To all who read this post, Merry Christmas! Today we celebrate the entrance of our Lord and Savior into the world, taking the form of a babe born to a Virgin in a manger. As Venerable Archbishop Fulton Sheen put it so eloquently, “Bethlehem became a link between heaven and earth; God and man met here and looked each other in the face. In the taking of human flesh, the Father prepared it, the Spirit formed it, and the Son assumed it.”
On this first day of the Christmas Season, we wish you a Merry and Holy Christmas!

​--James Breen, M.D.

​The Catholic Social Teaching principle of Stewardship reminds us that we human beings have a duty to safeguard God’s creation. While this principle is often applied to our relationship to the natural environment, the same principles can be applied to all resources bestowed by God for human flourishing. Just like natural resources such as air, water and land, other gifts such as human talents, material and financial resources are God-given and ought to be employed in a way that respects their provenance from the Most High, as well as their natural end to further the common good—not only for those living today, but also keeping in mind the welfare of future generations.
Extrapolating this line of thinking to our use of resources in the development and delivery of medical care, we see that several types of resources are required in order to provide such care. Financial investment, material resources and human ingenuity and intelligence go into the development of diagnostic tests, treatments and techniques that are used to further human health and healing. We should all be profoundly grateful for the bountiful gifts that produce such innovations for the purpose of restoring and preserving health.
However, it should be obvious to anyone who has had an interaction with the healthcare system that the delivery of healthcare is permeated with a vast amount of wastefulness. The medical field is consumed by an overgrowth of regulation resulting in byzantine payment models and delivery mechanisms that inevitably lead to a great amount of waste—waste of money and diversion of human talents in the service of bureaucratic and managerial functions that perpetuate many of the wasteful systems and practices that do nothing to advance the ostensible aim of the healthcare system (ie, treating and curing illness and furthering health).
The natural end result of the addition of a vast workforce of functionaries who are removed from actual patient contact by orders of magnitude is an inflation in the cost of care. This increased cost is baked into the price of goods and services produced by the healthcare apparatus. Governmental payors (namely, Medicare and Medicaid) place caps on what they will pay for services; commercial insurers negotiate rates with service providers (doctors, hospitals and the like). Only the uninsured patient is made to bear the list price of the medical care provided to him—in other words, the very person who is least able to pay the full ‘rack rate’ of his medical care is the one who must negotiate on his own behalf with the healthcare provider (hospital, clinic) for a resolution to the inflated prices for which he is held responsible.
Returning to the concept of Catholic Social Teaching, the scenario described above is a tremendous affront to the principle of stewardship on many levels. First, it is not a prudent or judicial use of the economic or material resources given by God for the promotion of health. A recent study found that up to 30 percent of US healthcare spending was spent on administration, and that at least half of administrative spending was wasteful.
Aside from wasteful spending, there is a large contingent of people whose positions serve primarily to maintain the existing system’s bureaucratic infrastructure without directly benefitting patient care. One could argue this represents a misapplication of human resources that could better serve the care of patients in some other way (or be directed toward some other pursuit outside of healthcare—think of retraining large numbers of billing auditors and referral coordinators).
Another way that the current healthcare system works against the principle of stewardship has to do with the way financial resources are applied within the system. In order to capture revenue from governmental payors and commercial insurances, providers must ensure adherence to measurable “metrics” and protocols. Administrative functions designed to comply with these directives result in a higher price for medical care—and they skew the aim of the care from being solely focused on the patient to being directed toward fulfilling regulatory and financial mandates. This works against the common good by diverting resources away from real care, inflating the cost of care, and increasing the dependence of individuals and families on third party payors for all their healthcare needs. In CST parlance, the current system undermines subsidiarity (ie, local control in decision-making) and solidarity (joining of justice and charity), by working in detriment to the common good.
How can we reverse some of the erosion of poor stewardship that is inherent in the prevailing healthcare system? For one, it is important to bear in mind that the material and personnel needs of different specialties and care settings are markedly different—think of the differences between the needs of a primary care office and those of a liver transplant service. For the purposes of this article, I will focus exclusively on stewardship in the primary care setting.
Unfortunately, the prevailing insurance-dependent economic model which is used to finance nearly all healthcare expenses (see my previous blog on “subsidiarity”) has plundered economic and organizational resources in primary care. The reason for this is manyfold—first, primary care is not an ‘insurable’ event in the same way as trauma or emergency room care are. This is because, unlike emergency room care, the majority of primary care is predictable and foreseeable. Most people expect to see their primary care physician at least a handful of times a year for preventive care or a random episode of relatively mild illness, or to monitor chronic conditions such as diabetes and hypertension. By contrast, people generally do not anticipate having a major medical event such as a heart attack or stroke that leads to an ER visit or hospitalization.
The second way in which the insurance-payment model has hurt primary care is by treating the primary care practice as a “loss leader.” This means that large healthcare systems prefer to treat primary care practices under their umbrella as a financial liability, for the purposes of driving patients toward more lucrative services and specialties. The enormous overhead saddled on primary care practices—who are responsible for such tasks as requesting insurance authorization for subspecialty referrals, imaging studies and the like—makes primary care practices appear to operate at a loss. For primary care practices that are owned by larger healthcare systems, referrals for ancillary services such as labs and imaging are routed to the larger system without regard for cost of the service.
A reorientation of focus on stewardship in primary care is best achieved by decoupling primary care from large multispecialty health system care, and even from the insurance/government-payment mechanism entirely. Because of its relatively predictable and low-cost nature, primary care ought to be accessible to the average American without resorting to the pre-paid money laundering scheme that is the insurance industry operating in tandem with monopolistic healthcare systems. In the end, the goals of primary care are at odds with those of the hospital system—at its best, primary care obviates the need for higher-level medical care, while hospital-based care tends to incentivize more costly care. Even newer schemes such as ‘value-based care’—the newest iteration of the failed managed care policies of the 1990s—face a large burden of regulatory costs and metric-driven protocols that work at cross-purposes.
In summary, the CST principle of stewardship is intimately related to the principles of human dignity, solidarity and subsidiarity. When applied to primary care, stewardship promotes human flourishing through a judicious use of economic and human resources in the promotion of the common good—relying on local autonomous control over the delivery of care in response to the demands of justice and charity. 

