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"Earning" Health Care

The second comment on my post about the new term "welfare health care," used to denigrate a subsidized health program for working people, asked, "What name would you adopt for giving people a service they don't earn?"

I was a little glib in my late-night response: "Justice." So let me put it another way: In what sense can a person who works 40 hours a week at Costco and gets health insurance be said to have "earned" it, while a person who works 40 hours a week at Wal-Mart and does not get health insurance has not "earned" it??

I'm hardly radical on these issues. I'm not a an advocate of explicit redistribution of wealth, or a socialist. I'm steeped enough in the tradition of negative liberty that I don't speak of health care as a "right." (Rather, it is a positive benefit that, by democratic processes, a society can choose to allocate or guarantee -- and as a citizen in that process, I would argue for broad allocation.) I've come to appreciate the revolution in social policy in the last two decades under which the benefits of the social safety net, including health care, are tied to work, rather than need need.

Providing health care for everyone is a difficult problem to solve. Subsidized programs like Minnesota's are a stopgap to deal with the tremendous uneven-ness in employer-provided health care. I accept that there will be gaps and unfairnesses in just about any system that is politically viable and/or that accepts a continued employer role in health care.

But what I cannot understand, and never will, is an ideology such as the commentor's, or Governor Pawlenty's and much of what prevails in what is still known as "conservatism," that holds that these inequities and gaps are somehow right and proper, part of some cosmic justice under which those who get health care have "earned" it and those who don't have not.

Posted by Mark Schmitt on January 30, 2005 | Permalink


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What's hard to understand about "I got mine; tough luck, sucker?"

Ok, that's a little flip, but nonetheless it does seem to represent a goodly portion of the leadership in Republican councils these days (e.g. Stephen Moore and Grover Norquist as well as the elected ones).

Posted by: Linkmeister | Jan 31, 2005 12:49:22 AM

But it's also fear: if these benefits are not "earned" and "deserved" due to hard work; if those who do without do so not because they are lazy or foolish or irresponsible, but because of factors beyond their controlthen their own privilege becomes rather terrifyingly contingent, and they must face the fact that something must be doneheck, they must do something themselvesto right a wrong. Scary. Possibly harmful. Much easier and better to sneer about desert and if you end up wrecking perfectly serviceable programs to bolster your easier, better, comfortable world-viewprograms that you'll be missing if you ever find out just how contingent your station in life really iswell, gosh, that's what irony's for.

Posted by: Kip Manley | Jan 31, 2005 1:16:21 AM

I am a redistributionist. I don't think that our resources are distributed wisely and humanely throughout our population and something needs to be done about it.

Posted by: la | Jan 31, 2005 1:36:56 AM

As a product of The Great Depression (altho not remembering experiencig same), I, for the first time, am about half way through John Steinbeck's "The Grapes of Wrath"

I see parallels in the way the owner of a campsite (he charged fifty cents a night for a family to stop) talked about those folks traveling to California (he blamed them for their problems and called them bums) and the way Republicans, neo-cons, righties talk about health care and other safety net programs.

We used to be able to have a public dialogue on these subjects, but since the advent of Gingrich, all we seem to have is shrillness, who can yell the loudest.

Is it that those who would benefit most by social programs are too busy working 2 or 3 jobs with no benefits to pay attention?

Posted by: Chief | Jan 31, 2005 8:00:40 AM

We have health insurance that is tied to working for an employer. Among many proglems, the most glaring is the fact that when an employee becomes ill, he/she no longer can work and is dropped from the insurance program. The employee can buy into a exorbitantly costly program to extend insurance if they can afford it. Most cannot and are therefore without coverage at the time they need it most.

Our health care system was designed by sadists.

Posted by: pagoff | Jan 31, 2005 9:11:40 AM

"I'm not a an advocate of explicit redistribution of wealth...."

This reflexive cringe by an at least mildly left-wing intellectual on his own blog says something about how much building the left needs to do. Not that Mark is unintelligent in any way, I (unfortunately) know where he was coming from here. Just that the basic tenets of a decent left have been so discredited in the public discourse that a great deal of bowing and scraping to the gods of the market is required before they are introduced into conversation at all. This whole post is a sensible and passionate argument for explicit redistribution (Mark's health care programs would presumably be funded by progressive taxation, no?) that the majority of Americans would probably agree with. Yet here he is apologizing for it right at the start. We never see the Repubs apologizing for their increasingly outrageous raids on the public treasury in the name of the dynamic, economy-driving entrepreneurs they purport to serve. I think many hard-working Americans at some level simply believe they no longer deserve government benefits, while the rich do. This is a deeper problem than policy arguments.

Posted by: Marcus Stanley | Jan 31, 2005 9:50:52 AM

It's easy to understand the hard-Conservative view: money equals merit, or money IS merit, and if you've acquired money legally, you deserve it. You owe nobody else nothing at all. Luck has nothing to do with your success. Connections have nothing to do with it. Inheritances have nothing to do with it.

And if you don't have money/merit, you deserve that, too.

