Ordinary Americans will soon learn how they are to figure in the grand story of the future the GOP is always telling. It’s a story that sees America and Americans as trammeled by rules that bug them and taxes so onerous they can’t sleep at night, that sees happiness as a precipitate left over after “school choice” causes public schools to evaporate. The Republican narrative promises to rescue Americans from a tyrannical government and recent policy “disasters.” Long-term security will grow rather than decrease once the nation is liberated from the Affordable Care Act (“Obamacare”) and the tangible health benefits it guarantees.
This rhetoric is about to collide with physical reality. Will a Republican-led Congress be so vain and rash as to abandon health guarantees that an entire nation has grown accustomed to? Yes, Congress should act to constrain premium increases and restore competitive insurance options where they are lacking, but why deprive the nation of the happy consciousness that we’re all in it together, which is, at bottom, the signal benefit of Obamacare? This is precisely what Republicans are most eager to destroy.
Under the present system, some well-off Americans are obliged to spend more for insurance than they would like; however, millions of Americans are newly insured, and hundreds of thousands are addressing health problems that have afflicted them for years. Knowing that we are achieving something so gloriously humane makes the hassle and collective sacrifice worthwhile. If Congress were wise, it would aim at enhancing this precious peace of mind.
Image: 80,000 miners listening to Theodore Roosevelt
(1905 daguerreotype by Underwood & Underwood), from this source.
We call them “entitlements,” the big three: Medicare, Medicaid, and Social Security. They’ve been in the news a lot lately. We’re told that they need to be ‘fixed’ and that is scary. It’s scary because they are huge systems, huge not just by one measure but by many: huge in scope and complexity, huge in benefits conferred, huge in social consequence, huge in their impact on the federal coffers.
The entitlements possess centrality. They are a source of political and economic vulnerability, yet their future is of momentous social importance. What happens to them represents, to some extent, what will happen to us, both as individuals and as a country.
Will Americans discover the means of prudence while continuing in their commitment to providing needed medical care to the ill who are poor and elderly? Will aged Americans be guaranteed a subsistence in their 80s and 90s, or will they be draining the resources of their families, or on the street begging? Will the government sensibly modify its social-welfare programs, or will it fudge on its responsibility to “promote the general welfare,” one of the purposes of federalism evoked in the preamble to the Constitution?
Moderation and broad vision are the keys to determining how best to effect the changes these massive programs need. The crisis of social welfare is not just national but global; it follows from a long historical trajectory. The interactive graphics that Gapminder puts together furnish a global longitudinal perspective on our current situation—on our great achievement and our difficulties.
The entitlement programs of today were part of a great historic initiative that altered human life in the 20th century. In the late-19th and early-20th centuries, many countries of the world created various sorts of social-welfare programs. As populations worldwide shifted from the countryside to cities, nations saw their citizens becoming newly vulnerable to hardships that living on the land in extended networks used to ease. As humans became more divorced from the land, they became cut off from a natural subsistence and more vulnerable to the shifts in fortune that market economies caused.
Nations were also moved by a humane desire to apply life-saving medical advances to the cruel diseases and conditions that cut short all too many lives, both here in the US and globally. Just imagine: in 1900, the average life expectancy for an American man was just 46.3 years of age; for a woman it was 48.6.Click the play button on this page to see how dramatically life expectancy for many peoples of the world has changed since then.
The creation of so-called safety-nets played an important part in improving both the health and wealth of developing nations. The graphic above suggests the strong relationship between these two qualities, with wealthiest countries of the world also enjoying the greatest life expectancies. While some countries are wealthier than the US, and others are healthier, the United States enjoys the distinction of being the largest mass society to enjoy both health and wealth to such a high degree.Wealth, especially when widely shared, is an important contributor to public health; conversely, public health is a crucial asset in determining what a nation can achieve.
