Am I my brother's insurer?

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.

 

Comments

[Will]

One untouched aspect of this issue is the option of relieving suffering by allowing migration. Especially with global warming (and water running out in Yemen, and lack of economic opportunities in Spain...) we might be able to do the most good for some people by allowing them to join our institutions/country.

I'm most comfortable with a mix of free-market principles and Obama's immigration reform on easing global suffering. A free-market must allow for human capital to move around at free will - so those people stuck in Egypt should be allowed to move to America and take advantage of our institutions.

I bring up Obama's amnesty to those under 30 because due to resource and political constraints the abolition of nation-defined internment will probably only be available to people under the age of 30. I hate to sound prejudice but I don't know if 50 year old's will ever be capable of adjusting to America in a fully productive way.

Oh and now you have to consider brain drain.

Ahhhhhh! So difficult.

[Brendan Saloner]

Bill,

I'm very honored that you crafted such a thoughtful post partially in response to my earlier comment, and I think Will also brings up another tricky and interesting issue with immigration.

The fact that we cannot administer Medicaid in Egypt counts as a very good reason why institutions can make a difference in our moral commitments. But I think the significance of institutions runs deeper than feasibility -- there are many things that we can do to aid non-citizens, but which we are not obligated to do. We could provide resources in the form of targeted foreign aid to reasonably competent and transparent governments (like Rwanda or Botswana) to provide comprehensive public insurance with services on a par with Medicaid (thus surpassing a standard of care in the developing world). That might do a lot of good, but it is not an obligation -- certainly not on a par with providing Medicaid to poor Americans.

I think institutions matter because they establish the ground rules for a particular political, social, or economically interdependent group of people, they represent the terms on which we who are intimately bound with one another should be treated. As our world becomes more global, and more interdependent, weaker ties are also created with non-citizens (for example, Chinese workers who make electronics and sneakers). The notion I was playing with -- but I'm not confident what I believe -- is that the spheres of obligation can be carved below the level of nations to encompass separate responsibilities and claims among people who live in the same cities, provinces, and states. I think the devolved structure of American government lends itself to this kind of an arrangement, even though I also see that a devolved system is a major source of inequality in America, and often a hindrance to progressive social policy.

I'll also blog about this at some point.

B

[Brad F]

As I read above, and listened to something from Health Affairs moments before, the ironic juxtaposition popped out. Its a lovely piece, and you will see what I mean:
http://itunes.apple.com/us/itunes-u/global-health-narrative-matters/id394958948

Its the 7/6 posting. Something to be learned.

Brad

[Brendan Saloner]

Yeah, it's very interesting Brad. I just gave it a listen, and recommend it to others.