, enrollment increased by several million — understandably, given that the poverty rate rose to 15%, roughly the same as the rate in this most recent recession. But between 2003 and 2007, when the economy was strong and poverty rates were relatively modest, SNAP enrollment nevertheless climbed to 26 million people. And after 2007, enrollment figures skyrocketed — climbing to 33 million people in 2009 and to 40 million in 2010.

Note that enrollment was climbing significantly already during the Bush administration, although the climb became steeper after 2007 owing to the recession. In part we might say that this latter climb simply demonstrates that the program is working. In hard times more poor people are receiving help.

Yet here’s the rub. Much of the increase in food aid programs reflects financial support that is not going to the poor. “Most of the increases in food-stamp participation in the past several years have instead resulted from an increase in benefits going to people above the poverty line” (emphasis added).

As early as 2004, nearly 40% of households receiving food stamps were above the poverty line… [I]n 2010 it reached 48% — nearly half of all households receiving food stamps. The increase in the number of households participating in the food-stamp program is thus being driven disproportionately by households above the poverty line.

Considered in terms of individuals more than half of all food aid recipients are above the poverty line. Most people who receive federal aid are not poor according to the government’s standard of poverty.

Armor Chart 3 Very Small Fall 2012

Just as striking is that most of the people above the poverty line who are receiving aid are well above the poverty line: “Another 7.2 million recipients have incomes between 130% and 200% of the poverty level, and an astonishing 8 million recipients have incomes that are greater than 200% of poverty.”

What’s going on here? In significant part it has to do with the relaxation of “categorical eligibility” rules under the Obama administration. “Categorical eligibility allows states to declare large numbers of families eligible for SNAP without actually going through the SNAP program’s own process for determining eligibility.”

Who are the culprits? It’s not necessarily who you would think and it bears little resemblance to the map of blue states and red states. The states that provide SNAP benefits to families with incomes up to 200% of the poverty line include Montana, North Carolina, and North Dakota, as well as Maryland, Massachusetts, and Washington. States that provide benefits to families earning up to 160% of the poverty line include deep red Texas and Arizona as well as Connecticut and New Mexico. Perhaps most interesting of all is that staunchly blue New York and California hold standards much stricter than many other states, keeping the eligibility line at 130%.

This makes a big difference. If all states awarded food stamps to individuals up to 200% of the poverty line – which is perfectly permissible under current federal rules, no less than 94.4 million Americans, nearly a third of the nation’s population, would receive food stamps from the federal government.

These numbers suggest that it is categorically wrong to blame the poor – or programs designed to help the poor – for America’s financial problems, or even for the recent growth of the welfare state. In fact, the vast majority of federal dollars redistributed in this country go to segments of the population above the poverty line and even to the middle class, including in particular seniors and veterans.

Republicans should abandon rhetoric critical of the safety net, or of programs designed to help the poor like Medicaid and focus instead on reforming these programs so that they actually help the people they were established to help. Too often Republicans are willing to criticize redistributive programs that benefit typical Democratic constituencies (think of Romney’s 47% comments) but not to criticize those programs that benefit their own favored constituencies (i.e., seniors). This suggests to many people – rightly or wrongly – that they don’t care about the poor. It also suggests that Republicans know how to be Santa Claus just as much as do the Democrats. The divide here is not as much about principle as many conservatives would like to imagine.

Democrats, for their part, need to ask themselves whether they really want America to be a country in which a third of the population is on food stamps. They also need to come to grips with the fact that raising taxes on the rich is not going to put America back on the path to welfare state sustainability. It’s all fine and good to talk about helping the poor and needy, but when it comes down to it it will be the benefits the federal government gives to the middle class that will wreck this country’s budget. It’s time for a serious conversation about what the American welfare state is actually accomplishing.

Letting Christian theology shape our politics: the Christian tradition and property Part 3

Many of the early church fathers, such as Ambrose and Augustine, argued that private property, like civil government, was a result of the fall. They believed that God had given material resources to human beings in common, and that individual persons would only have possessed such resources under the principle of stewardship. According to that principle, how I use my possessions for the good of others is just as important as my right to use those possessions in the first place.