Posted by: Summit Funk | Jan 31, 2005 11:59:56 AM

I think there's a bit of an unspoken false dichotomy here: the idea that either you must believe that money is always justly proportioned or you must believe that the often-arbitrary proportioning of money is explicity unfair (rather than arbitrary).

I work two jobs, with no health care of any kind. Am I less deserving than everyone who has health care, or makes more money? Probably not. But I don't think that means that this is actively unfair; it's just unfortunate for me, in the same way that it's unfortunate for me that I wasn't born into the Rockefeller family. Like Mr. Schmitt, I don't see health care as a right; unlike Mr. Schmitt, I don't subsidized health care as being a pragmatically wise choice. If the government weren't taking a substantial chunk of my fairly pitiful paycheck each month, I could pay for health insurance out of pocket several times over.

Posted by: E. Naeher | Jan 31, 2005 2:57:14 PM

If health care is a personal negotiation with your insurer, you are one serious illness from being uninsurable. If you get a diagnosis of cancer and are many 10s of thousands of dollars from health, what is to prevent your insurer from deciding you are no longer a profitable risk in your group of 1? What matters a lifetime of paying premiums and not using the services? Perhaps they cannot cancel your coverage, but they can certainly raise your premiums to a point that cannot be paid.

As a person who is already in this position, I find the current Republican health care proposals ludicrous. Ultimately they dump most catastrophic care on the government (much of it local), and create a financial windfall for the financial institutions and insurers that provide their political support.

Posted by: Nat | Jan 31, 2005 7:51:51 PM

The problem with seeing this issue as a matter of the virtues of negative liberty or of redistribution is that it gets the frame all wrong.

Having health care insured as we now do leads to enormous insecurity among Americans and enormous costs on the American economy. We have a system that discourages people from forming their own businesses (for fear of loss of insurance) and that imposes high costs on existing businesses.
Also insurance (of any form) is less expensive the more risk is pooled.

We as a country pool costs and benefits in a number of areas. Roads, police, the military, schools .. etc. Why not just charge individuals for the right to use every single road they drive on? Why not bill everyone who lives on a street for repairing a pot-hole on that street? That's what we do with health care. And that's a good route to having bad roads.

Why not give people an option to opt out of police protection?

We have decided that transport, police protection, and universal education are sufficiently a matter of public interest and public goods that it is better if the country, the state, or local regions support them as available for each American.

Is it a good thing that we have an interstate highway system? Is it a good thing that having it facilitates mobility for individuals and lowers the cost of almost every consumer good we all buy?

Why does no one talk about the DANGERS of redistributing wealth or positive liberty when discussing interstate highways?

Health care should be considered in a similar frame: will having all Americans insured improve national welfare, the national economy, or make the nation stronger in some other sense? (e.g. might we be better off in case of a bioterrorist event if we had universal health care?)

Posted by: Jamie | Jan 31, 2005 8:43:46 PM

Simple, it's the class war of the rich. The people who run the GOP don't believe that working people should have a decent wage, ot health care, or a secure retirement, or be able to form unions. Nor do they believe that unearned income should be taxed. They do believe that the US should have the same kind of skewed income distribution as a Guatemala or Haiti or Brazil. Of course they can't say that and win elections, which is why they talk about terrorism, family values, and freedom.

Posted by: aenglish | Jan 31, 2005 10:48:35 PM

This concept is one where the human mind is not well designed to handle the obvious truth of the situation. "Earned" is a concept that we have a surface understanding - it intuitively makes sense to us, but on deeper study is profoundly flawed as a concept.
Yglesias has had some good discussions on this, but I think the missing conceptual point is that there is a difference between the instrumentality of 'earning' something, and a deeper just desert, some people simply deserve more because their souls are better concept.
Instrumentatlity, to me, means that there are measurable benefits to incentivizing people by increases in wealth allocation. It is not that some one person is better or worse than any other, but that by providing financial rewards for, say, hard work, we are able to increase the pie for everyone in measurable ways.
In general, I think it is a natural reaction for people to blur this distinction. Education on this point is crucial.
The distinction is made clear by asking what besides genetics or environment contributed to the individual "earning" something. The choice then becomes deving men's souls or truly believing that all men are created equal.

Posted by: theCoach | Feb 1, 2005 10:31:39 AM

Oh for heaven's sakes. Providing universal healthcare coverage is not a difficult task to solve in the rest of the industrialized world. China, pounded by civil war and invasion until 1948, may not do quite the bang-up job that Germany or France do, but universal coverage has been done well in different ways by a lot of people.

In some mysterious way these other societies are able to figure out that spending your healthcare dollar smartly is actually good for the economy. In America, as a pathetic and misguided attempt at good health, we spend about $50 billion annually chasing 'drug users' and paying for the jail time of the ones we caught. Our reward for doing this for 30 years is the highest rate of illegal drug use in the industrialized world.

This is all pretty basic stuff and there is no reason to gaze at your navel for 100 years asking if people really deserve something. It's to our advantage to provide universal care and manage our investment wisely as a public asset, something we are quite obviously not doing right now.

It would considerably enrich our national discourse if liberals would deepen their 'knowledge bass' and then crank up the volume. When a company like the seller of Vioxx can cause 10-50,000 excess deaths, it's time to play hardball.

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