Wednesday, March 20, 2019

Medicare for all

David Brooks in his column, “‘Medicare for All’: The Impossible Dream,” (New York Times, March 4, 2019) argues that regardless of the appeal of adopting Medicare for all, the U.S. transitioning to Medicare for all is impossible.

Brooks is partially correct. Transitioning from the current mélange of health care insurance programs to Medicare for all will be exceedingly difficult. However, the difficulty in transitioning is an insufficient reason for not moving forward.

First, health care is a basic human right, a basic corollary of the right to life. The right to life is corroded by selfishness and greed every time somebody’s life is cut short or somebody’s quality of life is substantially diminished by a preventable or treatable condition for which the person could not obtain the required health care. Studies consistently show that people in the U.S. have shorter life expectancies and live lives impaired by more preventable or treatable conditions than do residents of other developed countries. In other words, Americans enjoy the right to life less than do people in other developed countries in spite of spending more on health care per capita than do people in any other country. Refusing the challenge of transitioning to Medicare for all permanently condemns Americans to enjoying an unnecessarily limited right to life.

Second, a huge number of people associated with health care currently produce little of real value: everyone connected with the health insurance industry (those who work directly for the health insurance company, those involved in billing health insurance, those involved in tracking per patient costs, almost all Medicare employees, all those whose work is tied to administering Medicaid, etc.). Nobody would need to determine an individual’s eligibility for care as everyone would be eligible. Medicare for all is estimated to reduce health care costs by 25% or more simply by cutting administrative costs. In implementing Medicare for all, the government should compassionately assist those harmed economically by the transition: displaced health care administrative personnel, health care workers, not just doctors, saddled with outsized student loans, etc.

Third, health care costs would fall. People would get less care, because preventive care is less costly than treatment and people who have free access tend to seek preventive care. Emergency room usage would sharply decline, as people substituted lower cost options for emergency room care, which is the highest cost source of care. Personal costs, often less tangible but nonetheless real, would diminish because people would not need to track health care costs, make copayments, etc. If Medicare for all paid for outcomes, not procedures, wasteful tests and procedures would go away.

Fourth, federal funding for health care could rely on a simple formula of $xx/person served with a higher rate of reimbursement in rural and other areas in which it is hard to get providers to locate. By pushing the funding down to states, and then allowing states to fund municipalities, the federal government could rely on local expertise and knowledge rather than attempting to decide how to allocate funding among local provider, i.e., rely upon our federal system to allocate health care funding recognizing that allocations may vary substantially from one part of the country to the next. Federal health care administrative costs would be reduced to fifty (or fifty-five, if one includes the District of Columbia and U.S. territories) monthly electronic transfers using the modified per capita formula outlined above. States might choose to utilize current state health department personnel involved in Medicaid funding to allocate the monthly check from the federal government, keeping costs to a minimum and allowing municipalities (city, town, or county) maximum leeway in spending the money or might adopt a more centralized form of control. That would be a state, not a federal decision. Federal enforcement of constitutional guarantees of equal rights would still apply, as it does in other fields, without needing a large, special bureaucracy.

Fifth, as implementation progresses, the federal government could also give the VA medical system to the state in which the VA facility is located, allowing the state the option of operating the facility, giving the facility to a municipality, or closing the facility. Veterans would no longer require special access to care because all Americans would have equal access to care.

The very simplicity of this proposal has two major strikes against it. First, special interests – insurance lobbies, groups focused on a special disease, health care companies – would inevitably strive at every opportunity to establish preferential treatment for themselves (just think of the U.S. tax code!).

Second, the U.S. has sadly become less of a federal system and increasingly centralized. Changing laws or rules at the federal level is easier than making those same changes in each state and territory. This negates one huge benefit of a federal system: the opportunity for states to adopt different approaches, policies, and programs, as a testing mechanism to find what works best. When one approach, policy, or program is widely perceived as the best, other states are generally quick to adopt it. People dissatisfied with the approach to health care delivery in one municipality or state could relocate, just as they currently do with respect to schools, employment opportunities, etc.

Even if you reject this proposal, not moving ahead with health care for all because of the difficulty in transitioning from the current mélange than harms so many and works well for only the privileged few is illogical and immoral. Health care for all is a fundamental corollary of the right to life.

