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Here on the Outer Cape, Fall has arrived with cooler temperatures and crisp light. As seen from my studio window, the foliage still glows mostly green in the morning sun, but here and there patches of orange and red, and spots of yellow, are beginning to show.
Although Washington, even Boston, seem a million miles away, I have been thinking about the Affordable Care Act. I have lately done a lot of writing about emotion and, about to do more, I was wondering what difference any of it makes. To be sure, I strive to shed light on a relatively obscure phenomenon and I flatter myself that I occasionally succeed. But what good is light?
Then I thought of Obamacare as a political accomplishment that crucially depended on public clarity. So will its future. I am confident that a few years from now, Americans will enjoy reliable health insurance and better healthcare. Those improvements will take the form of single-payor universal health insurance, along with its inevitable practical correlate, government control of healthcare costs. It will be the equivalent of Medicare for all, except that unlike now, that universalized Medicare system will be empowered to negotiate reasonable drug prices with pharmaceutical companies.
My optimism on this front is rooted in the conviction that given the right configuration of circumstances, conspicuous assaults on the public interest tend to issue in corrective legislation. In this instance, those circumstances include clarity on the part of the public. We know what we want from healthcare, what counts as affordable, what constitutes fair compensation for services, and what we can do in the face of gross abuse. Ironically, they also include extravagant rhetoric directed against subsidized healthcare, as well as stunning instances of price gauging.
A recent report in The New York Times documents hospital practices that involve circumventing cost controls by engaging the services of “out-of-network” providers. In many cases, the latter do little or nothing for patients, but charge high fees. The report cites the example of a man who was billed $117,000 by a neurosurgeon whose only role during a three-hour surgical procedure to repair a herniated disk was to observe the orthopedic surgeon at work. Supposedly, this was to make sure that none of the patient’s nerves ended up damaged. You would think that an orthopedic surgeon knows about nerves, but the neurosurgeon was an “out-of-network” provider called in as an “assistant”. His fee came on top of the orthopedic surgeon’s fee of approximately $40,000 and the cost of the hospital stay. Apparently, this not uncommon practice is gaining ground as a way by the healthcare industry to circumvent cost controls. Another report out today documents the sometimes astounding cost of emergency room care – up to $500 a stitch over and above the facility cost. The emergency room physicians are, again, out-of-network providers who accept no insurance and charge whatever the market will bear. These practices mock the spirit of the Affordable Care Act.
It does not take a naïve idealist to believe that the public’s tolerance for this sort of behavior has limits. Impatience with it will eventually issue in corrective legislation, not because the U.S. Congress has the public interest particularly at heart, but because its members can afford to disregard clearly focused public anger only for so long. Beyond that point, they are voted out of office. Happily for the public, there is no controlling the behavior in question without upgrading the Affordable Care Act in the ways outlined.
In addition to clarity on the part of the public, an essential element in this scenario has been a national press documenting abuses when they occur. It enables us to know that when we find ourselves victimized by those abuses, we are not alone, and that, in any case, we are all potential victims. But both public clarity and effective journalism depend on yet another accomplishment. The issue has to be framed properly, brought into clear focus as a problem that is real, that has a solution, and that it lies in our power to do something about. Sometimes, that framing occurs deliberately, accomplished by, again, responsible journalists or public minded writers. Sometimes, it occurs by accident.
The consciousness of the American public about healthcare costs has been shaped to a considerable extent accidentally, by ideological extremism about entitlement reform. For people over the age of 65, Medicare is an entitlement. For some years now, right wing rhetoric has striven to convince the public that we cannot afford Medicare. Apparently, the program will bankrupt the nation. But it takes no wizard to figure out that (a) Medicare will bankrupt the nation only in the absence of government efforts to control health care costs and (b) the refusal to make those efforts is mostly ideological. All that rhetoric has been ideology posturing as economic expertise. It involves favoring profit-making at the expense of people’s welfare, this in the name of the notion that the only reason healthcare is available to Americans at all is that its providers, or, rather, those who invest capital in the enterprise, are paid massive returns on their investment. Recognizing those contentions as false has helped frame the issue in the public’s mind.
