"Why in the world can’t you Americans achieve a comprehensive national health-care program like the National Health Service we have and prize here in England,” asked a dear English friend in her letter accompanying the Christmas card she sent. “We just don’t understand your recalcitrance.” Now those are good questions. I will try to answer them in this column, and then send the column to her for her perusal and response.

Before I get to her larger questions, it is important to distinguish between the kind of system she prefers and the Obama healthcare reform proposals that have prevailed in Congress. These proposals, in spite of the overwrought charges brought against them, do not constitute the kind of comprehensive national health service she was asking about.

Nevertheless, these programs address several worthy goals: to provide more people—especially the poor, the working poor, and those with pre-existing conditions—with access to affordable health insurance; and to hold down the ever increasing cost of health care in this country. The latter is a widely shared goal, even though the Nobel prize-winning economist Robert Fogel thinks that the rising cost of health care is an accurate representation of what consumers want: they want expanded and more sophisticated health care and are willing to pay for it (See: “Forecasting the Cost of US Healthcare,” The American, 3 September 2009).

Onto the larger set of questions: Why don’t we have a national, single-payer health care system in this country? Is it just because the wealthier portion of our society has good access to health care and selfishly does not want to provide the resources for those who do not have what they have? Is it also because the large “special interest” groups make good money by catering to that wealthy portion of the population and serve it by blocking what really needs to be done? No doubt, there is an element of truth in both charges, but it seems to me the reasons we do not have a national, single-payer health care system are deeper and less self-­serving than those accusations imply.

I have lived abroad for five different years—as well as for two other extended times—and would not trade the medical care and my access to it that I enjoy in this country for the care provided by socialized systems that I experienced in other countries where I lived—England, Germany, and Slovakia. I would rank the German private/public mix the best of the three, with Slovakia coming in a lowly third, mainly because its public sector is impoverished after the collapse of the Soviet-imposed centrally-planned economy. In the middle is the British system, which we utilized many times over the span of the three years we lived in Cambridge, a university town with highly-touted medical services.

My assessment is that Great Britain has a system that distributes routine medical care pretty well but does not do well with serious illnesses.  Even in routine care, e.g., treating high blood pressure, it raises the threshold for treatment to a level that would appall most Americans. Further, the medical equipment, in my experience, generally is not up-to-date, and the buildings are dingy. Doctors are overburdened by people with small complaints. Specialists are very hard to reach. I would not want to be treated there for a threatening—but non-urgent—illness if I could go back home. If one needed emergency care, there would be little choice, though in Slovakia I had handy the telephone number and location of a hospital in Vienna. There are private—but very expensive—outlets in Britain and Slovakia. Ominously, Canada forbids such a private medical system.

However, even if Americans agreed that the medical insurance and care our system provides is adequate for most people, why do we not adopt a single-payer national system? Most Americans lack confidence in large, governmental organizations. They are seen as ponderous, expensive, and inefficient. They seem to do less for more, much like the public school system in most states and localities.

Still, shouldn’t we be willing to put up with some inefficiencies and loss of quality for a more just distribution, similar to what we do with public education? Here is where we get into deeper issues, one having to do with the “spirit of America” and the other having to do with different renderings of justice.

Americans prize independence and self-reliance far more than residents of countries that have socialized systems. The spirit of independence—just like the spirit of compassion and justice—flows from Christian notions of human nature and obligation. Humans are free to manage their lives, and most Americans believe they ought to cherish, protect, and express that freedom. It is better to be independent and self-reliant in managing their lives than to be dependent. Not only do they prefer doing things for themselves rather than having them done by others, they are convinced that they flourish best when relying on their own resources and capacities as much as possible. They also recognize that if one cedes independence to other entities, e.g., the government, those entities have greater power over one’s life individually, and over the life of the country generally. All of this applies to health care: it is better to take care of oneself and one’s family than to rely on others, including the government, to do so.

