By Ann Neumann 

Use hospitality one to another without grudging. 1 Peter 4:9 KJV

I have a friend, Chris, who lives in my neighborhood and pours me pints at my local bar. He’s blonde, gregarious, and likely to say the damnedest things. In my close neighborhood in Brooklyn, Chris and his wife, Sue, are fixtures. Everyone knows them, they’re community.

Chris just found out he has a tumor in his brain that’s 37.4 millimeters in diameter. Cancer. Stage four. Melanoma. And growing every day. Chris doesn’t have health insurance. Neither does Sue, who is a self-employed toymaker. Like millions of others, they’ve been priced out by a system that awards health care coverage to the wealthy and the well-employed. The neighborhood is collecting funds, at The Chris Pish Brain Trust, to keep Chris and Sue under roof and out of hunger while they both focus on Chris’s treatments. They’ve just successfully collected enough for a “down payment” to the hospital for his brain surgery. The successful fundraising is a moving example of how a community can come together. But it shouldn’t be necessary. And it’s not enough.

Larger social systems, like disability insurance and Medicaid, should make our local collection efforts obsolete, or at least limit them to meals, visits and whatever errands and support a neighbor can provide. But, across the nation, they don’t. Why? Chris’s case and a close examination of charitable, community-based health care institutions–hospitals–exposes the inadequacy of charity to provide full and equal health care security to all of us.

The Affordable Care Act’s open enrollment and launch have passed, yet more than 40 million Americans are still without health insurance. For those who don’t qualify for free coverage but have been getting by on a wing and a prayer, those who are already sinking in the stagnant economy, Obamacare is still expensive. The fear of squeezing an extra couple hundred dollars out of the monthly budget, for many, outweighs the fear of a broken leg… or the unthinkable, catastrophic illness.

In an op-ed for the New York Times on January 1, the day Obamacare went into effect, Michael Moore highlighted the primary flaw of the program. It’s pro-business. Insurance companies (“By 2017, we will be funneling over $100 billion annually to private insurance companies.”), drug manufacturers (like “Novartis, which charges leukemia patients $90,000 annually for the drug Gleevec,”), and high-paid executives (“like Stephen Hemsley of UnitedHealth Group, who made nearly $102 million in 2009”) are all reaping indecent financial gains from our current health care system. Obamacare will only begin to reform this institutionalized corporate profit. Moore writes:

My friend Donna Smith, who was forced to move into her daughter’s spare room at age 52 because health problems bankrupted her and her husband, Larry, now has cancer again. As she undergoes treatment, at least she won’t be in terror of losing coverage and becoming uninsurable. Under Obamacare, her premium has been cut in half, to $456 per month.

Let’s be honest. How many people can actually pay $456 a month? When they’re sick and unable to work? And why should they when we know, from other countries, that back-breaking debt or bankruptcy don’t have to be the price of good health care. I agree with Moore that Obamacare is the right step toward the most efficient and effective health care system, single-payer. But the larger question of how to move from our current system, rife with run-away pricing, and  inequality, is more nuanced and complicated than Moore acknowledges.

While we’ve learned to expect profit-driven priorities and behavior from corporations, hospitals, the front line of health care provision, the life-saving pillars of our communities, continue to be seen as benevolent and noble institutions. “For many, hospitals still embody the human gift relation, a moral commitment to giving and receiving removed from the purely commercial realm and its cold, bottom-line mentality,” writes Guenter B. Risse in Mending Bodies, Saving Souls: A History of Hospitals. The idea that providing care entitles hospitals to special status comes in part from the origin of the modern hospital.

Both hospital and hospitality (hospitalitas) are derived from the Latin hospes–a host, a guest, a foreigner, a stranger. Hospitality, according to the philosopher Jacques Derrida, “is absolute in that it requires one to give all one has to another without asking any questions, imposing any restrictions, or requiring any compensation” (Mark W. Westmoreland, “Interruptions: Derrida and Hospitality”). For this reason, if we use Derrida to think of hospitality as an ethics and a culture, hospitality can be seen as a statement of social order that denies the self (the host) and welcomes the guest as the new person in charge, the one who decides how to use the home and it’s resources. To give unconditional care to our family and friends is easy; to give to a stranger, no questions asked, no limits placed, is no easy task. Yet this is the greater demand of hospitality. The meaning of hospitality and social obligation are far from static. Over the centuries, their meanings have been shaped by new social orders and beliefs, not the least of which, Christianity.

Homes for the sick existed long before the advent of Christianity but by the time the Roman Empire converted, hospitals were the domain of the Church, a manifestation of its mission to care for those in need. Mark 25:34-40 lays it out plainly:

“Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’

Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?’ “The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’

But the Christian concept of charity altered the original meaning of hospitality by establishing a hierarchy between giver and receiver. Even as Christ, in the ultimate act of charity, offered up himself for sacrifice for our sake, he was elevated as a representative of all humanity. Charity, then, relies on the continuation of a hierarchical relationship. We get something for our sacrifices, our acts of generosity, our extension of kindness. Or as Zizek puts it, charity “allows the capitalistic system to postpone it’s crisis.”*

Charity is a pretense that has allowed capitalism, the monetization of everything, to quietly seep in. It divides the giver from the non-giver and the giver from the receiver.  It looks and sounds like hospitality, but it has a price, whether that be status or rights or, in contemporary America, an impossible, often debilitating fee. “The only hospitality we have ever encountered in the West is conditional,” writes Westmoreland. Charity, or conditional hospitality, makes us feel good but it doesn’t solve the underlying problem of inequality, it only masks it.

