Patience Hardebeck: Benedictine Health Care: Making the Preferential Option

SPIRITUALITY TODAY
Spring 1988, Vol.40 No. 1, pp. 52-67.
Patience Hardebeck:
Benedictine Health Care:
Making the Preferential Option

By transforming a hospital and nursing home into a center to assist the poor and develop community resources to meet health care needs, a group of Benedictines rediscover their heritage.

Patience Lea Hardebeck, O.S.B., Ph.D., is a member of the Benedictine Order. She is Coordinator of Clearinghouse Resources at the Benedictine Health Resource Center, San Antonio, Texas.

RECENTLY a group of Benedictine Sisters in Texas gave up their successful hospital and long-term care facilities to create the Benedictine Health Resource Center. This article is about the Gospel values and elements of Benedictine tradition which led the sisters to this action. The Center now coordinates efforts of health care professionals, clergy, and others in ministry to address the spiritual gaps, weaknesses, and inequities which debilitate contemporary health care efforts. It works with policy makers and organizations -- church and civic -- to inject Gospel values into the public policy arena when issues related to health care are at stake. It proclaims the Church's ethical stance on life-anddeath decision-making. It promotes personal responsibility for achieving and maintaining good health. It offers technical assistance to help community groups -- churches, community organizations, and health care centers meet their societal responsibilities. It provides training in organizing retreats for older persons, for professional and volunteer caregivers, and for those with whom they work -- persons who are chronically ill or disabled, and their families. It encourages outreach efforts. Its goal is health and wholeness for the whole human family.
NEW WINESKINS
In November, 1981, the Catholic bishops of the United States issued a pastoral letter on health and health care.(1) In April,1985, a group of Benedictine Sisters in Texas completed a study of that pastoral. They and the board of St. Benedict Health Care Center had already been engaged in a related discernment process assessing "signs of the times." These signs included the financial and staffing difficulties of operating a small private hospital and nursing home in the face of increasing federal and state intervention. On the one hand, growing numbers of for-profit health care facilities staffed by dedicated, competent professionals, were proving themselves capable of delivering quality care to those who could afford their services. On the other hand, increasing numbers of poor persons in the state were financially unable to pay for adequate health care or health care insurance.(2) The Bishops' pastoral had said, Health and health care are subjects that profoundly touch the lives of us all. One's ability to live a fully human life and to reflect the unique dignity that belongs to each person is greatly affected by health. Not only for individuals, but likewise for society at large, health issues take on important significance because of the intimate role they play in personal and social development. Complex in their ramifications and universal in their relevance, these issues are of concern to us all -- rich and poor, young and old.
Slowly, a radical vision became a radical possibility. Obviously, the rich have access to fine health care. The poor, however, often are unable to afford the kind of care that could enable them "to reflect the unique dignity that belongs to each person." Time and energy are needed in order to impact systems and make the kinds of changes that enable poor persons to have their health care needs met. Could it be that the Sisters should exchange their sponsorship of traditional health care ministries (hospital and nursing home) for sponsorship of new forms of health and ministry? Should they concentrate on developing structures and linkages which could help communities and organizations in their efforts to provide universal health access to adequate health care? Should the resources tied up in operating an institution be re-channeled into a ministry for promoting and developing programs to enable all persons -- particularly the poor -- to realize the fullness of their human potential?
Sister Mary Sapp, O.S.B., with board members of the Benedictines' hospital and nursing home began to explore the concept that a religious community's health care ministry, at this point in history, can do no better than to help economically poor people to secure their access to adequate health care. Sister Mary had administered the community's traditional health care ministries during the preceding twelve years, introducing demonstration programs as models and encouraging creative approaches for meeting the needs of elderly or disabled or chronically ill persons. She and the board were thoroughly familiar with the dilemma of wanting to provide care to those who are unable to pay, while at the same time being required to meet the institution's fiscal obligations.
Months of reflection and discussion ensued concerning this dichotomy between a desire to provide health care for the poor, and the financial limitations inherent in today's non-profit institutions in the U.S., and particularly in the state of Texas. Ultimately, these considerations led the board to suggest to the Benedictine Sisters that they divest themselves of the hospital, nursing home, and other programs operated through St. Benedict Health Care Center. They would then be free to channel their energies into creatively implementing the recommendations of the U.S. Bishops' Health Care Pastoral, particularly with regard to the poor.
