Paying for health

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A person’s income determines his/her access to many things he wants and needs: food, clothing, transportation, housing, entertainment, and the internet, for example. And people who have higher income are able to consume more of all of these categories than people with lower income, if they choose to. More affluent people shop for food at Papa Joe’s or Whole Food; live in larger and more luxurious homes; buy their clothing from boutiques rather than Penny’s or the thrift shop; and drive multiple handsome cars. Poor people can’t afford the luxury end of these forms of consumption. And in some way our culture has judged that these sorts of inequalities of consumption are a legitimate and fair part of a market economy; if you judge that inequalities of income are justifiable (perhaps with some limits on extremes), then you pretty much have to support the idea of inequalities of consumption as well.

But what about goods that have a price but that are essential to living a decent human life? Food certainly falls in this category; if 30% of society could literally not afford to purchase enough calories to provide 2200-2900 calories per day for adults and 1800 calories for children, then we would probably have a different idea about the fairness of a market for food — the principle that says “to each according to his/her earning capacity” doesn’t seem very convincing in circumstances where it leads to malnutrition or starvation. In other words, if the normal workings of a market economy left a significant segment of the population without the ability to purchase enough food for subsistence, we would surely judge that this isn’t a fair or socially just way of distributing income and food. And there is an important point to be noted here: there is hunger in America, and the system of producing goods and income isn’t fully satisfying the subsistence needs of the whole population. (This is exactly what makes it compelling that our government needs to provide food assistance for the very poor, through food stamps or targeted income supplements.) So there is an important issue about the justice of current actual distributions of such basic goods as food, clothing, or shelter across the U.S. population.

But push a little deeper and consider the “market for health care”. Supporting one’s current healthy status is a costly effort; repairing the body in times of traumatic injury or serious illness is even more costly; and our society leaves a lot of the allocation of health care services to private purchasing power. Health insurance is the primary vehicle through which many Americans provide financially for their health care needs. Some people have insurance provided or subsidized through their employers; some families purchase health insurance through the private market; and many families lack health insurance entirely. Upwards on 45 million Americans are uninsured, including 20% of adults and 9% of children (CDC link). And this includes a wide range of Americans, from the extremely poor to the working poor to the solidly middle class.

It is clear that access to doctors, hospitals, nurses, and prescription drugs is a critical need that everyone faces at various points in life. It is obvious as well that one’s future ability to live and work productively and to enjoy a satisfying life is conditioned by one’s ability to gain access to health care when it is needed. It is also clear that uncertainty about the availability of health care is a major source of anxiety for many, many people in U.S. society today. So it is self-evident that decent health care is one of our most basic and unavoidable needs.

So what do people do when they lack health insurance and serious illness or injury occurs? This isn’t a mystery anymore; families go into debt to doctors and hospitals, they face bankruptcy, they find some limited sources of free care (free clinics, pro bono doctors’ services), and they forego “optional” treatments that may well extend the length or quality of life. And it is evident that this pattern results in very serious harms and limitations for people in these groups. People who have the least access to health care through our basic institutions may be expected to live shorter lives and to suffer more.

And what about people at the high end of the income spectrum? How do they relate to the problems of health? Here too the answers are fairly well known: they are able to seek out the best (and most expensive) specialists, travel to national centers for specialized treatment, and undergo advanced diagnostic tests that are not covered by insurance. (Here is a news story from CNN on boutique health care.) The affluent aren’t able to assure their health through expenditure — but they can certainly improve their odds.

In other words, ability to pay influences the quality and extent of health care that an individual or family is able to gain access to; and the health status of the family is affected by these variations in quality and access. So, to some meaningful extent, our social system places health care in the category of a market good.

But here is the question I’m working around to: what does justice require when it comes to health care? Is it right to look at health care as just another consumption good like shoes — affluent people wear Gucci and poor people wear Dollar Store, but everyone has his/her feet covered? Or is health care in a special category, too closely linked to living a full human life to allow it to be distributed so unequally?

It seems a bitter but unavoidable truth that there are very substantial inequalities in the provision of health care in our society. One person’s likelihood of surviving a devastating cancer may be significantly less than another person’s chances, simply based on the second person’s ability to pay for premium health care services. Further, it seems unavoidable that these inequalities are flatly unjust in any society that believes in the equal worth of all human beings. And where this seems to lead is to the conclusion that some system of universal health insurance is a fundamental requirement of justice.

Can America overcome racism?

