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On Health and Welfare, Moral Arguments Can Outweigh Economics
When Representative Mo Brooks said it was unfair that healthy “people who lead good lives” should have to subsidize the insurance of unhealthier ones who presumably don’t, he bluntly raised an often unspoken question that runs through policy debates in Washington: Who deserves government aid and who does not?
Such proposals can be — and often are — couched in the language of economics, with advocates and critics calculating the efficacy of incentives, returns on investment and long-run savings. As Ben Carson, the Trump administration’s housing secretary, commented last week while touring publicly subsidized housing in Columbus, Ohio, “We are talking about incentivizing those who help themselves.”
But the judgment of who is deserving — as opposed to what is most effective — is at heart a moral one.
In pushing for repeal of the Affordable Care Act last week, Mr. Brooks, an Alabama Republican, suggested that people with pre-existing conditions deserved to pay higher premiums, because they had not “done things the right way.” That could include a cigarette smoker’s lung cancer — or a newborn’s congenital heart disease.
The same theme of who is deserving surfaces in tax debates. Conservatives often argue that the wealthy deserve the biggest cuts because they contribute the most in taxes — and, besides, they create jobs. Liberals argue the opposite, noting that the top 10 percent reaped nearly all of the gains in income since the recession ended.
Similarly, Republican proposals to link work requirements to poverty programs stem in part from a longstanding impulse to distinguish the deserving poor from the undeserving. (An 1874 article in The New York Times discussed the difficulty of discriminating between “the really needy” and those “too indolent to help themselves.”)
House Republicans initially proposed that only people who work should be eligible for publicly funded health insurance. And now a handful of states, like Arkansas, Maine and Wisconsin, are pushing to institute such requirements on their own.
Policies to combat hunger are subject to the same debates. Representative Jodey C. Arrington, Republican of Texas, defended work mandates at a congressional hearing for food stamps by quoting the Bible: “If a man will not work, he shall not eat.” Soon after, Representative Glenn Grothman, Republican of Wisconsin, introduced a bill that would prevent states with high rates of unemployment from waiving the hunger program’s existing work conditions.
Suspicions about freeloaders have reliably shoved the question to the center of health and welfare policy, engaging both Democrats and Republicans.
“Before welfare reform, you had, in the minds of most Americans, a stark separation between the deserving working poor and the undeserving welfare poor,” Barack Obama said in 2008, explaining why he supported the welfare law enacted under President Bill Clinton. “What welfare reform did was desegregate those two groups. Now, everybody was poor, and everybody had to work.”
Yet as earnings for many working-class families have stagnated or stumbled despite nearly eight years of recovery, resentment about the size and cost of the social safety net has grown. That fed the wave of anger that helped propel President Trump into the White House. The greatest disdain is directed toward adults who seem capable of working.
The mentally ill, older adults and disabled people can do little to take care of themselves, Mr. Carson said, but “there is another group of people who are able-bodied individuals, and I think we do those people a great disservice when we simply maintain them.”
Mr. Carson echoed the views of Speaker Paul D. Ryan, Republican of Wisconsin, who argues that government assistance has done more harm than good.
“Ryan revived the idea that these programs hurt people rather than help them, that dependency is bad,” said Robert A. Moffitt, an economics professor at Johns Hopkins University.
Yet defining public assistance as inherently counterproductive denies the possibility that there may be a trade-off between values and effectiveness.
Both liberal and conservative researchers agree that tax credits, food stamps, child care support and Medicaid reduce hunger, illness and poverty among the poorest Americans.
Ron Haskins, a senior fellow at the Brookings Institution, who was appointed by Mr. Ryan to be a co-chairman of the federal Evidence-Based Policymaking Commission, dismissed the Republican catchphrase first popularized by President Ronald Reagan that in the war on poverty, poverty won.
“That’s tripe,” said Mr. Haskins, who was also a senior adviser on welfare policy to President George W. Bush.
Mr. Haskins is a longtime advocate of work requirements, but he argues that ethics and effectiveness mean the government should not “not take anybody’s benefits completely away without actually offering them a job.”
That piece is crucial, but he sees little support in Congress for funding such initiatives. “We’re just not trying hard to do it,” he said.
The distinction between the deserving and undeserving “is absolutely fundamental to understanding lots of policy debates and lots of social problems in this country,” said Mark Rank, a professor of social work at Washington University in St. Louis.
America’s secular and spiritual traditions both embody the notion. The American dream is based on the idea that hard work will result in success. Failure is in the hands of individuals, leaving citizens to feel less responsibility to offer help.
The notion of just deserts has deep roots in the Bible, based on the assumption that God rewards the good and punishes the wicked. Though modern medicine and the germ theory of disease have largely severed the link between goodness and health, the nexus with material wealth remains.
The “prosperity gospel,” which asserts that faithful Christians are rewarded with financial success, has been a bedrock of American evangelists from Oral Roberts to Joel Osteen. It is embraced by Paula White, a Florida televangelist known as Mr. Trump’s “spiritual adviser” and one of the clergy members invited to his inauguration.
“Winning to him also equates to good,” Ms. White said of Mr. Trump, “and good equates to God.”
Evangelical adherents to the prosperity gospel turned out to be reliable Trump voters on Election Day. A close analysis of poverty statistics over the past half-century, though, shows that two-thirds of all Americans received some kind of income-based benefits over their lifetime, like food stamps, disability payments or Medicaid, Mr. Rank said.
“Are we going to make the argument that all these folks are undeserving?” he said.
Mr. Rank designed a “poverty risk calculator” to illustrate how easy it can be to fall on hard times. Of the five largest risk factors for poverty — age, race, sex, education and marital status — three are out of anyone’s control.
Mr. Rank uses the game of musical chairs to illustrate his point. Looking solely at the difference between winners and losers turns the focus to individual traits: who is faster, pushier or more strategic. Instead, he suggested looking at how the game is structured — that there are fewer chairs than players — and why it is impossible for some people to win.
“Rather than an individual problem, this is a systemic problem,” he said. In the case of the economy, that means shifting attention from who lost to why the system produces so many losers in the first place. (Perhaps because of a shortage of well-paying jobs or insufficient wage growth.)
“That shifts from this idea of the deserving and the undeserving,” he said. “It’s a different framework.”
A news analysis article on Monday about policy debates on social issues like health care and hunger misidentified the administration in which Ron Haskins, who commented on the war on poverty, was an adviser. He served under President George W. Bush, not Mr. Bush’s father.
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Follow Patricia Cohen on Twitter: @PatcohenNYT
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