Every advanced nation has a functional healthcare system in the sense that quality care is widely available and generally affordable. Ours is the only one that tends to fall short in both respects. Even when healthcare is available, we pay a lot more more for a lot less. In the face of that by now well-known fact, ideology has started to yield ground to good sense. We have a ways to go, but we’ll get there. And here, too, continued rhetorical and practical excesses are speeding up the process.
In brief, when it comes to healthcare in America, I see no reason to feel pessimistic. I am sure instead that quality affordable care is just around the corner – almost inevitably, as it were. And the more determined the efforts to prevent that, the sooner it will be here.
The mills of American democracy often grind slowly, if at all. And before they can grind inevitably, an issue has to be suitably framed. In the case of healthcare, it has been – more by accident than by design, but framed all the same.
I come away from those reflections convinced that of the things that one can do to advance the public interest, few are more important than effectively framing those issues that compromise it. And the public interest in this context is not limited to constructive legislation. Indeed, legislation is mostly a last resort – a recourse to the threat of force in situations where constructive behavior cannot otherwise be assured. Broadly speaking, the public interest coincides with a people’s well-being, including, for example, what we collectively believe that is conducive to that well-being. Where those beliefs are off, an apt framing of issues can have a salutary corrective effect there too.
But that broad conception of the public interest apart, I see pessimism about our general situation (beyond healthcare) as caused by a lack of faith in democracy, and that lack of faith itself as due to obliviousness in relation to the need to frame problems in such a way that workable democratic solutions to them become conceivable.
There are areas of American life where optimism about the future can be hard to come by. They tend to be those where effective framing of the problem requires an enormous amount of work and accidental clarity is unlikely. Economic injustice is a prominent example of such a problem. The pessimism that its persistence inspires invites efforts to put to the test the proposition that greater clarity might enable us to solve it.
One may argue about what constitutes economic injustice, indeed even about whether such a thing actually exists. I’ll just say that we all know the phenomenon when we see it. As worker productivity has been consistently increasing over the past several decades, so has relative worker impoverishment. Virtually all the fruits of those gains in productivity have accrued to the owners of capital. Wages have stagnated. In practice, ordinary people are working harder to make ends meet and often fail to do so, and that’s assuming that they are still employed. Meanwhile, the rich flourish, doing better for themselves than they have at any time in the last one hundred years.
Whatever one may think about this state of affairs from a theoretical point of view, anyone who thinks at all recognizes that it is dangerous. Especially in a society endlessly given to talk about equality and human dignity, it induces anger in its victims, where it makes little practical difference whether the latter are conceptually right or wrong in seeing themselves as victims. Generate enough of that anger, and that society falls apart, or it blows up, with no predicting where the pieces will land.
A person who despite the fact that he or she works hard, can barely feed his family, or keep a decent roof over their heads, does not care about Adam Smith. Nor does a working parent living in a society in which quality education for his or her children is either unavailable or unaffordable. Nor, for that matter, does a college student facing the prospect of owing a fortune in student loans upon graduation and entry into a bleak job market. He or she will be close to retirement by the time those loans are paid off, assuming that s/he will have something left to retire on.
Unfortunately, America labors under the belief that the potentially dire consequences of economic inequality can be averted by convincing the disadvantaged that they have no business being angry. After all, they had the same opportunities as those privileged by Nature or circumstance do; they just failed to avail themselves of them. While that story may convince, it merely turns anger into depression and self-destructive behavior. By blaming them for their misfortune, it makes the disadvantaged feel like failures and worthless. No one wants to feel worthless. The result is a society largely reduced to mindless consumerism, obsessive pleasure seeking, and other forms of escapism. That, too, is dangerous. When people have to be moral heroes in order to bear their lot with grace, there will not be a lot of grace. Instead, there will be plenty of irrationality, vulnerability to demagoguery, and political extremism. The ultimate consequence is a socially and politically dysfunctional nation at risk of destroying itself.
When it takes external enemies and wars to induce a measure of national unity, or at least some semblance of collective sobriety, there will be a lot of enemies and wars. There will be, as always, endless talk about peace, but no peace. The disincentives to achieving it, such as the painful prospect of finally having to get down to our own real business, are overwhelming. Although neither affects us, the violated rights of women in Iran or Afghanistan to wear jeans or miniskirts, or the current quarrel between Russia and Ukraine, make for infinitely more gratifying public preoccupations than the shrinking access of Americans to the economic wherewithal needed for a life livable with dignity.