The social and economic inequalities in America that are associated with race are staggering and persistent. Pick almost any category where you’d rather have more than less — income, health status, property and home ownership, likelihood of having health insurance, life expectancy, or likelihood of having a favorable outcome in the criminal justice system. In all of these categories there is a wide gap between black and white Americans. And this remains true even when we control for income — the health gap between white and black Americans earning more than $80,000 remains significant. So America has embedded a set of economic and social institutions that reproduce racial disadvantage. America remains a deeply racialized society.

These observations don’t necessarily amount to a conclusion about racist attitudes and deliberate discrimination on the part of most Americans. Attitudes and outcomes need to be distinguished. It is likely enough that there has been a lot of progress in conscious attitudes about race since 1950 for the majority of Americans. But persistent discriminatory outcomes can arise without explicit racist attitudes or discrimination on the part of specific individuals. Central examples of these forms of embedded “structural” mechanisms of racial discrimination include residential segregation and unequal educational opportunities for black and white children, based on where they live. Segregation certainly arose in part through deliberate efforts at excluding black people from certain neighborhoods — real estate “steering”, mortgage and insurance redlining, and overt violence and intimidation. But the mechanisms sustaining segregation today may well be more impersonal. The fact remains that patterns of racial residential segregation help to reproduce the kinds of racial inequality mentioned above.

These racial inequalities are also deeply intertwined with the social geography of major American cities. The concentration of poverty, racial isolation, poor schools, poor health facilities, and high crime rates create a multi-stranded social mechanism for reproducing racial inequality. It isn’t impossible for an African-American child to thrive and achieve in this environment — but it is certainly much harder. And the probabilities are stacked against her.

So, back to the main question: can America overcome its racism? Several things are necessary if this can happen.

First, we have to honestly face the facts — the outcomes mentioned above. We can’t delude ourselves by saying “the problems of race are finished in America” because we’ve elected an African-American president. The facts of racial difference in life outcomes need to be recognized, and we need to be vigilant in uncovering the mechanisms that lead to these disparities.

Second, we have to recognize why it is so important for our political culture that we address and resolve these continuing racial inequalities. Most fundamentally, we believe in equality — equality of worth and equality of opportunity. The persistent inequalities between black and white populations are a fundamental affront to these values. And we believe in democracy –but a democracy cannot thrive in circumstances of what amounts to two levels of citizenship.

But third, pragmatically, justice is a necessary component of social peace. Our country has seen violent outbreaks for over a century over the facts of contemporary race relations — Watts, Chicago, Detroit, Harlem, Miami. It is only enlightened prudence to realize that we must aggressively and consistently attack the institutional realities that reproduce racial disadvantage. Securing racial justice is a good investment in future social harmony.

Finally, we will need to have the resolve it takes to provide the resources necessary to assure genuine equality of opportunity for all Americans. This will be the work of a generation. But it will lay the basis for a more sustainable, harmonious, and productive society.

Gradient of justice

Given that there is significant injustice in our society, and granted that we are a long ways from a society that establishes what Rawls called the circumstances of justice — can we at least have the confidence that we are moving in the right direction?

Some people would argue that our society is doing just that. They sometimes point to the fact of rising nutritional and health status in the poorest 40 percent of our population during a 50-year period, and they might say that the situation of institutionalized racism — and with it the circumstances of middle-class African-Americans — has also improved measurably in 50 years.

Unfortunately, these impressions are misleading. In fact, it is more likely the case that inequalities of income, wealth, and well-being have worsened in the past twenty years. Lower-middle income and poor people have the smallest share of the nation’s affluence that they have ever had. And many of the programs designed to provide a social safety net have been gutted or have disappeared altogether.

And on the racial justice side — if general social racism has diminished, the depth of racial inequality and lack of opportunity in large cities has almost certainly increased in thirty years. The lack of opportunity and hope that exists in Cleveland, Detroit, Chicago, or Oakland is truly staggering — and it is worsening. This wall of deprivation is drawn largely along racial lines. And all too often this impacted lack of opportunity leads to crime and violence.

So we don’t seem to be on a trajectory of general improvement when it comes to social justice. The myth of the “trickle-down society has turned out to be more trick than truth. The benefits of economic growth have not lifted the lower middle class. This growth has not dissolved the knot of urban poverty. The public is turning its back on public schools — surely one of the surest mechanisms of greater social justice over time. And we don’t seem to have a public commitment to the basic value of allowing all members of society to fully develop their talents. Even more disturbingly, we seem to be entering a period of time that will involve even greater economic anxiety. And anxious times seem to bring out the worst in people when it comes to competition for scarce resources and opportunities.

