HEALTH CARE/Joan Retsinas

Public Policy: Unfair but Wise

Six year-old Nora is fuming. With huge tears falling onto her cheeks, she shrieks, “It’s not fair!” The injustice of it! We, her doting grandparents, have taken her eight year-old brother on a baseball weekend, whisking him from park to park, game to game, leaving her behind. (In the interest of fairness, we the ultimate doters will eventually whisk her on a special weekend.)

Nora values fairness. She knows, even at six, that the world isn’t always fair. But she thinks it should be. And in that, Nora feels what most of us feel: there should be some congruence between merit and reward, between accolades and worth, between wages and work. When hedge-fund managers earn 50 times what schoolteachers earn, many of us lament the vagaries of the market. When people go homeless in cities dotted with mega-mansions, most of us recoil at the injustice. We want a fair system. While we may not want a strict meritocracy, we want a system that leans that way.

So when freeloaders get a free ride, we want to shriek, like Nora: “It’s not fair.” We don’t want to reduce the mortgage principal of homeowners who are “underwater;” it’s not fair to give them a break, while others have paid the full freight. We don’t want to give welfare to people who spurn low-wage jobs; it’s not fair to the workers slogging away at those jobs. We don’t want to give tuition breaks to undocumented students; it’s not fair to the legal ones. We don’t want to help ex-convicts when we don’t give the same help to law-abiding people. We don’t want bankers to bail out countries that haven’t tightened their belts. The sins against fairness mount.

Of course, theologians have their own take on fairness. Indeed, the kingdom of heaven seems unfair. The last are first; the meek inherit the earth. And the Prodigal son gets a reward that the dutiful sons might well resent.

Politicians, though, are rooted on earth. They seek not a compassionate society, but a fair one – even if fairness impoverishes all of us.

Consider life, a much-touted value. For some people, the key to life is medical care. A diabetic needs insulin; a person with cardiac maladies needs bypass surgery; a child with leukemia needs a bone marrow transplant. An expensive cadre of physicians, therapists, and medications undergirds life for many Americans.

But you need insurance to get those life-savers. Enter our much-criticized, much praised, free market system. If you are employed, you may, perhaps, get it from your employer, assuming your employer offers it and you can buy it. If you are poor and fit “eligibility” criteria which depend upon where you live, the government will provide it. From the start, that system leaves some Americans adrift.

Western European countries – the much vaunted bogey or model, depending on political perspective - insure everybody, even people who refuse to pay the premiums, who don’t take care of themselves, who need costly care. Open the floodgates to everybody, and a percentage of everybody will include freeloaders. The benefits: nobody is adrift, and the society as a whole is healthier.

While Obamacare, also much vaunted, much criticized, did not replicate those systems, it did move the United States toward universal coverage (much as Medicare offers universal coverage to older and disabled Americans – another unfair system, but one that nobody truly wants to dismantle). So, a bit like 6 year-old Nora, conservative opponents are screaming “unfair.” They don’t want government to guarantee insurance to a wide swatch of the citizenry, particularly those unworthy of the largesse.

The alternative, though, is a return to the status quo, with people uninsured and underinsured, with “pre-existing condition” clauses, with insurers’ earning mega-profits by denying care – in short, a far sicker society.

Nora might disagree, but “fairness” is not always the wisest course.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, August 1, 2012