Moving from the sponsorship of direct care into the sponsorship of an unknown quantity was a serious step. However, with Sisters' vocations to direct care at low ebb, and with operating costs and ethical dilemmas riding high, the Sisters agreed that a change was in order. They authorized a study of new possibilities for their health care ministry. Since operation of a Catholic hospital and long-term care facility was part of the group's identity, relinquishing the institution which they had painstakingly built was not easy. Yet, voices with a prophetic ring were citing the significance of the new, broader base developing in the health care field. Within the for-profit system, who would act as conscience? Who would disseminate knowledge of the Church's teachings relative to ethical decision-making? Who would form the disinterested link between private and public sectors in their efforts to provide services to homeless, or uninsured, or indigent individuals?
The Benedictine Sisters listened -- and said yes. The complex and difficult process of divesting themselves of hospital and nursing home was eased by concentration on the challenge of pioneering new forms of health care ministry. The new entity would be named "Benedictine Health Resource Center." Its target groups would be health care professionals, clergy, and other professionals in ministry, and also health care centers and community groups -- churches, and community organizations.
HEALTH, WHOLENESS, AND COMMUNITY
"Health and wholeness for all the human family" may at first sound more than a bit grandiose as a goal -- but no goal could better suit followers of St. Benedict. In his Dialogues, St. Gregory the Great recalls a time when Benedict, "according to his own description" saw "the whole world gathered up before his eyes in what appeared to be a single ray of light." Gregory interpreted that vision by saying, "Absorbed as he was in God, it was now easy for him to see all that lay beneath God. In the light outside that was shining before his eyes, there was a brightness which reached into his mind and lifted his spirit heavenward, showing him the insignificance of all that lies below."
If Gregory lived today, he might interpret the vision differently. Just as our present spiritual leaders are calling the nations to view one another as members of one family, so Benedict's vision can be a sign of the inter-connectedness of our world. Indeed, we all are "gathered up in a single ray of light" through the technology of video -- television, computers, and film.
Gregory spoke of him as "the Man of God, Benedict." Today, we speak of "the people of God," and truly, the whole world has been gathered up -- not for the vision of one man, nor of one group -- but for mutual inspection. First-world dwellers, especially, have pictures of a single world put before their eyes continually. For those dwellers who are following the rule of Benedict, these pictures confirm the value of a way of life which is familial, and which can allow the achievement of "spiritual peace and simplicity of heart in the midst of the technological complexity of contemporary culture . . . ."(3) However, the present picture is not of a world that has achieved any kind of peace, nor of structures that reflect simplicity of heart. Rather, the human family is divided; some members are writhing in pain and others are wrapped in pleasure; some members have the best of everything, and others are dying of deprivation. Benedictine vision looks past the pictures of division, toward a vision of wholeness in which the human family mirrors the Trinitarian family, interacting in continual healing and love.
THE SEARCH FOR GOD AND HEALTH CARE MINISTRY
Benedictines don't have particular 'works': ". . .monastic existence is a form of religious life having no secondary end. It is specified solely be consecration to God .... Tradition assigns no other end than ...'to seek God' or 'to live for God alone."(4) So when a group of Benedictines embarks on a 'work; it can be expected that the work will be seen as a means of seeking God. The Gospels tell us that God is found in Jesus -- and further, that we meet Jesus through acts of mercy: "...whatever you do for the least of these others, you do for me; ...whenever you neglect another, you neglect me" (Matt. 26: 40,45). Therefore, when Benedictines see that a work neglects some members of the family who are poor, while providing handsomely for those who are rich, they must step back and re-evaluate their participation in the work.
Health care delivery in this country (and in most of the world) is one such work which needs looking at. Why? Because present structures create and perpetuate inequities, the deliverers become, paradoxically, promoters not of health, but of illness. When disparity exists between the kinds of care available to those who can pay and those who cannot, followers of Christ find themselves at one of those crossroads for which he prepared us: "...invite the poor, the crippled, the lame, the blind; that they cannot pay you back means that you are fortunate ...." (Luke 14:13).
INFLUENCING PUBLIC POLICY: REMEMBER TOTILA
If Christian life is for ministering to those who cannot repay us, then what forms of health care ministry should concern the Christian community today? In their 1981 Health Care Pastoral, the bishops of the United States made several concrete suggestions concerning the kinds of actions most needed in the health care field. One of these recommendations is "to actively participate in the shaping and executing of public policy that relates to health care."