Wednesday, March 13, 2019

Restoring God’s Earth

The earth is the Lord’s, and all that is in it; the world and all who dwell therein. 

(Psalm 24:1)

The people of ZeroWasteChurch.Org write:

When we think about the planet, the solar system, the world as we know it, and as we learn more, and learn how much we don’t know, it is easy to feel incredibly small. When we hear of our world changing, climate changing, biosystems changing, animal species being destroyed, it hard to imagine how one person’s action, one person’s act of faith could possibly make a difference.

Mother Theresa said once, “There are no great things; only small things with great love.” She also said of herself, “I’m but a little pencil in the hand of a writing God who is sending a love letter to the world.”

What if there was something individuals could do? What if there were a series of small acts of faith, small practices, new habits persons could start that did make a difference in care and concern for God’s creation? Would you do it? has prepared an e-book of themes that collect small actions and habits that a person can take to incorporate the theme into her/his life. These themes have been shown, and they are optimistic, that these practices will indeed make a change to the ways we treat creation and the effects of human behavior on creation. call this process “Restoring God’s Earth: A Year of Personal Action.” Each month their free e-book of the same title will introduce a new theme, and each week it will offer several practical suggestions for you to try out. The free e-book is also available by clicking the link embedded in the photo of the book’s cover in the column to right.

They and I invite you to be God’s pencil in the world. As Archbishop Desmond Tutu said, “Do your little bit of good where you are; its these little bits of good put together that overwhelm the world.”

Wednesday, March 6, 2019

Some thoughts on Ash Wednesday

Today is Ash Wednesday, the first day of Lent, the Christian season of preparation for the annual celebration of Jesus’ passion and resurrection.

In some Christian traditions (including mine, the Anglican), churches hold special services at which attendees have ashes imposed on the forehead as a mark of sorrow and repentance for their sins and as a visible sign of the start of a Lenten journey. Lenten journeys are frequently characterized by an individual adopting a special spiritual discipline, giving up something (caffeine, TV, etc.) or taking on something (praying one of the daily offices, volunteering more time in helping others, etc.). In either case, the spiritual discipline is generally intended to help the individual focus more attention on God and on walking more closely in Jesus’ footsteps. These Lenten spiritual disciplines, though tailored to and chosen by the individual, function analogously to the practices of observant Jews.

Recently, some congregations and clergy have engaged in what they call “Ashes to Go.” The intent is to take ashes to people, whether on street corners or elsewhere in response to diminished attendance at Ash Wednesday services and a good faith effort to accommodate faithful but over-scheduled people. At least one priest, who is part of the “Ashes to Go” movement, tries to engage a person who wishes to receive ashes in a brief conversation about the person’s spirituality and then offers a brief prayer along with the imposition of the ashes.

Imposition of ashes outside of the Book of Common Prayer’s Ash Wednesday liturgy (or an equivalent service in another tradition) raises questions about the meaningfulness of imposing ashes. Is wearing ashes for the remainder of the day simply a method of drawing attention to the wearer’s piety, real or imagined? If so, a prima facie reading (and probably a careful exegesis as well) of Matthew 6:1-6, 16-21, the gospel text widely read on Ash Wednesday, condemns the practice. Is wearing ashes for the wearer’s benefit, rather than trying to send a message to anyone else? If so, ashes may help to remind the wearer, conscious of the mark on his/her forehead, of his/her dependence on God’s grace. Of course, similar questions apply to persons who receive ashes in a traditional Ash Wednesday service.

Awareness of personal sin is less pervasive today than in some previous generations. Furthermore, belief in hell has also decreased as has belief in a wrathful, unforgiving God. Many Christians and Christian clergy today believe in a God whose perfection is neither marred nor diminished by embracing imperfection in anyone or anything. Jesus’ death on the cross is increasingly regarded as a demonstration of God’s unbreakable, infinite love for us. This interpretation rejects expiatory, propitiatory, and substitutionary explanations of the crucifixion. Theses latter theories all have the unintended and often unvoiced consequence of conceptualizing God as either a child-abuser or masochist.

