The ACA, social insurance, and human solidarity

Most liberals and Democrats admit that the rollout of the Affordable Care Act has been a mess. How serious this is for the long-term success of the law is a matter of debate, but no one thinks this has been anything other than a rocky start. The most visible problem, of course, has been the all-but-non-functional healthcare.gov website, which has prevented people (how many is uncertain) from signing up for insurance plans under the new federal exchange. But more recently the focus has shifted to the architecture of the law itself–specifically changes to the individual insurance market which have resulted in people having their existing policies cancelled and, in at least some cases, seeing the amount they will have to pay to get new policies go up.

There are good wonky liberal responses to this–Jonathan Chait provides a nice overview here. The short version is that two groups–those without any insurance at all and those who purchased individual insurance–were always going to be the ones most affected by the ACA. For the former, the effects were virtually all positive: they would either be able to afford insurance on the exchanges, possibly qualifying for subsidies to help, or they might fall under expanded Medicaid eligibility. In the case of the latter group, things are a bit more mixed. Many of these people would find that they could now afford policies that were cheaper and/or better than what they had before. But at least some of these people (no one seems to know for sure how many) would end up paying more for policies comparable to what they had before. This is the much-vaunted “sticker shock” we’ve been hearing about.

As Chait explains, the reason for this is relatively simple: the whole purpose of insurance is to put people into risk pools in order to spread risk (and hence cost) around. Thus in any risk pool, those people with lower risks (in this case, the young and healthy) are going to end up “subsidizing” those with higher risks (the old, the sick, etc.). So people who were able to get policies for less, because insurers could discriminate based on your health history, may now find themselves paying more because they are in a pool with people who previously would’ve had to pay more, or wouldn’t have been able to get insurance at all. The very same principle operates in the employer-based insurance model, which is how most Americans currently get their insurance. People whose age and health vary widely are grouped into a single risk pool, with the younger, healthier people effectively subsidizing the older and less healthy.

From a certain point of view this all sounds horribly unfair. But only if you take an ultra-individualistic, short-term view of fairness. As David Kaib nicely explained in a post yesterday, the concept of social insurance rests on a sense of social solidarity. We spread risk around because we want everyone, within limits, to be taken care of and have a shot at a decent life. All wealthy societies have implemented forms of social insurance, including the U.S., despite our individualistic rhetoric.

The notion of solidarity rests not only on concern for our fellow citizens, but also a more realistic understanding of our own self-interest. Social and political philosophers like Alasdair McIntyre, Martha Nussbaum, and Susan Moller Okin have pointed out that much of the Western political tradition assumes that the typical or normative human being is a healthy, independent, male individual, and this has distorted our concepts of justice. In reality, all of us find ourselves, at some point in our lives, dependent on others, whether as infants and children, or because we get sick, or because we get old and frail and lose our minds. We are “dependent rational animals,” in McIntyre’s suggestive phrase. Vulnerability and dependency are instrinsic to the human condition.

This means that even if you are a young, healthy person, you will, inevitably, be an old or sick person. And when that happens, younger, healthier people will be caring for you. Social insurance is simply a way of institutionalizing this, making it less ad hoc and subject to chance.

It should be obvious that these principles are congruent with Christian ethics, which enjoin care for the neighbor, respect for parents, and justice for the poor, the widow, and the orphan. Moreover, the doctrines of original sin and unmerited grace emphasize our common human lot and fact that none of us can save ourselves. Conservative Christians sometimes argue that social insurance is not a proper responsibility of government but that relief for poverty and sickness should come voluntarily from churches and other non-governmental entities. But there’s very little in the Christian ethical tradition per se to support such a restrictive role for government; this view owes more to libertarian conceptions of the “night-watchman state” than anything specifically Christian.

Unfortunately (from my perspective), the U.S. is still caught in the debate over whether the government has a proper role in ensuring economic security for all its citizens. This distinguishes us from most European social democracies, where the debate is more about the means by which the government should do this, the precise levels of expenditure, etc. During the last election, the Democrats emphasized solidarity and interdependence to some extent (e.g., the president’s (in)famous “you didn’t build that,” and in some of the speeches at the Democratic National Convention), but American political discourse still seems largely driven by notions of individual rights and deserts. We need a stronger culture of solidarity to underwrite a commitment to social insurance, and thus the possibility of human flourishing for all.

