Subsidiarity in medicine—What is it and what does it look like?

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.