In America, those advantaged by Nature succeed and the disadvantaged fail or barely get by. By virtue of advances in technology, combined with the relentless race to maximize returns on capital investment, the number of the latter keeps growing. The middle class is gradually disappearing as its members sink into the lower class. Skills that a person could still exchange ten years ago for a decent living are now obsolete or, in any case, economically worthless. And the skills it takes to do the same thing today lie increasingly beyond the reach of the natural abilities of the average person. Understandably enough, we would like to believe that that is not so. We just don’t know what to do about the awful reality that it is so. Hence we keep telling that story about how all it takes is willingness to work and to avail oneself of opportunities, hoping against hope that it may be true after all. The results speak for themselves: widespread disillusionment, cynicism, escapism, endless political diversions, a nation increasingly in disarray, fear for our future.
There is plenty to be afraid of. The problem is alarmingly tenacious. Despite all the talking and warning, despite all the intelligent voices weighing in against it, economic inequality continues to grow. So is the likelihood of dire consequences. It may therefore be time to consider the possibility that we are boxed in by an economic system that though it may once have served us well, is itself becoming increasingly obsolete in relation to our collective goals, as is the ideology that underlies it. But no amount of reflection or discussion on this front is worth the candle unless it issues in clarity, unless, in other words, the issues confronting us in this context are effectively framed.
When I ask myself on this sunny Fall morning what those issues are, one stands out as more basic than all the rest. And it is not the destructiveness of capitalism per se.
II The Value of Ability
Suppose for the sake of argument that instead of material wealth being the reward of the exercise of superior abilities, that reward were honor. Imagine a world in which those who accomplish much are held in high esteem, while those whose abilities are mediocre, and who consequently accomplish little or nothing comparably worthy of notice, are held in low esteem. They are viewed with contempt, even by themselves. In such a world, no one would necessarily go hungry, but there would be nearly as much unhappiness as there is now. Virtually by definition, superior abilities are rare, mediocre abilities, common. Denied what this hypothetical society values most, namely honor and respect, most people in it would be hurting.
Capitalism is only one form that the naturally uneven distribution of abilities assumes when it is tied to differential rewards. It happens to be a particularly egregious form, since it issues in masses of people partially deprived of the fundamentals of physical well-being, like food, shelter, healthcare, and so on, or at least chronically at risk of such deprivation. But the core issue is not capitalism itself. It is the connection between the differential possession of abilities and differential rewards. That, not capitalism, is the main cause of man-made misery.
One may think, of course, that that makes Nature itself the main cause of that misery. After all, the uneven distribution of abilities is a natural phenomenon. Some people are born stronger than others, smarter than others, more resilient than others — in short, more fortunately abled than others. In that sense, the apparent injustice of human arrangements is simply a reflection of the unfairness of Nature.
Of course one can argue that nothing forces us to replicate that unfairness in our institutions. Unfortunately, doing anything else looks like depriving the fortunate of the fruits of what is naturally theirs – like institutionalized theft, in effect, no less theft because it is perpetrated for the benefit of the less fortunate. It can seem as unjust as disfiguring those who happen to be exceptionally beautiful in order to keep the rest of us from suffering because we look painfully plain by comparison.
But that take on our situation omits one crucial fact. The differences in human ability that matter do so for the most part in relation to the place of those abilities in our institutions and arrangements. Nature is unfair only in the sense that it does not equip everyone equally for optimal flourishing in that man-made environment. But Nature has not created that environment, we have. The resulting lack of fit is largely our own doing. So, therefore, is the misery in which it issues.
While it is true that even relatively exceptional abilities, like a facility with mathematics, for instance, acquire their value as assets primarily in relation to a particular orientation and arrangement in human affairs, the point only becomes critical when it comes to abilities that owe their worthlessness to those same arrangements. Because the human enterprise prominently includes science and engineering, mathematics is important, and being good at it makes a person economically fortunate. In the version of it that we apparently favor, the same human enterprise, however, includes nothing in which other sets of abilities and skills that people possess are similarly convertible into economic rewards that make a decent life possible. They happen increasingly to be those unexceptional people possess. To sharpen the point, as a society, we are well on our way to a state of affairs in which a dignified life lies beyond the reach of the majority of its members. Their abilities and skills are economically worthless, or nearly so. That state of affairs in the making, indeed increasingly upon us, is our doing. It is untroubling for the exceptionally abled, near catastrophic for everyone else.