Does grappling with health-related public policy seem too large or too secular a task? Benedictine tradition is one of facing large, secular-looking tasks, and through God's blessing, winning out. One example is St. Gregory's description of an encounter between St. Benedict, the Man of God, and the Gothic warriorking, Totila. In a dramatic scene, Benedict "rebuked the king for his crimes .... 'You are the cause of many evils; he said. 'You have caused many in the past. Put an end now to your wickedness ....' From that time on he was less cruel ...." In facing a ruling power and calling for conversion, Benedict took a risk on behalf of spiritual health and wholeness, both for the king, whose spirit was in danger of being engulfed by his promotion of cruelty, and for the people whose well-being was being threatened by that cruelty.
Public policy can be cruel when it promotes and endorses structures which keep some members of the human family from caring equally for others. In the face of unjust structures, something has to give -- either the structure or the health of the family. But Christians cannot compromise even one family member's health in favor of any structure. This is why Christians are called to provide the catalyst which is needed to move policy makers to do the right thing for those who are least powerful.
Efforts on behalf of the voiceless can be an effective way of promoting health in the human family through solidarity, union, and communion. People who have been entrusted with power can be urged to encourage or at least, allow, the rise of new or reformed structures to replace those structures which oppress. Obviously, we are not called to imitate Totila. Certainly, we are called to encounter cruel injustice, as did Benedict, and to be a leaven which enables the health care community to rise to its best in providing means of adequate, universal health care for everyone.
LAZARUS AND THE ALLOCATION OF RESOURCES
Seeing Lazarus sitting outside the rich man's gates (Luke 15:19), what follower of Jesus would pass Lazarus and go inside to minister to the rich man? Not that the rich man does not need our attention. He does, and badly. He needs our attention to his neglect of Lazarus. As for ministering to his needs, he can purchase whatever service he wishes, and many will be on hand when he calls, but the Christian is a family builder with two jobs to do -- first, to see that Lazarus gets food, water, and shelter, and second, to call to the rich man's attention that Lazarus is his brother, and that the riches with which he is entrusted belong as much to Lazarus as they do to himself. Of course, while this may endear us to Lazarus, we may get quite a different reception from the rich man. Nevertheless, if we are committed to the concept of human family, we will not leave that rich man in peace.
Today, rather than individuals it is institutions, corporations, and for-profit systems that are busily gathering up the earth's resources and bringing all the earth's wealth into their own barns and warehouses to the detriment of the poor. While individuals may be able to prick the conscience of corporations, the best hope probably lies in coalitions of people who band their organizations together to do so. The Benedictine sense of family can support these coalitions in their efforts to promote justice, and can scold those groups that are holding the goods that are needed by the inarticulate, needy, and desperate Lazarus groups at the gate.
St. Gregory tells us that once Our Lord appeared to a priest who lived near Benedict in the days when Benedict was indigent, living in a cave. The priest was preparing a fine meal for himself when Jesus stood before him and asked, "How can you prepare these delicacies for yourself while my servant is out there in the wilds, suffering hunger?" This is what needs to be asked wherever feasts are being prepared for some, while others are hungry, homeless, and alone in their illness. This is the question which the bishops addressed in their 1981 Pastoral Letter on Health and Health Care. Their call was to a broader audience than the health care community of doctors, nurses, and hospital administrators. They addressed us all, inviting us to consider ways in which the practical application of Christian values can transform institutions of various kinds.
How would some of our familiar structures and programs appear, viewed through the twin lenses of social justice and Benedictine spirituality?
RETREATS AND ASSESSMENT OF NEEDS
Just as water flows freely among rocks and reeds, so does the invitation to live in communion flow freely among both the strong and the frail. In small, integrated communities, interdependence is obvious, just as in small, spring-fed ponds, symbiotic relationships are easily observable. However, the world of today is no small pond, and just as in long rivers fed by many streams the free-flowing waters can tumble rocks against fragile plants, uprooting and breaking them, so in the rush of strong currents which influence all of our lives today, the more frail members may be bruised and broken, unless some force intervenes building dams and creating lakes, thereby overcoming disorder aiRd creating peace.
