Medicaid: An American Parable

By David K. Shipler

            Watching the Republican governors who still insist that they will not accept a penny of the federal government’s money to provide health insurance to their near-poor citizens brings to mind Alexis de Tocqueville, the French historian who traveled in the United States in 1831. He saw a country honeycombed with generosity taking the form of myriad associations organized to promote one worthy cause or another.

What he chronicled in his work, Democracy in America, has come down to us as evidence of our powerful impulses to charity, to philanthropy, to the common good—so much so that today, United Way chapters present annual Tocqueville awards to honor individuals who have been exceptionally generous with time or funds.

To be sure, Tocqueville was not a big-government advocate. He admired citizen-led private efforts over those that came from above. “Wherever at the head of some new undertaking you see the government in France or a man of rank in England,” he wrote, “in the United States you will be sure to find an association.”

But for a modern society, intricate with technological and economic complexity, this observation raises two questions: one practical, one moral. What mechanism is most practical in, say, the area of health care? What can be done privately, and what must be done publicly? And where does moral responsibility lie? Only at the local level of community, or on the broader plane of national concern?

These are the elements of our most acerbic debates as we struggle and disagree over where to locate the shifting line that should divide the private from the public.
We agree that roads, bridges, policing, fire protection, garbage collection, national defense, and (for the most part) secondary schools are government responsibilities. We differ over how much the public sector should subsidize housing, support the elderly, feed the poor, train the unemployed, sponsor the arts, fund research, pay for medical care, and so on.

Looking back is instructive. The nineteenth century was hardly a time of justice: Blacks were enslaved and women had no vote. But it may be reasonable to imagine that in Tocqueville’s America, there would have been no debate if, say, a wealthy gentleman, hearing of a certain family’s hardship, approached the family’s church and offered to pay for all of the family’s medical expenses for the next three years if the church would chip in later: just 5 percent beginning after that, and then 10 percent beginning eight years from now. The well-to-do benefactor would pledge to continue paying 90 percent indefinitely. Of course this is “Obamacare’s” magnanimous pledge to states to expand Medicaid coverage to those with earnings up to 138% of the poverty line.

It’s an offer you couldn’t refuse if you cared about the struggling family in your midst. Perhaps a special association would even be organized to see it through.

The parable is not so pretty today. The pastor and the congregation would meet to consider the proposition. They think of themselves as good and caring people, and the struggling family is known as hard working—so hard working that earnings put them just above the poverty line, barely enough to make them ineligible for Medicaid and certain other programs. That line is merely $22,050 for a household of one adult and three children, and to reach it, the adult working fulltime would need $10.63 an hour, $3.38 above the federal minimum wage, and $1.63 above the $9.00 minimum that Obama proposed and Republicans oppose.

Furthermore, this family performs essential services to sustain the comfort of other parishioners: mowing their lawns, washing their cars, painting their houses, delivering food to their grocery stores, cleaning their offices by night, stocking their stores’ shelves by day, dry-cleaning their clothes, and watching over their children at daycare centers. The private market does not pay them enough to keep them healthy.

You’d think that would move this church’s congregation, but in the end, the majority, led by its recalcitrant pastor, decides that they don’t like this wealthy man, don’t want an outsider sticking his fingers in their business, don’t want to pay for even a tiny slice of this family’s health care directly. They will pay for it indirectly in the long run, as the American Association of Retired Persons has documented, in higher fees by hospitals that have to treat the uninsured in emergency rooms, and in treatment for chronic illnesses once these folks reach Medicare age, diseases that might have been avoided by preventive care in middle age. But we are a people ruled by the fleeting fears of the moment, not the long and hazy future.

Fortunately, some who preach sink-or-swim ideology have been converted to accepting Washington’s largess, most recently Gov. Rick Scott of Florida. It will be interesting to see whether the Republican governors of Alabama, Georgia, Idaho, Louisiana, Maine, Mississippi, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Texas and Wisconsin also change their minds.

“Americans of all ages, all conditions, and all dispositions constantly form associations,” Tocqueville wrote. If we are to do in a vastly complicated society what our forbears did in his time, government is unavoidable as a complement to, not a replacement of, that drive to organize.

“They have not only commercial and manufacturing companies, in which all take part,” Tocqueville observed, “but associations of a thousand other kinds, religious, moral, serious, futile, general or restricted, enormous or diminutive. The Americans make associations to give entertainments, to found seminaries, to build inns, to construct churches, to diffuse books, to send missionaries to the antipodes; in this manner they found hospitals, prisons, and schools. If it is proposed to inculcate some truth or to foster some feeling by the encouragement of a great example, they form a society.

“I met with several kinds of associations in America of which I confess I had no previous notion; and I have often admired the extreme skill with which the inhabitants of the United States succeed in proposing a common object for the exertions of a great many men and in inducing them voluntarily to pursue it.”

Some conservatives worry that this individual initiative will be extinguished by extensive government. I don’t think so. The fate of generosity is more worrisome.