The challenge in this situation does not lie in finding ways of depriving exceptional people of the fruits of their labor, which is, any case, undesirable. It lies in finding ways of assuring access to a dignified life to people who are not exceptional by current standards of assessment. There is no meeting that challenge without changing the societal arrangements from which abilities derive their status as assets. That means an altered configuration of preferences regarding the nature of the human enterprise.
Attempts at bringing that generality down to earth typically founder in reflections about logistics. How, for example, are we going to come up with the economic wherewithal to support a dignified life for all? Who determines what counts as such a life and, more importantly, creates and enforces the rules that guarantee its universal availability? Etc. But all such concerns and discussions about them strike me as premature in the absence of clarity about what exactly we want and why. Let that clarity be achieved first, and then let our collective ingenuity devise the possible logistics, ideally in such a way that we do not end up taking away with one hand what we give with the other.
To sharpen our focus, let’s start with what, other than the obvious, we do not want .
Enhanced by education and training, the endowments of some people enable them to do a lot for a few. Orthopedic and cardiac surgeons are an example. The exercise of their skills can greatly improve the quality of the lives of those afflicted by failing joints or hearts. The beneficiaries, though numerous enough, make up a relatively small percentage of the total population. The different endowments of others enable each of them to contribute a little to the lives of many. The efforts of the public landscape worker, the street sweeper, or the nursing home attendant, for instance, enhance the quality of the environments that affect the lives of many people. Attractive parks and clean streets affect us all. And for the growing population in nursing homes, the quality of the attention each receives can make for the difference between an otherwise depressing environment and a tolerable one. While all that is well-known, knowing it does not keep us from thinking it right that the average annual income of surgeons is at least twenty-five times that of landscape workers or nursing home attendants, or that the former are generally held in high esteem and the latter not. But how many swept streets does it take to match the accomplishment of one cardiac surgeon?
The question sounds absurd because what one might think right or equitable has no bearing on the matter. Anyone can sweep streets, but not just anyone can bring off a triple coronary bypass. Unlike the skill of the former, that of the latter is in relatively short supply and in high demand. Therefore, it fetches a higher price. Call it a fact of life! In reality, however, it is such a fact only in relation to institutions and to an ideology that have the value of skills coincide with what they fetch in the market place, which ultimately comes awfully close to leaving human dignity at the mercy of the impersonal operation of market forces.
However much everyday life in our society reflects that reality, it invites the question wether Americans actually believe that human dignity ought to take a backseat to the operation of the free market. Even if some do believe it, the majority do not. It is tantamount to thinking that only the capable, and the relatively exceptionally capable at that, are entitled to a life with dignity. Most Americans believe that everyone is entitled to such a life. The intrinsic worth of people is not a commodity. But that conviction happens to be sharply incompatible with a state of affairs in which the value of ability is determined by the operation of market forces.
If we genuinely believe that it behooves the economy to serve the values of democracy, not the other way around, then something has to give in this situation. It is either our commitment to the ideal of universal human dignity or our implied collective consent to living under a system that has the value of individual ability coinciding with its market value.
Provided that they do not depend on taking gross advantage of people, no one begrudges surgeons the incomes or quality of life those incomes make possible. And the same goes for anyone else who uses his or her abilities to improve the lives of others. What we do not want is a state of affairs in which people who also do that – street sweepers, landscape workers, and nursing home attendants, for instance – are denied access to a dignified life by market forces that devalue their abilities. What we do not want is a society in which the value of ability is governed by markets. For that is a world in which human dignity is subordinate to economics. And in such a world, universal dignity turns into an ideal that we cannot afford. Opting for it is tantamount to confessing that we cannot afford the ideals of democracy.
Although one may not distinctly hear that message in them, our current political debates convey it. We cannot afford Medicare or Medicaid. We cannot afford Social Security. We cannot afford to raise the minimum wage. We cannot afford food stamps. God knows, we cannot afford quality education for all. It sounds as though we cannot afford anything that comes even remotely close to assuring a dignified life for anyone who is not exceptionally able enough to provide it for himself.
