post by Bill Gardner
I wrote that the ACA is, among many other things, a scheme wherein the health insurance of (some of) the poor in the red states is partially subsidized by more affluent taxpayers in the blue states. (Possibly highly subsidized: see Phil Galewitz here.) And I argued that blue state taxpayers should have no objection to this, because "Americans need and deserve health insurance regardless of where they live."
Brendan Saloner responded (in the comments to that post) to warn me about where this argument leads:
But, EVERYONE needs and deserves health insurance whether they live in Manhattan or Madagascar... why draw the boundary at national borders?
That is, if I feel obligated to subsidize insurance for someone in Egypt, Texas, don't I have a similar obligation to someone in Cairo, Egypt? Brendan assumes, correctly, that I don't think we are obligated to make people in Cairo or Matamoros eligible for Medicaid. But why not? Liberal principles encourage us to treat individuals equally regardless of where they were born. Why should living south of the Rio Grande or on the Nile matter?
Brendan argues there can be morally valid reasons to limit the scope of some of our obligations at national or even US state borders:
[One] could hold that duties to others are limited by shared institutions -- in Massachusetts, we all abide by the state tax system (which supports us if we are young, very old, or low income), and which we pay into at other stages of our lives. These institutions do not bind us with people in other less generous states or localities -- even though we share a national connection, and are ultimately bound by the same sovereign authority.
I agree, but why does the lack of shared institutions relieve us of the obligation to care for another member of our community? One reason -- there are others -- is that we have no obligation to attempt the impossible. The lack of shared institutions makes it impossible to administer US Medicaid in Egypt. We'd have to figure out how much the Egyptian government ought to pay in, how they would control fraud, and so on.
But that doesn't completely settle the issue. Human institutions are mutable. If there is global suffering or a global threat that can't be addressed because we lack the requisite common institutions, then we are obliged to consider whether such institutions can be built.
In the case at hand, the better solution is for the Egyptians to develop their own health insurance system. Global warming, however, is another matter. We may need to find collective and global solutions to global warming, but we do not currently have the institutions that can support the solutions. So we have to think through what institutions the global community needs, and how to build them.
And here, let me say that this summer, Something Not Unlike Research is going to begin discussing the moral issues posed by global warming. We are looking forward to your comments.