Nevertheless, evil and sin are pervasive. The prayer of confession in Enriching Our Worship elegantly expresses the pervasiveness of evil and sin: “God of all mercy, we confess that we have sinned against you, opposing your will in our lives. We have denied your goodness in each other, in ourselves, and in the world you have created. We repent of the evil that enslaves us, the evil we have done, and the evil done on our behalf.” Admitting one’s sin, turning towards God more fully, and seeking to make reparation for one’s sin are steps away from evil and toward more abundant living.

If the imposition of ashes, whether in a traditional Ash Wednesday service or from someone offering Ashes to Go, assists one in that spiritual journey, then receiving ashes is worthwhile and commendable. Otherwise, the imposition of ashes seems to replicate practices Jesus rebuked: "Beware of practicing your piety before others in order to be seen by them; for then you have no reward from your Father in heaven.” (Matthew 6:1)

Wednesday, February 27, 2019

Ecclesiastical dieting for better health

Approximately 70% of the U.S. population is overweight or obese. Similarly, The Episcopal Church (TEC) after decades of declining attendance and membership is organizationally overweight or even obese. The sooner TEC diets, the greater the probability of TEC returning to ecclesiastical health and vitality.

TEC can lose weight. A prior Ethical Musings post examined the episcopacy. In that article, I advocated reducing the number of dioceses to better serve TEC’s declining number of congregations. This essay identifies ways TEC’s congregations (a category that includes both parishes and missions) can improve their organizational health by shedding unhealthy burdens of excess programs, staff and facilities.

Corporate worship constitutes the programmatic and spiritual heart of most Episcopal congregations. I have served a congregation that needed to add a third Sunday morning service to accommodate the growing number of worshippers because of limited parking. I have also served congregations with two Sunday morning services held in naves that could accommodate three or four times their combined peak Sunday attendance.

New congregations invariably begin with a single Sunday worship service. A congregation adds a service when seating or parking ceases to accommodate attendees. Unfortunately, one unintended result of adding a service is that attendees at each service quickly evolve distinct identities based upon their preference for a particular time or style (silent or sung, Rite I or II, etc.). Those separate identities then take precedence over identity as members of the larger congregation. Consequently, congregations continue to offer multiple Sunday services even after the disappearance of the original reason for those services.

Fragmentation of congregational unity is perhaps the most visible cost of unnecessary Sunday services. Clergy while conducting a service are unavailable for pastoral conversations, teaching, or other ministries. Volunteer time is wasted on marginally beneficial, duplicative activities such as needing two sets of ushers and lectors. Multiple services may increase the cost of utilities, janitorial services, and bulletin preparation/printing if each service has its own leaflet.

Small savings in small congregations may have an outsize impact on growth and mission as well as aid in balancing budgets. Although consolidating Sunday services is frequently contentious and may result in losing a few regular attendees, potential gains usually exceed costs. Surveys consistently suggest that newcomers tend to seek thriving, larger congregations instead of inwardly focused, small congregations.

Concomitantly, many congregations can realize gains from eliminating some special services and other programming. Neither Scripture nor tradition dictates that every congregation offer a nearly identical schedule of worship and programs. Instead, reasoned cost-benefit analysis can point the way to shedding the excess weight of once important, now superfluous services and programs. Illustratively, in some small congregations, an early Christmas Eve family service and a Christmas Day service designed for the elderly who do not like to drive after dark may better meet needs than the diffusion of effort and attendees entailed in also offering Midnight Mass. Likewise, not all congregations need a Sunday School, a program initiated in the nineteenth century to teach reading and writing to children whose parents could not afford to send a child to school. Additionally, congregations can reap savings at little or no cost by eliminating any service or program that exists primarily to satisfy the clergy’s needs or wants.

Congregations, by prudentially retrenching the number and variety of worship services and other programming, will reduce the amount of staff time required to support the remaining services and programs. This will permit cutting the hours of part-time musicians, sextons, educators, and secretarial help and/or boosting their compensation. Few small congregations need or realistically can afford a secretary, by whatever title the position has, i.e., parish administrator, operations manager, etc. Mobile phones, ubiquitous word processing skills (who can graduate from college, let alone seminary, without word processing skills?), online liturgical resources, and other twenty-first century technology allow priests to perform those duties about as quickly and efficiently as coordinating and supervising another person’s completion of the tasks. Many non-ecclesial organizations have already streamlined their operations by eliminating similar positions. Contracting with human resource and accounting firms may generate significant savings over employing a bookkeeper to perform those functions.

