HEALTH CARE/Joan Retsinas

Universal Insurance: Protecting the 'Undeserving'

The Biblical admonition to be your brother's keeper is not hard. Family ties are so strong that most people try to help their assorted kin. (Look at the elected officials who tuck a moronic in-law or two into civil service sinecures.) Fratricide a la Cain is both revolting and rare. Similarly, "Love thy neighbor" doesn't ask much. Neighbors tend to resemble each other, if only in socioeconomic status. More importantly, we know our neighbors, so loving them &emdash; while unlikely &emdash; is not implausible. "They" &emdash; whether kin or neighbors &emdash; share ties with "us."

It is harder to care about strangers with different values, different cultures. And it is even harder when we don't like those strangers' cultures. That is why we give welfare so stingily, insisting that recipients emulate the middle class values of taxpayers: hard-working, ambitious, anchored in families. Our "welfare-to-work" requirements demand that mindset. While taxpayers willingly subsidize the "deserving" (of help) poor, taxpayers balk at subsidizing the "undeserving" ones. (In a semantic twist, the people undeserving of welfare are seen to deserve their penury.)

Under universal insurance, however, everyone &emdash; the lazy, the unpatriotic, the criminal, the depraved &emdash; will come under the protective governmental yoke. That is the rub with universal insurance &emdash; one reason that politicians, running in a year of deficits, run from this idea. One reason states are not expanding their Children's Health Insurance plans, where the government insures children whose parents earn too much for Medicaid, yet not enough to buy insurance. One reason states are paring their Medicaid rolls. The wider the net of government insurance, the more "unworthies" that net will catch: people "we" wouldn't like if we knew them &emdash; people whom we hope we never meet. Taxpayers will be subsidizing genuine strangers.

So politicians draw a Jesuitical line through health insurance: the "universal" idea is out. In this recessionary season, the government must winnow out the unworthies. Children, especially young ones, are in, but their parents &emdash; particularly the profligate rarely-employed parents &emdash; are out. Certainly the parents who could afford to buy insurance are out: They are "gaming" the system, eager to save a buck. Indeed, some states have instituted premiums for insurance, even though some parents - presumably the irresponsible ones - won't pay. "Fiscally responsible" politicians, wooing tax-weary voters, want to keep government insurance an extension of welfare, with stringent eligibility.

But self-interest (a very middle-class value) should skew this discussion. Compassion, generosity, justice &emdash; those virtues may have little coinage in politics. Self-interest, though, does; and in the name of self-interest, we should insert "universal" back into the discussion. It is in the interest of fully-employed, fully-insured taxpayers to cover everybody &emdash; not just children, but their parents &emdash; giving Americans under age 65 the same protection that those over age 65 take for granted.

Here are reasons to insure (not love) the strangers &emdash; even the unworthies &emdash; in our midst.

First self-interest reason: Infectious diseases. Hepatitis, measles, rubella, tuberculosis, AIDS, and their ilk cross social barriers. At work, at school, in movie theaters, in supermarkets, on public transit, both the worthies and unworthies mingle, sometimes sharing bodily fluids. Self-interest demands that everybody get vaccinated and treated. While insurance coverage does not guarantee treatment, it increases the odds.

Second self-interest reason: Productivity. A soaring Dow depends upon productivity, which depends upon an industrious, creative &emdash; and consequently healthy &emdash; workforce. Workers with chronic diseases, like asthma, diabetes or arthritis, need regular medical oversight. And healthy workers who get sick also need medical attention, to return to work quickly. Again, insurance coverage won't make workers take care of themselves; but it increases the odds.

Third self-interest reason: Money. The United States spends more of its GDP on health care than countries with universal coverage, yet we are buying not just MRIs and CAT scans, but marketers, advertisers, utilization reviewers, and million-dollar CEOs. Today's pastiche of plans, each with its administrative coterie, is expensive &emdash; making Medicare, with its 3% administrative overhead (and its government-salary CEO) a bargain. Universal coverage will cost less than the status quo.

Ultimate self-interest reason: Us. "We" may someday be "them," vulnerable to a pink slip, an illness, a bankruptcy.

Ironically, the liberals pressing for universal coverage are not fiscally rash. Instead, the politicians who press for insurance-as-welfare are the profligate ones, because "Protecting everybody" is not so much a Biblical injunction as an Adam Smith one.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I.

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