Among the main principles of Catholic Social Teaching is the principle of Subsidiarity. Similar to the principles we’ve already discussed (dignity of the human person, solidarity), the principle of subsidiarity is intricately connected to the other CST principles. That is to say, it is incomplete to discuss subsidiarity without a clear understanding of its relationship to solidarity and the dignity of the human person.  We’ll get into that in a bit.
For starters, let’s define what we mean by subsidiarity. The Catechism of the Catholic Church (CCC 1883) presents subsidiarity in the following way:
“The teaching of the Church has elaborated the principle of subsidiarity, according to which ‘a community of a higher order should not interfere in the internal life of a community of a lower order, depriving the latter of its functions, but rather should support it in case of need and help to co- ordinate its activity with the activities of the rest of society, always with a view to the common good’.”
In other words, subsidiarity states that it is fitting and proper for responsibilities and decision-making to encourage participation and take place at the lowest level of community life possible—without interference from elements of higher order than is necessary to fulfill a function. Contrary to the assertions of some, this does not make subsidiarity an anti-government principle. For example, there are functions that are best fulfilled by higher levels of governmental order (ie, national defense, law enforcement) which would be disastrous if left to lower-level aspects of the community. In sum—and similar to the principles of solidarity and dignity of the human person--the proper application of subsidiarity is directed toward the advancement of the common good.
With regard to medical care, the concept of local control has been largely abandoned in favor of health system consolidation, algorithmic practice protocols, medical documentation and payment infrastructure that has homogenized the way care is delivered. What’s more, the infiltration of the public health concept of “population health” into the lexicon of medical education for student-doctors has further eroded the most subsidiarity-based of all relationships in medicine—the doctor-patient relationship. The rationale for these forms of collectivism in medicine is based largely on the idea that healthcare is too expensive and complex to be successfully managed at a local level—in other words, that some form of economy of scale is needed to realize cost containment and efficiency needed to deliver care across a country as large as ours.
There is a category error in this assumption that cost and complexity mandate a higher order of management over the administration of medical care. This error is that “healthcare” is a monolithic entity that is best managed and financed with similar mechanisms across all aspects of medicine. In reality, the different disciplines of medicine are inherently distinct with regards to the resources and personnel each needs to perform its function, as well as in the volume and circumstances of the demand for each. As examples, primary care is, by definition, the entry point of most people into the medical system. The need for primary care is often predictable and routine, and the services it provides are relatively inexpensive when compared to other specialty care. On the other hand, services such as trauma care and intensive care are less frequently used by most people, are more unpredictable, and cost more to provide. Therefore, it would follow that the financing models for each of these disciplines ought to be different from that of primary care.
By making these three care domains—the primary care office, trauma bay and intensive care unit—reliant on the same insurance-based model, the system drastically inflates the cost of primary care and severely limits the ways that care can be provided. Rather than burden primary care practices with the hefty overhead and confining regulation inherent in insurance participation, a decoupling of primary care from insurance and governmental payors actually frees physicians (and patients) from encumbrances and limitations imposed by those third parties. It restores primary care decision-making to the level of the doctor and patient—the lowest (and most appropriate) level of management in this most intimate of human interactions. It works hand-in-hand with solidarity by conferring the responsibility for the medical needs of people in the community to local agents, and it respects the dignity of the person by making primary care more accessible to all people, irrespective of whether they carry an insurance card or not. (In cases where a social safety net is necessary, patients—rather than state bureaucracies—ought to be the main decision-makers over the way resources are allocated.)
Locally responsive practices that respond to local conditions and the needs of patients. An economic model that decentralizes care and allows for ownership of care by patients and doctors. A practice model that does not exclude anyone on the basis of insurance networks or employment status. In summary, this is what subsidiarity in primary care medicine looks like. 