However, Americans also believe that when others cannot take care of themselves, there is an obligation to help them. Thus, we have free medical clinics along with food kitchens, shelters, rescue missions, and a vast array of private agencies to help those who cannot help themselves. Americans cultivate compassionate service for those who are dependent, even as they prize their own independence. They are ambivalent toward those who are able to help themselves but don’t. Even so, they tend to err on the side of helping rather than judging.

Yet most admit that this admirable system of private charity cannot cover everyone with medical needs.  Americans believe that the government must step in where private charity cannot do the job, but they also hold that those who receive assistance should be truly needy. They believe in “qualified” rather than “absolute” positive rights, that it is better to order justice toward qualified positive rights rather than absolute positive rights.

A positive right is one in which another is obligated to perform positive actions toward you. Every person, for example, has the positive right to be treated with respect, not merely or solely as a means. Indeed, such a positive right is absolute—all are due the positive attitude of respect.  But what about services, not just attitudes? For instance, what actions or services does the government owe citizens? And does it owe them to everyone?  Or to only those who show need for them? Are the rights absolute or qualified?

There is at least one absolute positive right to services that most Americans believe the government owes its citizens. The government is required to provide fitting education to every citizen through high school. That is a huge obligation and task which the government takes seriously. Fortunately, however, it does not require that everyone accept those public services. It allows private schools to educate students whose families are willing to pay for their private education, with the stipulation that those families also pay taxes to support the public system.

Should health care be an absolute positive right? It seems even more basic than education. Or should shelter be an absolute positive right? That seems even more basic than health. Not many governments—save totalitarian ones such as the Soviet Union—take on responsibility for such an array of absolute positive rights. And those that have done so often use the ensuing dependence of the populace to manipulate and oppress them.  No, it seems unwise and perhaps unjust to elaborate too many absolute positive rights. It makes for an overpowering government and a dependent people.

The American approach views the provision of health care as a qualified positive right. The government and hospitals are obligated to provide health care for those who cannot afford it or will not provide for themselves. The very poor have access to Medicaid and to charitable offerings. They also use emergency rooms and hospitals for their health care, which shifts costs dramatically to the hospitals, which pass them on to insurance companies, which in turn leads to higher premiums for individuals and institutions. This arrangement is not very efficient and leaves many people out. Even those who take advantage of this qualified approach do not receive consistently good medical care.

Thus, it would be far better to provide graduated vouchers or tax credits to those below a certain income level to purchase private insurance of the sort roughly equivalent to the kind I currently possess.  Such persons could then claim their positive rights within the same healthcare system that the majority of Americans enjoy.  They would not be relegated to a massive, inferior, government-run health care delivery system.

How to contain ever-increasing health care costs? I doubt if we will ever be able—or even want —to contain them dramatically. As Fogel argues, we want excellent, sophisticated health care and we are willing to pay for it, for the most part. But offering vouchers or tax credits to a large segment of the population would be expensive. Further, we would probably need some sort of government subsidized insurance for those with pre-existing conditions.

Some excellent ideas have surfaced.  Allow insurance companies to compete across state lines. Introduce tort reform to cut down excessive litigation. Reward health-care providers more for keeping people healthy than for treating them when they are sick. Encourage the kinds of highly efficient, integrated systems that have emerged in a number of cities. Encourage states to experiment with innovative approaches. Increase out-of-pocket co-pays so that customers cannot ignore the actual costs of what is provided for them. No doubt there are many others of which I am unaware. Further, we should look carefully at the mixed private/public systems of countries like Germany to find out how they are financed.

These are some of the responses I will offer to my English friend. It is not irrational to resist the introduction of a massive, untried, government-financed system. Most Americans enjoy some of the best healthcare in the world, but we have a problem with fairly distributing that fine service, as well as paying for it.

Finally, it is not unjust or uncompassionate to prefer an approach that features qualified positive over absolute positive rights as long as we are determined to treat those who qualify for them justly and compassionately.

Robert Benne is Director of the Roanoke College Center for Religion and Society.