Meanwhile, and by contrast, it seems that we can afford not to curb the behavior of people who take advantage of the economically deprived and make their lot worse. We can afford an entire class of people who help themselves to a living by exploiting the needy. The gross extreme of that phenomenon is populated by payday lenders, who typically charge exorbitant interest rates. Recent legislation has capped those rates at 36%, but only where the borrowers happen to be members of the military. 36% is bad enough, but for anyone else, the rates are even higher. Already badly inadequate incomes end up additionally burdened by the predations of usurers.
Usury does not necessarily wear the recognizable face of storefront lenders in poor neighborhoods or near military bases. A Macy’s credit card, for instance, comes with an interest rate of 24.5%, when the current average rate on non-store credit cards is closer to 12%. It may not be usury in any legal sense, but whatever one calls it, usury or clever business practice, it takes a toll on people who can least afford it.
Usury aside, the same phenomenon wears many other faces. In poor neighborhoods, people typically pay more for shoddier goods. Used car dealers extract their pound of flesh, not from those who know better and have the means to insist on getting their money’s worth, but from those who don’t. The same goes for housing: the less you can afford, the larger the difference between what you pay and what you actually get. It is a lot easier to take advantage of the poor than of the rich. Think of all those fly-by-night education programs that enroll people with the promise that the training they dispense will open the doors to good jobs. Their paying customers are the gullible, the poor, or the working poor, who desperately need better jobs, and who usually discover at the end of the exercise that they have been taken for a ride.
When it comes to this general phenomenon, let’s add that the needy, in this context, include not just those who lack the means to hold body and soul together. They include anybody who, for one reason or another, find themselves over an economic barrel. They include all those, for example, who work in jobs that do not pay a living wage, or that extract more from them than they receive in return, because that is the only jobs they can get. Not always, but more often than it would be nice to believe, the people on the other side of that transaction are predators who take advantage of other people’s distress and duress.
In brief, it seems that we can afford hospitality to predators who, admittedly, are also people, not infrequently hard up themselves, but who nonetheless make an already dangerous situation even more dangerous by increasing the suffering of others.
It seems that our collective sense of of what we can afford is badly off.
The ideals of democracy include actual, not theoretical, access to human dignity for all. For a nation that makes as much of those ideals of as ours does, a nation that virtually defines itself in terms of its commitment to them, it is not an option to sell them out so as to spare itself the trouble of living up to them. Translated into concrete reality, living up to the ideals of democracy involves disconnecting the value of individual ability from its market value. Speaking concretely in relation to the current state of affairs, that means acknowledging the value of abilities that have none in the market place and, moreover, doing so not just in theory, but through societal arrangements that make a practical difference for people whose inventory of abilities is in that sense currently worthless.
That, I would say, is the core issue that confronts us in economic inequality. We want a society that lives up to the ideals of democracy and we can’t have it without disconnecting the value of individual ability from its market value. The situation presents us with an intimidating dilemma that we understandably try to dodge with talk about equal opportunity. That talk does not work when economic opportunity is conspicuously unequal and when we are not willing to make the momentous societal changes required to equalize it.
Once we face that issue squarely, we can worry about logistics. Whenever I start doing that, the thought occurs to me that in our society plenty of now worthless ability coexists with nearly endless unmet need.
On one side of the fence, young working parents need childcare that they often cannot afford. Or their children need education than no one can afford either. While some people growing old are happy to be left alone and value their independence, others, growing older, need help. With their bodies failing and their mobility impaired, they would welcome someone cooking their meals, doing their shopping, or driving them to a nearby grocery store. They might even welcome some companionship. Instead of living marginalized and out of sight, depressed by their uselessness, they might enjoy an opportunity to share what they know after seven or eight decades of living. Although they lack the strength to build it themselves and can’t afford to have one put in commercially, they may need a garden shed or have theirs repaired.
Even in the affluent town in which I live, some friends of mine heat their house with coal. It is considerably cheaper than heating oil or electricity. The downside is having to haul that coal up from the basement to their stove and cleaning out that stove every day – physically demanding work. A day will come when they can no longer do it. They are in their seventies already and that day is not far off. When it comes, they will need help. Of course they could move, but they love their home.
Even out here on the Cape, there are towns with some streets depressing in their ugliness. The houses cry out for paint, the windows need washing, the gardens tending. The people living there lack the means to attend to those tasks or to pay someone to do so. A disheartening local environment compounds their already dreary lives.