Most importantly, congregations should closely examine their need for clergy. Estimates vary, but congregations with an average Sunday attendance under 150, and probably under 200, do not require a full-time priest. Compensation for a priest is usually a congregation’s largest budget item. Congregations may want to share a priest with another congregation (made more feasible by reducing the number of worship services), call a bi-vocational priest, or call a non-stipendiary priest. An intriguing and innovative possibility is for a diocese to pay all seminary tuition, fees and living expenses for a candidate for holy orders with the mutual agreement that the person will return to the diocese for ten years of ministry in a bi-vocational or non-stipendiary setting. A payback of 200 to 300% over ten years in lower costs for clergy makes the high up-front cost an attractive investment. This scheme may prove especially attractive to individuals pursuing ordination as a second career. This proposal will never be the complete solution to educating mid-career clergy but may be one element of a mosaic of solutions.

Clergy compensation too often saps congregational funds better spent on other ministries and missions. The answer is not to cut clergy compensation for those serving small and mid-size congregations. The answer is to rethink how best to deploy clergy and the hallmark(s) of “successful” congregations. At a minimum, the hallmark of a “successful” congregation is a congregation vitally engaged in loving God, one another, and their neighbors.

The prevalent view that having a full-time priest is a (arguably, the) hallmark of a “successful” congregation is anachronistic. TEC is not an established church that must have a priest in every parish. Furthermore, TEC congregations lack geographic boundaries. People, including clergy, generally commute by vehicle and communicate electronically. Meetings, for example, occur by videoconference with increasing frequency. Religion’s cultural marginalization is diminishing expectations for clergy participation in community and civic events. Distinguishing parishes from missions based upon the former’s ability to pay a full-time priest reinforces the mistaken perception that “successful” congregations must employ a full-time priest.

Finally, TEC can reap great benefits from reducing the property it owns. Too often, most of the resources small congregations have – money and volunteers – are devoted to a losing struggle to support a priest and maintain aging buildings crippled by deferred maintenance. Few small congregations attract the visionary, charismatic leaders who are catalysts for numerical and spiritual growth. Allowing small congregations to fritter away scarce resources on their few remaining souls neither honors God nor best serves God’s people.

The unhealthy congregational mentality that permeates TEC complicates implementing this strategy. Congregations tend to view themselves as largely independent entities. Many congregations ignore TEC’s connectional polity and property rights. The courts have upheld those property rights in a flurry of recent court cases filed by various schismatic groups.

A relative handful of small congregations have a strong missionary justification. For example, some serve isolated constituencies, though the number of such congregations diminishes as TEC establishes full communion the ELCA and other denominations.

More commonly, small congregations result from changing demographics such as changing urban neighborhoods and the depopulation of rural areas and small towns. These demographic shifts have also caused a clergy distribution problem: too many priests hear a call to urban and suburban areas; too few hear a call to rural areas and small towns.

Meanwhile, newer suburbs and revitalized urban areas may lack an Episcopal congregation (or a congregation of a denominations with which TEC is in full communion). Proactive bishops and dioceses will identify dying congregations. Then, instead of futile life support efforts which are extremely unlikely to reverse that prognosis, they may close the congregation, sell its underutilized property, and redeploy the funds to establish new church plants in under-served areas, even if that means transferring assets from one diocese to another. This process, painful as it may be, is arguably more faithful to the intent of the donors whose gifts paid for those properties and will most probably best advance God’s work.

Losing weight is rarely easy. The habits and values that prevent weight loss are deeply ingrained. Yet, by almost any measure, TEC is overweight, burdened with too many small congregations, many of them in the wrong location, and most of them doing little more than struggling to survive. God calls us to be and do better. God calls TEC to renewing its commitment to following the way of love, honest examination of our stewardship, and then to take the painful yet essential steps to better align our resources with the world’s current needs while never forgetting any part of the faithful remnants in small churches. God wants and deserves our best effort. Then and only then can we, with the author of I Timothy, say that we fought the good fight and, with Paul, say that we raced to win.