In The Wake of Obamacare: Should We Guarantee Care for All?


A reasonable case can be made for sometimes “standing by” rather than believing society has an open-ended obligation to provide unlimited health care, writes Dr. Stuart Butler of the Heritage Foundation.

Editor's Note: Dr. David Nash of the Jefferson School of Population Health and Dr. Stuart Butler of the Heritage Foundation will be the featured speakers at the inaugural program of the Bernard Wolfman Civil Discourse Project. The program, “The Role of the Federal Government in Health Care,” will take place on March 28, at 7:30 p.m., at Beth Sholom Congregation, 8231 Old York Rd., in Elkins Park. The Civil Discourse Project, for which the Jewish Exponent is the media sponsor, is built upon the Jewish principles of tzedakah, Talmudic debate and the prohibition of Lashon Hara (evil tongue). It strives to model civil discourse in addressing controversial issus.
Admission is free, but requires pre-registration at: or by calling 215-887-1342.


Should health care for seniors be an “entitlement” in America, and who should pay for it? Like all reasonable people, Jews wrestle in their minds with this question and — probably not surprisingly — often end up disagreeing when it comes to policy proposals.

Together with virtually all Americans, Jews typically feel that the wider community should step up to the plate when someone is struck down with a medical emergency and needs financial or other help. Indeed, Leviticus commands us: “Do not stand idly by the blood of your neighbor.”

It’s true that “blood” implies to most people an emergency, probably a life-threatening one. But surveys show that most Americans also believe that everyone should also have affordable access — underwritten if needed by society — to at least “basic” care without regard to their means. So does that mean there is an unlimited obligation on us to assure health care to all? Whatever a doctor recommends for any illness? Equally to all? Without regard to cost?

Bearing in mind these questions, there is actually a reasonable case for sometimes “standing by” rather than believing society has an open-ended obligation. Recall that under Jewish law, we are not automatically expected to endanger ourselves and our family physically to protect our neighbor. By extension we can as a community decline to commit funds to health that would endanger other community needs. As total health costs continue to rise that is a real issue today.

So it is reasonable to insist that the budget for Medicare should “compete” on a more level playing field against budgets for other goals, such as education for our children or defense for us all. That surely implies that Medicare for the elderly should no longer be an “entitlement” in the sense of taking automatic preference over, say, education.

Today Medicare does pre-empt dollars available for most other needs. So how could we change that? In the recent health reform legislation, the government would try to push down Medicare spending by allowing an unelected board systematically to cut fees to doctors and hospitals to stay within budget. Now that is just a thinly veiled way to reduce services by giving doctors the choice of treating some patients for little or nothing — a kind of indentured physician charity care — or paring back on care.

I favor the more transparent approach of giving seniors more direct control of the Medicare budget by giving them what some disparagingly call “vouchers” and allowing all seniors to choose between alternative Medicare plans, as about one-quarter of Americans on Medicare do today. The amount would be adjusted by income so seniors on modest incomes would not pay out of pocket.

There is plenty of debate, too, about what actually constitutes “basic” care and who is primarily responsible for its cost. Specifying “basic” coverage in detail, as we do in Medicare and will do generally under the Obama health legislation, forces others in the community to pick up the tab.

So a debate rages over what should be included, what an individual should be expected to pay for, and what should be offset by the community. To a degree this is just a subset of the general debate over income support for the less well-off. But it is also a dispute about the definition of “basic.”

And that debate is never going to end, because the definition can’t be resolved by first principles in the Torah, the Talmud or in the Constitution. It is best understood instead as a “membership benefit” associated with being part of a community. The consensus about what constitutes such community benefits can and will change over time.

The politics of health care have been particularly hard edged over the last few years. That’s unfortunate, because it has gotten in the way of the serious and reasonable conversation needed for resolving difficult questions about our obligations in health care.

Dr. Stuart Butler is director of the Center for Policy Innovation at the Heritage Foundation in Washington, D.C., where he lives and where he is a member of Adas Israel Congregation.


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