What we seem to need is a greater sense of community, a greater recognition of our inter-connectedness and inter-dependence, and a greater common commitment to making sure that our society and its policies work to improve the lot of all its citizens. But most regrettably — this sense of the strands of community is exactly what is most imperiled by the facts of current inequalities. It is difficult to maintain the strands of civic commitment to each other when fundamental inequalities separate us further and further.

So perhaps we ought to consider the unhappy possibility that our society may be inching towards the deepening chasm of inequality that characterizes South Africa, Mexico, or Brazil today. And if this is true, then the future is ominous.

“Too much” inequality? Yes!

How much inequality is too much? The range of income and wealth inequalities in the US has increased sharply in the past 20 years. The share of income flowing to the top 10% and 1% has increased significantly. And the level of income for the bottom 40% has slightly declined during these years. But to say whether that’s a bad thing, we need first to think clearly about what inequality means for our society — for the quality of life for people at the bottom end, for the strands of community that knit a society together, and for the idea that every member of society is equally worthy of respect and consideration. And we need to think about the mechanisms through which these inequalities are created in our economy — and through which these inequalities have increased so sharply.

First, the effects. It appears also to be a fact that the symptoms of poverty are more extensive today than they were twenty years ago. The demands on food banks have increased; homelessness appears to be more extensive in many major cities; and of course the problem of lack of access to health insurance and affordable health care appears to be even more pressing. So it would appear that the increase in income inequality in the past 20 years has had a depressing effect on the lives of the least-well-off in our society. At least the economic processes that have improved the incomes to the rich and the super-rich have not also improved the incomes of the middle-income groups and the poor. So the philosophers’ argument — inequalities are not inherently bad if the bottom end is pretty well off — doesn’t apply to today’s circumstances.

Second, there is some evidence that the social distance between the very-well-off and the not-well-off has increased, with fewer points of contact between social groups. This is sometimes described as the “disappearance of the middle class.” The substantial transformation of the American economy that has occurred in manufacturing and the auto industry is emblematic: the jobs that created the possibility of a blue-collar, middle class life in Michigan, Ohio, and Illinois are disappearing, and the next generation of manufacturing jobs are creating incomes that are perhaps only 60% of the levels of the previous generation. So rising inequality is manifest, in part, in the loss of well-paying jobs in the middle — producing a greater degree of social separation.

This brings us to respect and equality. It isn’t too much of a stretch to infer that in a society increasingly separating into “affluent” and “poor”, the idea of basic democratic equality — that everyone is in the same boat; that everyone has an equally worthy life; that we all depend on each other; and that everyone is equally worthy of respect — has less and less social reality. These widely separated groups have less and less lived experience that reinforces these ideas of connection and equality among all citizens.

So there are ample reasons for judging that the rising material inequality in America is a very bad thing. It is bad because of the consequences it has for people on the lower end of the spectrum; it is bad for the corrosive effects it has on basic democratic values of fundamental human equality; and ultimately it has to be bad for the civic values that undergird a peaceful and harmonious society. How much inequality can a community absorb before it begins to pull apart into mutually antagonistic groups? How many more gated communities will this society need if we continue to fail to achieve the kind of material fairness that allows every citizen to look the other in the eye and say, I respect you and I know that all our benefits depend upon our mutual contributions to society?

If our economy continues to separate our society into rich and poor — if our largest cities continue to intensify the inequalities of access, opportunity, and quality of life between the urban poor and the suburban affluent — then surely we have some seismic social conflicts brewing.

Why affirmative action?

Since the Supreme Court’s Bakke decision in 1978, universities that practice affirmative action in admissions have premised their case on the educational benefits that accrue to all students from a diverse student body. This is the heart of the successful University of Michigan defense of affirmative action in the Supreme Court in 2003. What has been largely lost in this debate is any explicit effort to assert that there are fundamental reasons of social justice that should require American social institutions to practice some form of affirmative action. And yet those reasons are if anything more immediate, more fact-driven, and more compelling than the “indirect educational benefits” justification.

Three arguments based on social justice are particularly important. First is the history of slavery and racial discrimination in this country, a history that has persistent consequences up to the present day. Consider the premise that current educational and economic disadvantages for African Americans as a population derive chiefly from these historical facts about slavery and past discrimination — facts that are manifestly unjust. Is it not then apparent that justice requires concrete social actions and policies today that have the effect of reducing and eliminating current-day disadvantages that derive fairly obviously from past injustice? And given that those historical disadvantages create exactly the current educational deficits that make further educational progress more difficult, is it not clear that there need to be processes in universities to assist in increasing the percentage of African American students who have benefited from high-quality university education? This line of thought creates a positive obligation for current institutions to “affirmatively” work to overcome current inequalities created by past injustice. The tool of affirmative action is one such tool, and justice requires that it be used.