Capitalism, liberalism, and the good life

I enjoyed this review by philosopher Gary Gutting of Robert and Edward Skidelsky’s How Much Is Enough? (I haven’t read the book.) The Skidelskys, according to Gutting, argue that, under capitalism, we find ourselves with relative material abundance but without enough time to pursue “intangibles such as love, friendship, beauty, and virtue”–which are essential ingredients of a good life. Moreover, capitalism, with its seemingly insatiable drive toward increased production and profit, creates in us the desires for more and better things, and these desires crowd out our desires to pursue the intangible “higher goods.” They say we need to redirect our society toward the good life with measures to curb these pernicious effects of capitalism–such as a guaranteed basic income and a consumption tax on luxury goods.

This isn’t an unfamiliar line of argument, but Gutting goes on to consider two types of objections. First, utilitarians might argue that the good life consists in maximizing subjective states of satisfaction (i.e., happiness as commonly understood), not the attainment of objective goods. Appealing to Robert Nozick’s “experience machine” thought experiment, Gutting replies that it’s implausible to think that subjective satisfaction is sufficient for a good life–though he agrees it’s probably necessary. And he thinks the Sidelskys could easily take subjective satisfaction on board as part of their account of the good life.

More difficulty for the Sidelskys’ argument is posed, Gutting thinks, by liberalism’s insistence on personal autonomy and its demand that the state be officially neutral among competing views about what constitutes a good life. Liberal societies, according to this view, shouldn’t try to impose a specific vision of the good life as a matter of public policy. So the Sidelskys’ proposals seem like non-starters because they would violate the liberal commitment to anti-paternalism.

Gutting thinks the liberal objection can be met by a renewed emphasis on liberal education. Such an education exposes us to different ways of living and can act as a counterweight to the acquisitiveness fostered by capitalist society. This would provide, Gutting hopes, a “bottom-up” rather than a “top-down” corrective to the problems the Sidelskys identify:

There is a risk that free citizens educated in this way will not arrive at the truth we have in mind. They may, free and informed, choose the material illusions of capitalism. But, in a democracy, an ideal of the good life has no force unless the people’s will sustains it. Liberally educated consumers—and voters—are our only hope of subordinating capitalism to a humane vision of the good life.

While this is good as far as it goes, I think Gutting may be underestimating the resources political liberalism has for addressing these concerns. Gutting says that the “basic goods” advocated by the Sidelksys, such as “health, security, respect, personal freedom …, harmony with nature, friendship, and leisure” differ from the “primary goods” that liberals advocate as prerequisites for effective individual freedom to pursue a variety of lifestyles. But I wonder if the Sidelskys’ list is really at odds with what liberals like John Rawls or Martha Nussbaum (or for that matter sophisticated utilitarians) would advocate at the level of public policy.

People sometimes underestimate how radical the implications are of what philosophical liberals advocate. If we really took seriously the requirement to ensure equal access to primary goods (Rawls) or capabilities for functioning (Nussbaum), or equal consideration of interests (utilitarianism), I think American society would look a lot different. It would be much more economically egalitarian and probably as a result would produce fewer luxury goods. Besides, on any reasonable, non-totalitarian view of public policy, there has to be some scope for people to make choices that depart from some officially preferred vision of the good life. Indeed, as liberals from J.S. Mill onward have argued, such freedom is an indispensable ingredient of the good life. On a practical level, then, I’m not sure how much the Sidelskys’ desired end-state differs from that of liberalism.

Friday Links

—What Makes Life Good? An excerpt from Martha Nussbaum’s new book.

–Johann Hari makes the case against the British monarchy.

–How progressive are taxes in the U.S.?

–Ten teachings on Judaism and the environment.

–Marilyn of Left At the Altar reviews Laura Hobgood-Oster’s The Friends We Keep: Unleashing Christianity’s Compassion for Animals.

–A very interesting New Yorker article on the love-hate relationship between fantasy author George R.R. Martin and some of his fans.

–The fantasy of survivalism.

–Intellectual disability and theological anthropology.

