Today on NPR there was an interview with Republican Representative Jeff Fortenberry of Nebraska about a town hall he just held, and about how difficult – but important – that town hall was. He told a story about two constituent letters – one from a farmer named Scott who had trouble paying his increasing premiums because of the current price of corn, the other from “Catherine” a woman with a pre-existing condition who could finally afford coverage under the ACA.
Fortenberry told this story in order to argue his point – that it’s not about either of these constituents being correct, but rather than they are both right. Because both constituents have valid claims, they should both be addressed.
Fortenberry sounded eminently reasonable. He was not out to hurt people, he honestly, wanted to help all his constituents, and he honestly believed that some variant of the Republican plan was the best way to do it. I wanted to engage with starting from the assumption that he was being genuine in his beliefs and objectives. So the question is, does a solution that emphasizes, freedom, choice, and personal responsibility make sense?
Fortenberry’s position implicitly assumes that it is within the control of each individual to alter their health-coverage position.
The reality is that neither constituent is in complete control of their ability to pay for health insurance. “Scott” is at the whim of the corn market, while “Catherine” is at the whim of the insurance companies (from here on I am creating fictional characters, I know nothing about these people). The assumption is that by removing government restrictions, both will be better off because there will be more (and cheaper) options available on the market and they will be able to pursue the health coverage that is most in line with their preferences and needs. However, without any regulation there is no guarantee that this coverage will actually exist in a meaningful way: the easiest way for insurance companies to reduce their costs (and thus improve profitability) is to exclude those at high risk of drawing on insurance – those with pre-existing conditions. Individuals like Catherine will be left out or priced out because it is not in the financial interest of insurance companies to cover them.
But let us assume that the coverage does exist, and that it doesn’t exclude people with pre-existing conditions, and it is currently at a price of $100. Let us also assume that Scott and Catherine can both afford to pay the same amount for health care, say $90 a month.
For Scott, the assumption is that for him to afford health insurance he merely has to bring the amount he can afford up $10. For a healthy, employed, individual we can say that the amount of money that he can afford to spend on healthcare is some function of net income. And net income is some function of the individual’s capital, labor, and spending. It makes sense then, that if Scott wants to afford health care, Scott can do specific things to accomplish this. He can reduce spending on other goods by $10, he can work more and earn the additional $10, or he can dip into his savings to cover the added expense. If this isn’t enough, we can assume that Scott – given his desire to have a basket of certain goods that include health insurance – will pursue employment elsewhere or plant a different crop that will net him that extra $10. In short, we can consider Scott to be an agent who has (at least some) control over his income.
Let’s assume that the same thing applies to Catherine, and let’s for the moment assume that the insurance market has not discriminated against her because of a pre-existing condition. Her ability to afford health insurance is the same function: some combination of capital, income, and spending.
However, unlike with Scott, Catherine’s access to capital, control over her spending, and her income is mediated by her illness. While Scott has been saving 10% of his income every month since he first started working, Catherine has had to devote that money to medication. She still saved as much as she could, but those savings were all wiped out last year when she had to get surgery related to her condition. Catherine doesn’t have any disposable income that can be re-routed. Her money goes to food, housing, transportation, and her medical bills. As it stands, she currently spends $90 a month on medical bills, and even if she were to reroute that completely to insurance, she still can’t free up $10 more to afford the insurance.
Like Scott, Catherine can also theoretically shift jobs or alter the focus of her current work. But we must remember that for Catherine $90 a month is automatically directed to medical expenses, while Scott has much more flexibility over that money. Currently, Scott saves $75 a month and spends $15 on lottery tickets and lattes. Scott can easily reduce his latte intake, or his savings rate, if he values health insurance enough. Catherine has no flexibility here. Most importantly, however, Scott can afford to take a day or two off if he wants to. Or he can afford to buy some soy beans as an experiment to see if they grow well. He can also afford to buy double paned glass windows from his savings to reduce his monthly bills by $10.
Catherine does not have these options. She cannot quit her job to try to get a new one, she likely cannot afford to take a day off to go to the interview or to look at cheaper apartments, she cannot dip into savings, and she cannot adjust her spending.
Already it should be clear that while these claims look to be the same on the surface, they are effectively much different. Scott’s ability to engage with the insurance market as a free and rational economic actor is far less constrained than Catherine’s – and that matters tremendously.
Now we haven’t addressed the fact that Catherine is a woman, so on average, she is going to earn less than Scott in any profession. She will also not have access to the same opportunities.
Catherine is also a woman of colour, so the disadvantages she faces as a woman in the labour market are compounded even more. In short she has always earned less money in jobs that she is overqualified for than her white, male peers. Due to her sex and race, Catherine has a history of being chronically underemployed and underpaid.