Later Christian theologians muddied the waters, and with the rise of the market economy and the beginnings of what became capitalism these theologians articulated careful justifications for the idea of property. But even then both scholars and pastors consistently emphasized the obligations of property owners more than their rights. The commandment ‘you shall not steal’ was always explained in light of the teachings of Jesus not simply as a prohibition of someone taking my property, but as a requirement that I use my property to serve the needs of others. This is a matter of justice (giving another his or her due), not simply “charity.” (See Post 1, Post 2, and also a complementary post by Brad Littlejohn.)

Now in all of this I have said very little about civil government. Yet it is fascinating to see that virtually all of those who objected to what I have written in one way or another engages the issue on a political – or specifically an Americanized political – level. Very few critics actually engaged the substance of the Christian tradition. Many American Christians, it seems, even those most worried about nefarious doctrines like that of the two kingdoms, don’t like having their modern assumptions about property and the poor tested by the actual substance of Christian theology. They judge Christian theology from the perspective of their American political convictions, rather than the other way around (though they often baptize their political convictions as Christian in the process).

Let me give two examples:

1) In contrast to the Christian tradition, which has generally viewed both property and civil government as good but as the results of the Fall, American Christians tend to view civil government as highly suspect and private property as nothing less than sacred. And although there is a general consensus that God appointed civil government as his minister to enforce – i.e., coerce – justice, there is a marked reluctance to view government as having even the right (i.e., authority) to tax property holders for the sake of ensuring justice for the poor.

Note, this objection is not simply an objection to the manner in which government is using tax revenues to protect the poor. There are plenty of good Christian reasons, for instance, to oppose communism or even socialism on the grounds that 1) they do not work; 2) they are often destructive of civil society; and 3) they hurt the very poor they are trying to help. But many libertarians will not even allow us to consider or debate the best ways in which government should help the poor. They question the notion that government should help the poor at all because they reject the Christian notion that an individual’s property rights are qualified by the more basic rights of the community or in particular of the needy.

2) Many American Christians believe whether or not a person is poor should be determined based on that person’s income or possessions. On that basis, they say, there are virtually no poor people in America, and there are certainly no responsible people who are poor. But this assumption is hardly biblical (not to mention the fact that it ignores the fact that the reason there are so few poor in America is because government helps those who would otherwise be poor). In Scripture the concept of the poor is much broader than an assessment of economic resources suggests. The poor are those who are 1) oppressed or vulnerable to oppression; 2) excluded from meaningful participation in the community; 3) lacking the basic resources necessary for life. The specific examples Scripture often provides of those who are poor are slaves, immigrants, women without husbands, and children without fathers.

Now anyone remotely familiar with American society knows that these groups make up a significant percentage of the American population. While many of the “widows and fatherless” in our society are what they are because they’ve been abandoned by irresponsible men rather than because those men died, that hardly changes their basic plight. The poor are still with us (as Jesus said they would be), and it is good that our government seeks to protect them.

Now none of this dictates that any particular policy or program is the appropriate way to protect or help the poor. Civil government should not be equated with civil society (or the rights of the community and the poor), and the first level of support for the poor and for one another should come through the organic structures of civil society. This is a fundamental point needing recognition in a society that wants to be free, and a point often ignored by well-meaning folks on the Left. But I also believe government has a responsibility to make sure this happens, and it seems, increasingly, as if this point is acknowledged by fewer and fewer on the Right (to their own political and moral disadvantage).

It is true that many government programs designed to protect or help the poor have actually done them great harm. Dependency is never a good thing, and America seems to be becoming an increasingly dependent society. But the dependent, contrary to popular perception, are not simply the poor. Most of the programs that are redistributive in this country, whether through grants, entitlements, or tax credits, redistribute resources directly to the middle class or to the wealthy because they are not means-tested (think education, Medicare, Social Security, the mortgage tax credit, lavish public pension programs, and the plethora of subsidies for various businesses, industries, or research programs).

It is obviously true that American government is too big and in too much debt. But it is not Medicaid, nor is it basic provision for the poor, that is bankrupting the country.

It is clear that we need to have, and are having, an open debate about the future of America, and about the nature of government’s responsibility to its citizens. But whatever positions Christians advocate in this debate – and we should advocate positions that make sense economically, politically, and morally – we should not forget the teaching of our own theology. Calvin argued from Scripture that a magistrate will be judged based on how well he protects the poor under his charge. In a democracy, when we are all magistrates insofar as we influence legislation or political debate, we should be mindful that we will be judged on the same basis.

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