Second, the broad conception of equality of opportunity discussed in a prior posting has special relevance to the case for affirmative action. If various sub-populations in a society have less than full access to current opportunities because of substantial structural inequalities of access to critical resources in the past, then it is very convincing that society needs to find tools for leveling out these opportunities. Access to excellent higher education is fundamental to achieving decent life prospects. Again, affirmative action is such a tool and should be available.

Finally, these two arguments converge when we consider that the current educational disadvantages suffered by young African American students themselves derive from current social arrangements that are deeply discriminatory. The fact that current racial structures impose very different life prospects on different groups gives rise to a pressing non-historical reason for “affirmatively” addressing these inequalities. Unjust racial inequality of outcome is not simply a fact about the past; it is a fact about the present. The racism associated with the fact that inner-city (largely minority) schools are underfunded and substantially inferior to suburban (majority white) schools in providing educational opportunities to the children they serve, indicates a powerful basis for concluding that affirmative action programs need to be available as a tool. Affirmative action can help redress current injustice along racial lines.

So there are powerful reasons based in facts about historical injustice, equality of opportunity, and the injustice of the current distribution of educational resources, that all lead to the conclusion that affirmative action policies should be lawful and available to large social institutions, especially in education and employment. The fact that the terms of debate have been limited in such a way as to simply exclude these considerations of past and present racial injustice is itself an obstacle to our society’s successfully addressing these injustices.

Real equality of opportunity?

Let’s say that our basic moral commitment is the idea that every human being ought to have real equality of opportunity as he/she pursues a life plan. What does this mean, in detail, and what implications does it have for social justice?

Equality of opportunity can be construed in broader or more narrow ways. Narrowly, we might say that persons have equality of opportunity if they are considered for positions, benefits, and burdens without respect to “personal” characteristics — their family origin, race, age, ethnicity, health status, etc. Only the objective and person-independent features that are relevant to performance ought to be considered in selecting people for opportunities. (This is how equality of opportunity is construed in employment.) Does this narrow construction really capture the moral value of equality of opportunity, however? Evidently it does not, because it ignores the history of how various individuals came to have the objective characteristics and talents they possess today. If two candidates for firefighter are compared on the basis of their current physical fitness, but one had a childhood of normal nutrition and the second was chronically malnourished, then we would be reluctant to say that they are currently enjoying equality of opportunity. The choice between them today depends on objective differences of fitness for the job; but the differences that currently exist were not themselves created through a fair process.

So we should broaden the definition of equality of opportunity and require that each individual should have had access to the resources normally necessary for the full development of his/her capacities as a human being. These would include decent nutrition, access to health care, and access to education of comparable quality. And we might even add in an empirical assumption, that there is a range of levels of provisioning of these social goods within which any individual has the possibility of achieving high levels of performance. That is, it might be maintained that there is a (reasonably high) level of provisioning of health care, nutrition, and education that is “good enough” to permit the individual to have a fair chance to compete for opportunities in a ” narrow equality of opportunity” environment.

If we take this somewhat broader view of equality of opportunity, then we are immediately forced to consider the workings of basic social institutions and the distributive consequences they have for rich and poor. Do the resources available to the poor exceed the minimum level of provisioning specified above? Or are significant numbers of the poor sufficiently disadvantaged in their current performance by the history of unequal access to resources, that today’s competition fails the broader “equality of opportunity” criterion?

In many of the instances we can observe today the answer to the final question is “yes”. Children who have attended under-resourced elementary schools and high schools have substantial deficits in terms of high-end cognitive achievement — so a “neutral” competition between them and better-educated children fails the test. Children whose nutritional status and health status is sufficiently compromised that their cognitive development has been impaired, are equally unfairly treated when subjected to “narrow equality of opportunity” processes. And this has immediate implications for the social inequalities that exist in American society between rich and poor, urban and suburban, white and black, and rural and urban.

When we shift the focus to international inequalities across levels of human development, we come to a similar conclusion: because of gross inequalities in the availability of resources during the process of human development for children and young people, we cannot conclude that contemporary distributions of positions, opportunities, and burdens are the fair result of institutions embodying equality of opportunity. Nutrition, health, and education are factors that are very unequally distributed in the country and the world today; and the bottom end of the distribution falls well below any reasonable standard of “good enough” for full human functioning.

The implication, then, is a strong one: if we think that fair equality of opportunity is a compelling moral principle, then we also must conclude that a very significant reform of some basic social institutions must occur if we are to be able to assert that contemporary society is just.