A little while ago, I took part in a discussion about how medical care is paid for. It took a negative turn, as you would expect, since American health care is the world’s most expensive and the medical insurance field is highly dysfunctional. But the complaints were aimed especially at patients, since a couple of people I was talking to were jaded by observing apparent Medi-Cal fraud too many times over the years

I’ve been working in a medical office for nearly a year now, my first job in the medical field, and for the first time am getting a close look at what goes on behind the scenes at a doctor’s office: how many things can go wrong with skin (it’s a dermatologist’s office), how much patients are cheered and made to feel better by the simple act of talking with someone who can perhaps heal them, the complexities of billing and navigating the disparate requirements of insurance companies, the difficulties of receiving adequate medical care when one is disabled or poor, and so on.

The limits on what one can earn while receiving Medi-Cal, a free (to the patient, of course) state-run health care, are quite low, set at only 138% of the federal poverty level. For a state like California, with its relatively high cost of living, those limits are very much a low-ball estimate of what one can actually live on in an average California city. The qualifying limit on the yearly wage for a household of two, for example, is roughly the same as an average year’s rent alone.

Anyway, in the aforementioned conversation, anecdotes were passed around of people who present with Medi-Cal insurance, yet own expensive smartphones (data plans are not cheap, either!), nice clothes, talk about their vacations and nice cars, have tattoos and elaborate salon hairdos, and so on. This, of course, raised the question: how could they afford these things if they’re actually poor enough to qualify for Medi-Cal? Putting aside obvious objections, that they may have purchased those things before losing their jobs or becoming disabled, or that their family and friends supply the ‘luxuries’ as gifts, etc, the implication was that applying for taxpayer-funded health care should be an option of last resort, only after the smartphone is returned and the data contract expired, the nice clothes worn out, the valuable car sold.

One person proposed this solution: those too poor to afford health care insurance and other necessities of life should be given a one-time check. If they choose fritter it away and don’t spend it wisely, let them suffer the consequences. People who are responsible enough to have the money to pay for health care when they need it, should be the ones who get it; the rest are on their own.

I understand the frustration of those fellow conversationalists. We all know people who chronically don’t (can’t?) ‘keep it together’: they don’t (can’t?) get and keep decent jobs; they squander their money on junk food and useless luxuries and cheap trendy things that don’t last more than a season; they date or marry or make babies with ‘losers’ who drain their finances and don’t contribute; they don’t have a savings account for emergencies, and so on. Those habits are maddening, and don’t endear the possessor to those around them. Many of those habits drive their family and friends crazy, and arouse much resentment in others who end up paying the costs.

But I never hear the opposite argument: some people who have the money to pay shouldn’t get the healthcare resources. We know that some people who have money don’t contribute anything of value to society, and even do a lot of harm. There are some who make their money polluting or from sweatshop labor; there are some who are the lazy, spoiled, entitled children of wealthy parents; there are some who defraud their customers or knowingly sell toxic drugs to addicts; and so on. Why should they get to use up valuable, finite healthcare resources, then, if they, too, have lousy habits and are a drain or a bane to society?

So why the discrepancy? Does having money make one, generally, more deserving somehow? I think the discrepancy in our attitudes toward who should get health care, and who should not, reveal what most of us in the United States implicitly, unquestioningly accept, as a core value of American culture. It’s not so much that might makes right. Cash does. If you have the money to pay for something, you not only should get it, you deserve to get it. Period.

It’s not hard to see why we assume that this is so. We are a capitalist society, founded on the values of our country’s Calivinist founders. Money is the reward for our labor, and a sure sign, described as such in earliest Biblical times, of God’s approval. To accept money-as-deservingness as a core value is to encourage hard work, thrift, and innovation. Money is the surest way that a capitalist society automatically rewards its most productive, contributive members; obviously, those who work hard deserve the most money.

And very often, this is the case: doctors and other healthcare professionals, leaders of industry, civil-rights and defense lawyers as well as prosecutors, scientists, judges, professors and leading public intellectuals, and so on, do vastly important work, and they are, justly, well rewarded.

But wait a minute. How about those examples we just considered, of people who have money that don’t work hard or don’t contribute? There are myriad exceptions to the rule that the most deserving get the most money. A money-centric society also encourages theft, cheating, lying, fraud, ‘let-the-buyer-beware’ selling tactics… the list goes on and on.

And how about all those people we know whose work is among the hardest and most contributive, but who don’t make much money? In our country as in much of the world, for example, we are awash in a wealth of ready accessible, super cheap, delicious, quality food, such as the world has never seen before. That’s largely because masses of people work for subsistence wages, often in harsh conditions, for most of their waking hours, for years if not all of their life. In fact, the health and wealth of our society absolutely depend on these people’s labor, since without it, we are all impoverished, and would have little time and energy to expend in innovation, the arts, all the best things society a society produces, without a steady, high quality food supply.