Of course, many factors contribute to life expectancy: culture, environment, and genetic inheritance as well as living standards and public policy. The case of Russia, which continues to have a remarkably low life expectancy despite its considerable resources and size, shows how a nation can be dragged down when all these elements ill combine. On the other hand, the elite group of countries enjoying the greatest health and wealth include all the Western European countries, with their Cadillac safety nets, as well as many former imperial possessions of the U.K.
Now, however, the very success we have achieved in promoting health and long life is contributing to a crisis being felt worldwide. We can see it in our own country, where entitlement spending is a major contributor to our ballooning federal deficits, but it also appears in the massive debts that European governments are accruing, as well as in the sometimes violent struggles over “austerity,” pensions, and public health insurance retrenchments in countries such as Spain, Italy, France, the UK, and Greece. The underlying connections among these crises are a reminder that the problems we are facing are by no means unique. Shaped by the same historical factors and the same demographic trends, the same problems are bedeviling many other nations.
At the same time, the historic role of these programs in helping nations secure greater blessings for their people argues for their continuing importance in an increasingly competitive and precarious world. Countries that demonstrate the most prudence and creativity in reshaping the social guarantees they extend to their citizenry are those most likely to flourish and dominate in the future. The worst paths for the US and other countries are those defined by extremes. Preserving our entitlements unchanged or gutting them mercilessly are alternatives equally foolhardy. Acknowledging the great social advances we have achieved with the aid of entitlements should go hand-in-hand with discovering creative and discriminating ways to move ahead.
Click on the image to enlarge, or check out the pdf version from Gapminder.
YESTERDAY WAS a great day for majorities. A majority of the Supreme Court upheld the majority of the Affordable Care Act, a complex but very necessary piece of legislation that majorities in Congress had passed more than two years back.
Besides the great satisfaction that comes from watching the various branches of our government working in the intricate ways our forefathers envisioned, yesterday’s events furnish an opportunity to reflect on the great courage required of leaders in our contentious democracy. I hope every congressman and senator who voted for the passage of the ACA will feel more comfortable taking credit for this landmark legislation.
I’m sure the Affordable Care Act is imperfect and that down the line it will need to be tweaked. But the complex provisions of the law are complex for the very reason that they represent an accommodation: an accommodation of many powerful private interests, institutions and professions, as well as a dizzying range of individual, programmatic, and social needs. The health-care reform act will affect us all, and it will shift around the burdens of health care in our society; but it marks a path toward a healthier society, so far the only one a majority of our legislators has managed to agree to.
A minority of Americans will continue to rail against our national institutions, and will try to convince the rest of us to hate a measure likely to confer broad benefits on us, both individually and as a society. May their cries fall on deaf ears, and may they remember that the very foundation of our system is a respect for majority rule.
Today, for a third day, the Supreme Court will continue to hear arguments regarding the constitutionality of the Affordable Care Act. Crowds pack the courtroom; protesters swirl around outside; and those of us farther away are hearing same-day audio broadcasts of the proceedings, a rarity. If nothing else, this event shows how knit together we’ve become as a nation. As a capital, Washington DC used to be mocked as a place out of sight and far from the minds of the people; today it’s at the center of things, a nucleus of discourse and controversy.
The case is a landmark in another way. There’s a lot of hype about it, and passions are keen on all sides. Everyone understands something momentous is happening. Unlike many Supreme Court decisions, which concern distinct subsets of people—union workers, say, or pregnant women, or juveniles in prison—, this one will affect all Americans directly. Perhaps that’s what gives the proceedings a different feel. Will we end up with a single integrated health-care system that acknowledges and includes us all, or will we continue with the old balkanized system that denies the fact that we are connected through it already? Because, one way or another, we do already pay for the care that the uninsured need, and bear the indirect costs of their being ill, if you are inclined to monetize issues that way.
To strike down this complex and undoubtedly imperfect legislation would be undoing change that is happening already; more to the point, it would re-affirm Americans’ separatist tendencies: our determination to go it alone no matter what the costs or consequences. On the other hand, should the constitutionality of the Affordable Care Act be affirmed, we will find ourselves on a new road together, engaged in a massive and complex experiment whose likely outcomes are truly unknown.