One new provision in the Affordable Care Act that unmasks the commodification of charity is the requirement that hospitals report their itemized charitable activities every three years.

This matters. As Elisabeth Rosenthal wrote at The New York Times recently, “many experts argue that most hospitals today do not deserve their tax-exempt status.” Non-profit hospitals–of which there are 2,894, according to the American Hospital Association–are not required to pay federal or state income taxes. Rosenthal reports that such taxes would amount to more than $12 billion a year.

A pending case in Pennsylvania highlights how non-profit hospitals have chosen to spend their cash. The city of Pittsburgh is challenging the University of Pittsburgh Medical Center’s tax-exempt status in court. From Rosenthal’s article:

“Its commitment to charity is dwarfed by its preoccupation with profits,” E.J. Strassburger, the city’s lead lawyer on the case, wrote in a letter to the city solicitor. He said that the hospital failed most, if not all, of Pennsylvania’s criteria for a tax-exempt charity, and that its annual report described it as a “$10 billion global health enterprise,” with excess operating revenue of nearly $1 billion and reserves of more than $3 billion. The institution paid 20 executives more than $1 million annually, he said.

Qualifying for tax-exempt status turns out to be easier than you’d think. Lawyers and researchers are beginning to ask what, exactly, the hospital considers “charity care and community benefit.” The answers are telling.

According to a study published last April by the New England Journal of Medicine (and referenced by Rosenthal in the article cited above), hospitals have been categorizing their charitable works on tax forms since 2009, when the IRS made it mandatory. The study, led by Gary J. Young, analyzed data from 1,800 hospitals and found that their total charitable giving came to a surprisingly small 7.5% (with a range of 1% to 20%). Young and his team also found that the acts hospitals considered charitable weren’t really what many would call giving back.

Sure, providing local immunization programs and contributing to community activities count. But what about “health-professions education” (i.e. paying residents and interns… which, by the way, might explain our escalating doctor shortage, despite an annual hospital subsidy, by Congress via Medicare, of $10.1 billion)? Even “clinical services provided at a financial loss” is questionable when you consider how that financial loss is tabulated. “If a hospital forgives a $3,000 bill for three stitches for a poor patient, how much of that should be counted as charity if the charges are greatly inflated?” asks Rosenthal.

Which brings us back to my friend Chris. What about “unreimbursed costs for means-tested government programs” like Medicare and Medicaid, which pay only a part of the total hospitals would otherwise charge patients or their insurance plans? Yes, charity. For example, to keep the math simple, let’s say that Chris’s hospital sends him a bill for $900,000. Even if Chris and Sue negotiate with the hospital to reduce the bill to $600,000 (which makes one wonder what actual costs for materials and services are), that’s an enormous amount of money to raise. If, after months or years of unsuccessfully trying to collect the total, the hospital could write it off as “charity”–and therefore secure its continued tax-exempt status.

Charity, then, is really a means of continuing our inadequate and entrenched system of health care inequality because it offers care and demands money (and submission to the charade of benevolence) in return. Could the strengthening of Medicare and Medicaid, could the establishment of a single-payer system move our culture toward hospitality that is unconditional? I don’t know. But it would save my friends from the current plight, of scrambling for dollars to live.

In the meanwhile, I know two strangers who need you. You can donate here.

**

Do religious hospitals provide more charity? How about the 645 Catholic hospitals in the US? Do they receive more funding from Catholic sources? In my next column, I’ll discuss a timely new report, jointly produced by the MergerWatch Project and the American Civil Liberties Union, that examines the ways in which Catholic hospitals threaten access to reproductive health care, despite providing no more charity than their secular counterparts. “Miscarriage of Medicine” was released in December. You can read it here.

*Zizek, Slavoj, Living in the End Times (Verso, 2010), page 240: “What this amounts to is nothing less than an elevating of figures such as Soros or Gates into personificatins of the inherent self-negation of the capitalist process itself: their charity work–in the form of immense donations to public welfare–is not just a personal idiosyncrasy. Whether sincere or hypocritical, it is the logical end-point of capitalist circulation, necessary from the strictly economic standpoint, since it allows the capitalistic system to postpone its crisis.”

Ann Neumann is a Visiting Scholar at the Center for Religion and Media at New York University and contributing editor at The Revealer and Guernica magazine. She’s written for Guernica, New York Law School Review, Bookforum (January 2014), Lapham’s Quarterly, Religion & Politics, Killing the Buddha, and The Nation, among others. She’s appeared on NY-1 News, WBAI radio and Voice of America and taught journalism at Drew University. Neumann’s chapter on class and hospice appears in Living with Class: Philosophical Reflections on Identity and Material Culture (Palgrave Macmillan, December 2013), edited by Brian Seitz and Ron Scapp. Neumann is currently writing a book about a good death.