But of course, the wages of field workers are not mostly determined by deservingness in accordance with the importance or value of the work done or the contribution made, and neither are the wages of most people. Wages are determined by supply and demand, or by how easy it is to replace one worker with another. Laboring in a field requires stamina and the will to work, but not education or highly skilled work experience. There are a seemingly endless supply of people who are willing to work in the fields for low wages in order to escape even worse living conditions or starvation, or increase the chances of success in their children’s future. The same conditions determine wages for myriad other areas of work, such as factories, restaurants, in-home and facility care for children and the elderly, and so on. And of course, there are those who did valuable work all their lives, until advances in technology rendered a lifetime of experience and skill useless. The stenographer, the postal worker, the journalist, the machinist, the autoworker, are seeing their jobs replaced by robots, computers, pundits, and overseas low-paid workers, and they are left middle-aged, suddenly unemployable, with large bills and children still demanding they make decent salaries, to start all over again in a job market that doesn’t need them anymore, with depressed wages for the entry-level work they must now accept when and if they can get it.

In contrast, there are those whose work is in demand because the product of their work is desirable, such as luxury goods, but the people who produce them are in short supply. Designers and developers of video games and movies, including violent and misogynistic ones, can make a great deal of money. Same goes for high-end fashion designers, CEOs of pharmaceutical companies, speculative bankers, plastic surgeons, lobbyists, and so on. The product of these people’s work range from the most beneficial, beautiful, and life-enhancing, to the most useless, harmful, and ugly; either way, the work they do can be highly lucrative, since their work is in high demand.

As we can see, the value of money-as-deservingness may originate from some of our best instincts and desires, such as justice in compensation, the liberty to pursue our own goals, and the drive to better the lives of ourselves and our children. But in the real world, things don’t play out that way, not by a long shot. The cynic, the cheat, the liar, the predator, is all too often more adept at making money than the honest, hard worker. The possession of money is not a reliable reflection of character, nor of the actual value of one’s contribution to society.

So as we’ve just seen, money-as-deservingness is deeply problematic at best, and nearly useless at worst. Money is a tool, nothing more, and the fickleness and vaguaries of the market, not worthiness of the work done, mostly determines who get the most.

So to return to the example we opened with: what conclusions should we have reached in our conversation about health care and who should have access to it?

It’s hard to say, exactly. It seems that collective action problems (the tragedy of the commons, for example) are part-and-parcel of every real-world society, and capitalism is one way around them, as it’s an (ideally) impartial, and therefore fair, way of allocating resources. This may solve many efficiency problems, but to my mind, it doesn’t solve a far too many other, even more important problems, including those that arise from our concern with justice, human flourishing, dignity, the value we place on individual human lives, and so on.

And we haven’t even considered the dilemma of how we are to care for people who are not ‘marketable’: constituted in such a way that they can’t contribute in the ways the market rewards: they don’t have the health, mental capacity, or perceived attractiveness that make them likely to get a decent job, even if they are able to try. Do we return to a society that depends only on elective charities to care for them, reneging on the commitment we’ve made over the years to take their care on as a collective responsibility? Remember, public assistance programs arose precisely because elective charities weren’t doing the job: if they were, there would have been no-one to need public assistance. Do we return to a eugenics-based belief system, where only the ‘fit’ deserve to survive? But this ignores that which makes human beings simultaneously the most intelligent, capable, and successful species: our highly developed social skills, in which we cooperate, pool our resources, and build on on the work and ideas of others to invent language, technology, and culture such as the world had never seen or likely will again if we eventually go the way of the dinosaurs. If we undermine our own moral sense and hard-heartedly ignore and dispose of the ‘unfit’, we blunt our moral sense and head down the path of mutually assured destruction, where it takes more and more qualifications to remain in the category of the ‘fit’. We’ve gone down that slippery slope before, have already caught a glimpse of such a dystopia in mid-century Europe.

My proposed solution? Re-classify and institute healthcare as the same sort of infrastructure as our system of roads and bridges, the military, the water supply, food-safety administration, our currency, and so forth, as all of these are basic necessities of life, communication, and trade. Collective action problems always have and always will exist, in the free market as well as in public welfare systems, and to give healthcare over to the vaguaries of the free market as if it’s an elective luxury, is a failure of our society’s commitment to the value of the life and liberty of each individual person. Our free-market healthcare system, which leaves so many without the care they need, is not a solution, it’s the result of a lack of political will and imagination, and a moral disgrace to boot.

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Sources and inspiration:

Ariely, Dan. Multiple works on behavioral economics, including his TED talks, lectures, and articles.
http://danariely.com/

Heath, Joseph. Economics Without Illusions, 2010.
http://books.google.com/books/about/Economics_Without_Illusions.html?id=4V8cvQo1Dw8C