​--James Breen, M.D.

One of the key elements of Catholic Social Teaching is the principle of Solidarity. What does this mean to us in practical terms? And how is this applicable to the way we consider healthcare? Does the principle of Solidarity have any relevance to how we, as Christians, seek out (and--for medical personnel--provide) medical care?
The concept of Solidarity in Christian teaching is based on the idea that we are all called to care for one another, as sisters and brothers living in society. Justice and charity demand that we all work together to secure the protection and well-being of other members of our community, with special attention for those who are vulnerable or marginalized. As Pope St. John Paul II defined it, Solidarity is “a firm and persevering determination to commit oneself to the common good; that is to say, to the good of all and of each individual, because we are all really responsible for all." (On Social Concern, No. 38)
‘Now that all sounds very good’, you might say, ‘but how does this concept apply to medical care in a society like the United States, where there exist public assistance and social welfare programs to care for the poor?’
It is true that our country has developed a sizeable social safety net to account for the healthcare needs of materially poor Americans. Over the decades, this safety net has expanded to include an ever-larger segment of the American populace. At their inception in 1965, the Medicare and Medicaid programs were intended to provide assistance to the elderly and to poor Americans in need of healthcare. Over the years, the number and percentage of the American populace enrolled in these programs has expanded; they are no longer reserved for a small segment of marginalized Americans. As of 2022, Medicare and Medicaid comprised 24% and 19% of all US healthcare expenditures—the second- and third highest-spending entities after private health insurance. The implementation of the Affordable Care Act (ACA) in 2010, and the relaxing of eligibility requirements and freeze on Medicaid disenrollments during the Covid-19 emergency, have served as inflection points that greatly expanded the numbers of Americans covered by these programs.
Returning to the concept of Solidarity, it is important to remember that in its most authentic form, Christian solidarity is a matter of personal—not governmental—responsibility. Elected officials and bureaucrats may craft public assistance programs, but these do not substitute for the demonstration of true solidarity to our fellow men and women. On the contrary, one could argue that the encroachment of public payors (and commercial insurance payors) over the whole US healthcare system is one of the leading contributors to the unaffordability of basic services for ordinary Americans. This occurs when these government programs dictate payment schemes (ie, how much service providers will be paid for a given service), as well as the regulatory mechanisms that determine the conditions of payment. Because these processes (payment controls and regulatory oversight) are decoupled from the costs of providing services—and from the true need of the services by patients—the cost of healthcare tends to be inflated when the government plays a larger role in healthcare financing.
Sadly, one of the factors that has led to US primary care being driven into the ground has been the very government programs that ostensibly provide “access” on the part of a larger segment of the American population. The increase in practice overhead needed to comply with the rules and regs—not to mention the payment amounts dictated by programs (in the case of many Medicaid plans, less than the cost of providing care)—has forced many independent primary care practices to sell out to larger health systems to survive. This in turn has worked to the detriment of working-class Americans who lack private insurance and do not qualify for public assistance. In essence, the position taken by advocates of an expansion of Medicaid and Medicare is one that forces more people to depend on government assistance for even the most basic medical services—such as primary care.
In summary, government public assistance differs from the Christian notion of solidarity in three fundamental ways:

1. Government programs are incapable of expressing solidarity because they are, by definition, faceless and nameless bureaucratic institutions. They lack the capacity of building human relationships and compassion, which is the cornerstone of solidarity;
2. Public assistance programs are themselves a sort of political currency. Their expansion and funding are used as a lever of control to promote desired social outcomes, which is a far cry from solidarity’s foundation on justice and charity;
3. Rather than serve as a temporary assistance for needy individuals who are struggling to access medical care, governmental programs promote intergenerational dependence on government. An expansion of the numbers of people who depend on public assistance means that fewer people will be able to provide for their own needs without relying on government programs, which itself undermines the dignity derived from work and in meeting one’s own needs and the needs of the family.

A Christian approach to primary medical care is called upon to provide care for the vulnerable and marginalized in the local community. One of the ways it can respond to this need is by offering care that is economically accessible to working-class people, while also offering care to materially poor people who would not otherwise be able to access medical services. By viewing solidarity as a starting point, Christian primary care practices prioritize economic accessibility and welcome for the vulnerable as expressions of justice and charity. 

--James Breen, M.D.