A time of retreat can be like a dam. It can stem the flow of confusion, and create a peaceful space in which people can settle into God, where they will see more clearly their own blessings and their own needs. After all, only individual persons can say how they feel they stand with God. Retreat times can become "needs assessment" experiences and can provide a chart for moving into the future.
Retreats, like Shakespeare's mercy, are "twice blessed," blessing both those who give and those who receive. Training people to offer retreat-type experiences to chronically ill or disabled parishioners can effect this kind of double blessing. Such experiences of thoughtful interaction among parish members can help to create an atmosphere in which the strengths and weaknesses of each can meet, heal, and be healed. Ideally, planning and follow-up sessions would draw together those who are ill or disabled with church leaders and volunteers. Once begun through meaningful, shared faith encounters, this interaction can then overflow, as it should, into daily life.
THE NEEDS OF CHRONICALLY ILL AND DISABLED PERSONS
Experience with persons who are chronically ill shows that their primary spiritual needs match the primary spiritual needs of us all -- the need to love and be loved, the need to accept and be accepted, the need to belong to a family. However, chronic illness can militate against physical presence to others. The person who is homebound and caught up in a painful or weakening illness can feel cut off and alienated. The same can be true of persons who live with disabilities - mental, physical, social, and spiritual handicaps. Normally, the experience of God as Loving Parent is known through experiencing others as Loving Sister/Brother. But the absence of manifest caring and attention can result in feelings of desolation and abandonment.
To the extent that any of us are desolate, we are "excommunicated." For Benedict, excommunication was the harshest of punishments, reserved only for the recalcitrant (Rule, chapters 23-27). Benedict understood that while excommunication provides an opportunity for people to reflect and be converted, on the other hand, it can also be a time in which a person can be overwhelmed by excessive sorrow" (chapter 27). Therefore he tells the abbot to "exercise the skill of a wise physician and send in senectae, that is, mature and wise persons who under the cloak of secrecy may support the wavering one..." (Ibid).
THE NEEDS OF CAREGIVERS Benedict did not expect one-sided efforts, however. In his chapter on care of the sick, he follows his first sentence which calls for a Christ-centered approach to the sick, with a second sentence which reminds sick persons that they have obligations toward their caregivers: "Let the sick on their part bear in mind that they are served out of honor for God, and let them not by their excessive demands distress those who serve them..." (chapter 36). In fact, throughout the Benedictine Rule, attention is focused on those who are serving and providing care: "Let those who are not strong have help so that they may serve without distress" (chapter 35, on kitchen servers). In order that the weekly reader not be weakened through prolonged fasting, "the one who is reader for the week is to receive some diluted wine before beginning to read ...." Those in charge of the guests' kitchen should receive additional help when necessary "so that they can perform this service without grumbling."
Benedictine concern for the spiritual well-being of both frail and stronger members can be applied to the broader human family. Caregivers -- whether by choice of profession, by free voluntarism, or by dint of family circumstances -- need support if they are not to experience "burnout." They need help if they are not to find themselves beginning to "grumble," and perhaps, to abuse. After all, how can a person believe in the solidarity of the human family if no help is given in times of stress such as that occasioned by round-the-clock attention to the needs of a frail family member?
RESOURCES OF THE ELDERLY: PARISH POSSIBILITIES
A recent Notre Dame Study of Catholic Parish Life(7) indicates that parishes could do much more both in outreach and in providing support, especially to families during difficult times. We hear complaints of parishes being considered "spiritual filling stations." Perhaps the label is unwittingly deserved; perhaps not. Nevertheless, an understanding that spiritual health is bound up with physical, mental, and emotional health could motivate church leaders to be more comprehensive in their approach to individuals and to the concept of the parish as a family.
What are some broadening things parishes could do to respond better to the health needs of their members? First, they could become centers for training people who are willing to help take care of homebound individuals, and who can give some time to providing respite or relief to full-time family caregivers. Parishes could also link those in need with those who can help. They could become health resource centers -- centers for meaningful community building. Parishes could encourage networking among churches, community organizations, and health care facilities. Finally, they could create an atmosphere in which parishioners have access to ways for making known their needs, and for organizing to meet those needs.
The bishops' pastoral pointed out that the Catholic parish is a visible and integral part of the local community, with significant roles to play in the health apostolate. By recognizing how intertwined are our spiritual, psychological, and physical states, the parish can become leaven in the community, fostering a spirit of neighborly concern among civic as well as religious leaders. Parishes can encourage health education programs and preventive health care services at the local level.