–Do we need “Passion/Palm Sunday?” Seems like this comes up every year, and I’m not sure there’s a good solution.

–Mark Bittman on the cost of “lifestyle” diseases.

ADDED LATER: On Dutch efforts to ban traditional Jewish and Islamic practices of animal slaughter.

ADDED EVEN LATER: The spiritual benefits of headbanging, riffing (pun intended) on this Atlantic piece: How Heavy Metal Is Keeping Us Sane. (Thanks, bls!)

ONE MORE: It sounds like the movie version of Ayn Rand’s Atlas Shrugged is every bit as bad as you’d expect.

Nussbaum’s capabilities approach to justice

I mentioned a while back that I was reading Martha Nussbaum’s Frontiers of Justice. To re-cap briefly: Nussbaum criticizes social contract theories of justice for their inability to deal with three cases: duties to the disabled, to foreigners, and to nonhuman animals.

As a supplement (or replacement–it’s not entirely clear to me), she recommends her “capabilities approach.” Instead of arriving at principles of justice by way of a hypothetical contract entered into for mutual advantage, the capabilities approach identifies certain key capabilities that are essential for each member of a minimally just society to have. These relate to functions that, according to this view, are essential for any flourishing life.

The capabilities Nussbaum lists are:

1. Life
2. Bodily health
3. Bodily integrity
4. Senses, imagination, and thought
5. Emotions
6. Practical reason
7. Affiliation
8. Relationship with other species
9. Play
10. Control over one’s environment (both political and material)

These capabilities don’t define the good life in a comprehensive way; rather, they’re supposed to be necessary conditions for a variety of lifestyles. Nussbaum’s view is a “liberal” one in the same way that Rawls’s is: the account of justice is “political not metaphysical.” That is, adherents of a variety of conceptions of the good life could, in theory, agree to this list of capabilities as a minimum set of entitlements that a just society should guarantee to each of its members. (Following Rawls, she refers to this as an “overlapping consensus.”)

Nussbaum’s view is also liberal in a second sense. It leaves the decision of whether or not to exercise these capabilities up to the individual. For example, it’s not up to the state in a just society to ensure that people are living healthy lives, but it does have a responsibility for ensuring their access to the capability for living healthy lives (by, for example, establishing a system of public health care that guarantees universal coverage).

In Nussbaum’s account, this list of capabilities is an elaboration of a certain intuitive idea of human dignity and what is required to flourish as a human being. These evaluative underpinnings determine what capabilities are proper for justice to secure. There are capabilities that humans have–for cruelty or sadism, for instance–that are not necessary for a flourishing life.

This is a point where I’m unsure how Nussbaum’s theory works. If the capabilities depend on a prior idea of “human flourishing”–one that excludes some capabilities and not others–where does the idea of flourishing itself come from? Nussbaum is clear that flourishing can’t simply be read off from nature, as it were. Humans have many capabilities that they shouldn’t necessarily exercise. But Nussbaum doesn’t provide–at least in this work–a worked-out account of just what flourishing consists in and how we determine that.

I think what Nussbaum would say is that all she needs for her approach to work as an account of political justice is for the capabilities to be derivable from or consistent with various accounts of flourishing that are entailed by different views of the good life found in a pluralistic society. For instance, a Christian and a secularist may disagree profoundly about the nature of the good for human beings, but still be able to agree on Nussbaum’s capabilities list as necessary for the realization of both of their visions.

As she writes:

Insofar as a highly general idea of human flourishing and its possibilities does figure in the approach, it is not a single idea of flourishing, as in Aristotle’s on normative theory, but rather an idea of a space for diverse possibilities of flourishing. The claim that is made by the use of this single list, then, is not that there is a single type of flourishing for the human being, but, rather, that these capabilities can be agreed by reasonable citizens to be important prerequisites of reasonable conceptions of human flourishing, in connection with the political conception of the person as a political animal, both needy and dignified; and thus these are good bases for an idea of basic political entitlements in a just society. (p. 182)

This is appealing, but “reasonable” seems to be doing a lot of the heavy lifting in this paragraph. How do we determine which conceptions of human flourishing are reasonable? Are they just whatever ones support the capabilities on Nussbuam’s list? But that seems to be arguing in a circle. Otherwise, we need some substantive notion of “reasonableness” that rules out some conceptions of flourishing as beyond the pale. This would seem to amount to a kind of “meta-account” of human flourishing that includes a variety of more specific conceptions within it. But how can we determine what that is?