On the other side of the fence, there is nearly endless ability, much of it going to waste because it has no market value. But it has value in relation to all the unmet needs clamoring from across the fence. It takes no degree from MIT to take care of a child, or half a dozen of them, to tell them a story, or to teach them to read. It only takes a car and a driver’s license to drive an old neighbor to a store, and less than that to cook them a meal. All it takes are average abilities to do all of the things mentioned earlier.
“Yes,” I hear you say, “but everyone needs to eat. Where is the food coming from? Who is building the car used to drive that aging neighbor around? Who mines and delivers the coal? Who puts in the electrical wiring in the houses? Who provides the healthcare?” Who indeed! The same people who do that now, except that, unlike now, they would not do it because they have to, or because they want to get rich, but because they want to. They want to because the value of ability lies in its power to meet human needs. And it is up to everyone to figure out where his or her abilities will do the most good.
No doubt there are jobs that no one wants to do because they are so unpleasant. Let machines do them. Instead of exercising ourselves, as now, about how to build high-end cars that park themselves, we might choose to focus more intently on technology that alleviates the drudgery and unpleasantness of some forms of necessary work.
But how about the fields in which that food is grown, the factories in which those cars are built, and the materials needed to build them? Well, what about them? They are forms of wealth, the accumulated fruits of ability, concentrated ability, if you will. What is wealth good for, if not to meet needs?
Of course a different mentality would have to replace the one with which we operate now. According to it, our business as individuals is to build a society that is genuinely hospitable to the core ideals of democracy and to build it, not because someone tells or forces us to do so, but because we are committed to those ideals. That mentality will eventually emerge once it is clear to us what we want and don’t.
As for the logistics, I am perfectly content to have that story emerge from the exercise of our collective ingenuity. A nation that can put a man on the moon and bring him back in one piece has plenty of it. I will only suggest that one large consequence of the ideological change envisaged here would be an enormously reduced waste of our natural resources. Building cars for transportation, for instance, we would have an interest in building cars that last, and none whatsoever in wasteful built-in obsolescence. In the face of a shrinking availability of fossil fuels, not to mention climate change caused by their consumption, we would be building houses kept warm in the winter by radiant heat. Where I live, the temperature of the ground water – summer or winter – is a constant 56 degrees. It takes a lot less energy to get a house from that temperature to 68 degrees than from outside winter temperatures of 20 or 30. Let that water course through radiant heat installations, supplemented by solar energy, and heating costs would be a tiny fraction of what they are now. So would waste of energy, as well as its impact on the climate.
On the other side of those and similar realities, individuals would have an incentive to think twice before adding burdens to a support system that, however generous, has limits. They would waste less. They would not throw away food that others grow, or while some people go hungry. Nor would they thoughtlessly add mouths to the table by producing children as though there were no tomorrow. We all love children, but what can you do with five of them that you cannot do with two? People who need more than two might take care of their neighbors’. Now at seven billion, the world’s growing population is a problem too, one just waiting to place a serious strain on the planet’s resources, if it doesn’t already.
It is getting to be afternoon and I should probably stop here. Let me just briefly add this.
While I talk of commitments to ideals that present themselves as abstractions, those ideals reflect emotions. My revulsion in the face of a state of affairs that effectively denies millions of people access to dignity wells up as empathy. For all the differences between us, they are each of them a person like myself. I hardly dare imagine what it must be like to have to live as they do. And in the interest of my peace of mind, I shouldn’t; I should suppress my empathy because it induces distress.
Coming full circle, I happen to think of that as another front where clarity is thin on the ground. The roots of our moral and social obligations are essentially emotional. A world in which those obligations are unmet or unmeetable insults human sensibility. Empathy is part of basic humanity, not as prescription, but as fact. And as I think of the ideals of democracy, they represent an attempt to enshrine that fact in institutions that strive to acknowledge it and to do it justice. In my mind, commitment to those ideals reveals human beings at their edifying best as beings who feel and feel for each other. That is not (yet) the actuality of America, but it is her promise. All our political and ideological nonsense, including much right-wing rhetoric, speaks loudly of the heart of a culture averse to the sight of grotesque human realities, trying to pretend that they are not real because that sight is unbearable.
©Serge Kappler 2014