Who in the parish has time for these kinds of activities? Older persons can be great resources. Retreats for older persons often surface their desire to participate and to share their talents, and their sense that meaningful activities are not readily available in most parishes.(8) Why is it that older people -- natural teachers and healers in the human community -- tend to be left out of meaningful consideration when groups are looking for organizers, administrators, and implementors of important work?
We have many stereotypes of older persons: frail, dependent, in nursing homes, isolated and neglected by families too busy to care. Yes, we have older persons that do fit in those categories, but so many that do not. Most older persons reside within the community and range from the very independent who manage without assistance (in fact, they may be your parents, your next door neighbor, your supervisor, or your president) to the very frail, cared for and supported by family and friends... (9)
St. Benedict took an intergenerational approach to community. Age is not a factor in a person's responsibility to seek God daily, and to turn to God continually. In speaking of frail, elderly members, he also refers to frail younger members. In the "Instruments of Good Works" (chapter 4), his seventieth counsel is "Respect the elders and love the young." Interaction is the Benedictine norm, not the exception.
'Respect' comes from the Latin re-specere: to look again. We must look again at what older people have to offer from their lives, their experience, their wisdom. We need to receive from older people their love which has matured through years of experience with life. Given their rightful place in the community as teachers and healers, older persons form a marvelous pool from which to draw in seeking leaders who can connect community members with one another, especially in connecting chronically ill and disabled members with the rest of the community. Furthermore, they can make a powerful impact concerning public policy and in many other arenas to which they have access.(10)
Older persons can especially benefit from retreats which help them review God's active presence in their lives. Recognition of God's faithfulness leads to celebration of that faithful love, and a desire to share. It is then a small step to find opportunities for older persons to demonstrate their love and concern for others in need. Many older persons can visit and be physically present; others can offer telephone reassurance and letter-writing. All can be a sign of God-with-Us.
As children, we are at the mercy of our elders. As elders, often we are at the mercy of our children. The years between are most fruitful if they are spent in a spirit of family-building. This is true health care -- to work for unity, wholeness, a sense of personal responsibility for ourselves and of societal responsibility for one another. Parishes can model this unified approach to the wellbeing of both their immediate and broad membership. As leaven in the wider community, parishes can use their connections to activate the conscience of others, and to insist that we, as family, are meant to interact lovingly .
...AND AT THE HOUR OF DEATH
Strong or frail, we all die. The hour of death can be the best gift a person gives to others. Unfortunately, this time of transition, which can be the highlight of a life well lived, can also be exploited. All manner of technical interventions and experimentation is on hand today; making decisions about treatment can be traumatic for family members, for concerned professionals, and most importantly for the dying persons themselves. Much pain could be foregone if all involved - ethics committees, physicians, clergy, family members -- were aware of the Church's teachings on extraordinary means and personal autonomy. Volumes of writings -- entire courses -- are built around the topic of decisionmaking and terminally ill persons. Suffice it here to say that the spirit is in jeopardy when the hour of death is exploited. Joy, peace, mildness -- all are threatened, and for this reason, we have the Church's teachings. Making these teachings known is essentially an act of mercy which can lead to avoiding pain and perhaps despair for those who are dying, and which can give peace of mind to the rest of the family. Those who have been blessed with opportunities to learn the Church's stand on healthrelated issues today have at hand a great opportunity to promote spiritual well-being by passing on what they know to others, who in turn can both act and teach out of that knowledge.
THE PREFERENTIAL OPTION
Today, those whose access to the fullness of life is most jeopardized are frail persons who are economically poor. In a spiral of destruction, poverty attacks fragility, and attacked fragility in turn becomes less and less able to survive. The "least among us" seldom receive timely health care because, increasingly, they cannot afford to pay for any health care.(11) People with ready access to care can nip illness in the bud, or better yet, practice preventive health care and avoid unnecessary illness. On the other hand those who cannot afford health insurance often reach a state of crisis before health care intervention is sought.(12) Even then, first-rate health care is not within the grasp of the indigent person, who is relegated to a second or even third "tier," while paying clients are taken care of in the first tier with no cost spared. Lazarus sits outside the gates, while within, the rich person is made comfortable and showered with the latest technological benefits.