I confess I don’t have a clear or fully informed understanding of the theory. So take this for what it’s worth as a kind of first impression.

Friday links

–The Australian broadcaster ABC’s Religion and Ethics site has a series of articles by Martha Nussbaum on democracy and education: parts 1, 2, and 3.

–Coal is not cheap.

–Vegan nutritionist Virginia Messina argues that healthy diets can include meat analogues. (A corrective of sorts to anti-processed-food extremism.)

–At the great metal blog Invisible Oranges: why lyrics matter.

–Camassia has the first part of a review of Miroslav Volf’s interesting-sounding new book Allah: A Christian Response.

–Radiohead has released their new album “King of Limbs” a day early. You can download it here. I haven’t heard it yet, but the early reviews seem to be mixed. On the other hand, Radiohead albums generally take several listens to digest, so I’m withholding judgment.

–Paul Krugman on the budget “debate.”

–What’s going on in Bahrain?

–The Madison protests are about union-busting, not budget cuts.

–The history of using the National Guard to break strikes.

–According the calendar observed by Lutheran and some other Protestant churches, today is Martin Luther’s feast day (he died on this date in 1546).

ADDED LATER: The Nation‘s “Breakdown” podcast, hosted by Chris Hayes, tackles “the confusing concepts that make politics, economics and government tick” via questions submitted by listeners. This week’s episode tries to answer a question I asked: Why exactly are government deficits bad? (If or when they are.) Chris’s guest is economist Robert Pollin. You can listen here.

This seems appropriate for today:

Nussbaum on problems with social contract theories

I’m reading Martha Nussbaum’s Frontiers of Justice, which is an expanded version of her 2003 Tanner Lectures. In it, Nussbaum develops and applies her “capability approach” to social and political justice in three areas that traditional moral theories have often ignored: duties toward the disabled, foreigners, and nonhuman animals.

A major part of Nussbaum’s project is criticizing the social contract tradition, which, she argues, is incapable of dealing with these three issues. In her view, this is because most social contract theories (including that of John Rawls, whom Nussbaum considers to be the best exemplar of this tradition) are built in such a way as to exclude the claims of the disabled, the foreigner, and the nonhuman animal by definition.

In a typical social contract theory, principles of justice are derived by stripping away irrelevant features of actually existing human societies and asking what principles would be agreed to in a hypothetical contract arrived at by rational, self-interested persons of roughly equal bargaining power, physical strength, intellectual ability, etc. Nussbaum notes that some earlier forms of social contract theory (e.g., Locke) are impure or hybrid varieties because they incorporate elements of an earlier natural law tradition–for instance, the idea that each person has an innate moral dignity that entitles them to certain treatment. But as we get further away from that tradition, the features of the social contract more closely approximate an agreement between rational, self-interested agents without any prior moral constraints.

The reason social contract theories can’t adequately account for her three anomalous cases, Nussbaum thinks, is that the principles of justice they come up with are, by definition, those that would be appropriate for “normal” adults–i.e., people who are roughly equal in physical and intellectual capability. This is for the very simple reason that the parties to the social contract are assumed to be such normal adults (even in Rawls’s rarefied “original position”) and the principles they agree on are those they would choose to protect their own interests. Thus, the principles of the social contract can’t adequately account for or protect the interests of those who fall short of this kind of rough equality (e.g., the disabled or nonhuman animals). In fact, many social contract theorists explicitly deny that we have direct duties of justice to such “marginal cases.” We may care for them, out of sentiment or a sense of benevolence, but they are not owed anything as a strict matter of justice. (Although it’s not one of Nussbaum’s focuses, it seems that children would also fall beyond the pale for similar reasons.)

Most of Nussbaum’s book is aimed at showing how her capability approach–which, as I understand it, is kind of an updated Aristotelianism–can more adequately deal with these borderline cases than traditional theories, particularly social contract ones. I’m especially interested to see how she applies it to the case of nonhuman animals.