Since her wages have been lower than they should have been from the start, Catherine’s options for where to live have been limited. She currently can afford a house near the highway, but that means inhaling exhaust fumes day and night, which exacerbates her asthma. There are also no grocery stores within a ten minute drive that stock fresh produce, so she tends to eat a lot at the fast food restaurant on the corner, which is still cheaper than buying the food at the corner store. She knows it’s not the best food, but she always opts for the ‘healthier’ options like the chicken salad, not realizing that even though it’s branded as ‘healthy’ it is still almost 1000 calories and contains more than double the amount of sodium she should receive per day.
Catherine’s ability to pay for her health care, and her ability to control her health (through diet and location), are largely independent from her efforts to do so.
No matter how hard Catherine tries to adjust the income, savings, spending function, she is going to have a much harder time of doing so than Scott. Of course it is possible to do, but it is not likely that she will be successful.
And this is the heart of the failure of the Republican position. Like many positions I’ve seen them take lately (e.g. security, trade, literally anything else) the tendency is to reduce the issue down to something very simple and without nuance. And yes, on the surface, it looks simple. Both Scott and Catherine have seem to have an equal opportunity to adjust to the market – or to not participate in the market. So by freeing that market, both Scott and Catherine will be better off. This may or may not be true in the ideal situation embraced by the Republicans, but it is most definitely not true of the picture that I have presented here. A picture, I would argue, that is more in line with reality.
If it is accepted that external social, political, environmental, and biological differences exist between individuals, then we have to ask if these differences:
a) affect an individual’s tendency to have poor health, and/or
b) affect an individual’s ability to exert control over their income, and/or
c) affect an individual’s ability to exert control over their spending.
If any, or all of these, are true, then a system that depends wholly on an ethic of personal responsibility and freedom is fundamentally flawed.
As an educator, I see it as my duty to complicate this link between agency, structure, freedom, and responsibility. Students need to understand that there is a difference between what Berlin would call negative liberty, the freedom from something (like government regulation), and positive liberty, the freedom to do something (like actually be able to afford health insurance). They must understand that one’s education, neighbourhood, employment, diet and transportation options are not entirely within their control – that if you start a 100m dash a kilometer behind me, no matter how much you train you will never catch up. Hard work and personal responsibility are important, and they should be rewarded, but they are not the only things that contribute to outcomes.
During the town hall, Rep. Fortenberry asked the crowd two questions:
“How many people feel that health care is a right?”
“How many people feel that health is a responsibility?”
The first was met with cheers, the second with a few claps, but much less enthusiasm. I feel this is misguided. Fortenberry is not wrong, health is and should be a personal responsibility – but not entirely. You cannot blame the residents of Flint, Michigan, for the fact that their children were exposed to high levels of lead, and you cannot blame the residents of Beijing for having asthma if they are too poor to afford an effective air filter.
We would be better off to think of personal responsibility as being banded – something that only applies within a certain range of outcomes that are determined by forces outside of our control. Yes, Catherine has a choice when choosing what to eat. But her choice is not between a grass-fed grilled chicken salad or a greasy pizza (like Bob’s); it is between a McDonald’s Burger Combo, and a KFC salad with deep fried chicken, or a bag of chips from the corner store. Maybe the salad is healthier, and maybe she chooses it every time, but it is not going to have the same effect on her health and well-being as it would if she had Bob’s options.
Responsibility and choice require power and agency. If someone has the power, knowledge, and agency to choose to eat a healthy salad, but instead opts for a bacon double cheeseburger (like they do every day), then I have little sympathy when their health falters, and I have trouble finding objections to charging that person more money for health insurance. However, the idea that everyone has an equal amount of power, knowledge, and agency, is a dangerous and flawed assumption to make. Once the social, political, environmental, and biological determinants of disease and wealth are taken into account, it is clear that individuals don’t have as much control over their health or wealth than we might initially assume.
The problem with this perspective is not that it requires personal choice or responsibility; indeed the impulse towards more freedom for individuals is an attractive one. The problem with this perspective is that it assumes – and requires – a level of freedom that simply does not exist. And any plan that is premised on freedom and control over one’s own actions, when applied to a population that doesn’t have this freedom and control, is bound to fail.
We can expect the young, the wealthy, the white, and the men in America to do well under these proposals. And if you are all of the above, then well, you’re probably already a special advisor to the President and don’t need health insurance. But for everyone else, to get decent and affordable health insurance you will need to exercise power that you do not have, you will have to exercise agency on processes over which you have no control, and you will need to take risks that you cannot afford to take. You will be expected to take responsibility for your health, but you will not have the opportunities or the tools to do so. And when you die, those who do have insurance will shrug their shoulders and sigh “it’s so sad about Catherine… if only she would have worked harder and not eaten at KFC all the time.”