Herein lies the tension which moved the U.S. bishops to observe that "...it is clear that the debate of health care issues in America includes a certain conflict over basic moral values ...." They continue, "Catholics, and especially Catholic scientists, must bear a special witness, standing firm to defend the basic dignity of the human person. It is our role to promote Christian values, to keep them present in public debate, and to join hands with others who seek to promote such values." First of all, as we have seen, there is the question of allocation of resources stewardship -- and secondly, there is a whole field of ethical questions which revolve around decision-making: Who lives? Who dies? Who pays?(13)
The human family today is clearly neither healthy nor whole. Health and wholeness are manifested in peace. Where peace is absent, the need for healing is present. Where family members live in peace, frail members are not in danger of being neglected or bruised by stronger members and the stronger members do not allow one member to be overburdened while the others go unreflectingly on their ways. In a true family, all are valued, and all are involved in creating a mutually supportive, nurturing, outreaching, loving situation. This conviction makes all things possible -- letting go of a good work for the sake of a better; braving powerful opposition on behalf of the powerless and the weak, and rousing ourselves to the challenge:
Let us get up then at long last, for the Scriptures rouse us when they say: It is high time for us to arise from sleep. Let us open our eyes to the light that comes from God, and our ears to the voice from heaven that every day calls out this charge: If you hear his voice today, do not harden your hearts. And again: You that have ears to hear, listen to what the Spirit says to the churches. And what does he say? Come and listen to me, children; I will teach you the fear of the Lord. Run while you have the light of life, that the darkness of death may not overtake you... (Prologue to the Rule of Benedict, 8-13).

NOTES

"U.S. Bishops' Pastoral Letter on Health and Health Care," Origins, December, 1984, pp. 396-402.
Final Report, Task Force on Indigent Health Care, State of Texas, December, 1984.
The Rule of St. Benedict, 1980, "The Rule in History," p. 151.
"Benedictine Spirituality," New Catholic Encyclopedia (New York: McGraw-Hill, 1967), vol. 2, p. 285.
"...one's ability to live a fully human life and to reflect the unique dignity that belongs to each person is greatly affected by health. Not only for individuals, but likewise for society at large, issues take on important significance because of the intimate role they play in personal and social development. Complex in their ramifications and universal in their relevance, these issues are of concern to us all -- rich and poor, young and old." "U.S. Bishops' Pastoral on Health and Health Care," ed. cit., pp. 396-402.
The Benedictine Sisters owned and operated St. Benedict's Nursing Home in San Antonio, Texas, between 1926 and 1984: "The scope of services provided by St. Benedict Hospital and Nursing Home makes this private, nonprofit facility unique in the San Antonio area and possibly within the state and nation as well. St. Benedict's operates a hospital, a nursing home, an adult rehabilitative day hospital/day care program, and a home health agency." From "Offering Continuity of Care for the Elderly," by George R. Beringer and James R. Hardman, Hospital Progress, September, 1978.
David Leege, "Parish Organization: People's Needs and Parish Service," Origins, August 28, 1986, pp. 206-16.
Sister Bernardine Reyes, O.S.B., directress of BHRC's Growth in Faith Program, has piloted retreat programs for older persons in rural and urban areas and in the Anglo and Hispanic communities. In every instance she finds older people eager to contribute to the community, and desirous of parish structures which would allow them to do so.
Interview with Sister Mary Sapp, O.S.B., on services and programs to help older persons remain independent as long as possible, Benedictine Health Resource Center, 1987.
Note the 60,000 member national Grey Panther movement, started by Maggie Kuhn in 1970, which addresses the health care system, Social Security system, world peace, shared housing, abolition of racism, sexism, ageism .... (Sarah Pattee writing for the San Antonio Light, June 6, 1985.)
The U.S. Census Bureau estimates that more than 35 million persons live outside the health care system.
More than half of those without health insurance protection are employed, according to a study by the Robert Wood Johnson Foundation in Princeton, N.J., a foundation which supports health care research. Stephen Rassenfoss, a Texas news reporter, learned in an interview with Drew E. Altman, deputy director of the Foundation, that "All the evidence is [that] the people without health insurance get dramatically less health care than those with it. When they do go for care, they are much sicker and the care tends to be more expensive."
See Joseph A. Califano, Jr., America's Health Care Revolution: Who Lives? Who Dies? Who Pays? (New York: Random House), 1986.

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