Should people be forced to choose between quitting a job they hate and losing their health insurance? In the wake of a Congressional Budget Office (CBO) report suggesting that 2.3 million people were working only for health insurance, and will likely quit when Obamacare can insure them, influential conservatives have been arguing yes. Rep. Paul Ryan (R-WI) was “troubled” by the fact that fewer Americans would be “getting the dignity of work.” Ross Douthat saw a consensus on the right around the idea that work’s “decline” is “something to be fiercely resisted.”
The liberal response has been two fold. First, to point out this is a false choice: many of the people quitting their jobs would be opting for kinds of work, like entrepreneurship and stay-at-home parenting, that conservatives have been lauding for years. Second, to argue that it’s wrong to force people to work on pain of losing their health insurance.
Of the two, the second is more important. It speaks to the heart of the disagreement between progressives and some conservatives about healthcare and freedom. And new research about the harm done by losing your health insurance, released just this Monday, helps pinpoint just how frail any theory of freedom is that fails to recognize access to health care as absolutely critical to human liberty and dignity.
Two economists, Jessamyn Schaller and Ann Huff Stevens, asked a question that hadn’t been answered in depth before: what happens to people when they lose their insurance after losing their jobs? A lot of previous research had shown that job loss hurts people’s incomes, and even makes Americans 10 to 15 percent more likely to die soon, but no one had yet been able to figure out why job loss hurts so much.
Schaller and Stevens took a sample of about 10,000 people who lost their job, and ran data on their health over time through equations designed to isolate the specific effects of job loss on health insurance and people’s health in general. Unsurprisingly, losing your job makes you more likely to have health problems — 18 percent more likely to report “fair or poor” rather than “excellent, very good, or good” health, to be precise.
In the short run, the worst of these problems were mental health-related. “The probability of self-reporting fair or poor mental health,” according to the authors, “rises by 38 percent after job loss, and reports of depression or anxiety rise by about 22 percent” after job loss. (In both physical and mental health, the authors note, patient perception is a pretty good proxy for actual illness.)
And the people least able to get health care for their ailments were people whose insurance was tied to their jobs. By picking out people who were on employer-based plans, rather than their spouse’s or a private plan, Schaller and Stevens could figure out exactly what the effect of losing your insurance was on your health care habits.
Turns out, people who lost their insurance with their jobs are — uniquely among people who lose their jobs — significantly less likely to use health care services. “Loss of insurance coverage reduces office visits and use of prescription medications by approximately 15 percentage points,” as well as the likelihood of visiting an emergency room by 25 percent. When you make insurance dependent on work, the unemployed don’t get health care.
Schaller and Stevens don’t shy away from the implications of their research. “The fact that we do see substantial reductions in health care utilization among the subset of displaced workers most likely to lose health insurance,” the conclude, “suggests that access to insurance, or perhaps continuity of care, could play an important role in generating long-term effects on mortality.” In plainer terms: taking away people’s ability to pay for health care may very well make them more likely to die.
There’s no other way to describe the threat of losing insurance, then, then a kind of coercion. Schaller and Stevens’ work — along with the wealth of research on insurance and health supporting it — shows that people working only for the insurance are being forced to make a choice between good health and doing what makes them happy. Normally, when we threaten someone with physical or psychological harm in order to do something, we call that “forcing them” to do it. Conditioning access to goods that quite literally affect one’s chances to survive is on work is a form of unfreedom.
You can take this idea pretty far. Philosopher Phillipe Van Parijs wrote a famous paper, titled “Why Surfers Should Be Fed,” arguing that states should provide a universal basic income high enough that no one should have to work. People who are endowed with the talents necessary to succeed in a competitive labor market (Van Parijs calls them “Crazies”), through nothing beyond the luck of being born that way, take control over social resources and use that control to exact rents that impoverish the non-workers. Any government that doesn’t discriminate against a certain class of citizens — the people less talented at work — should ensure the non-workers aren’t forced to choose between starvation and misery.
That’s a pretty extreme position, but Van Parijs’ basic insight is sound. The obvious answer to Van Parijs-style arguments is that governments should encourage the lazy to work. Work is necessary for society to function, it’s only fair that everyone does their part, and people are simply happier with their lives when they provide their income. It’s a point even Marxists can appreciate, but it only goes so far. People need to work, sure, but that doesn’t justify forcing people to do a particular kind of work — one they wouldn’t choose to do otherwise — at the pain of bad health. Child-rearing, for instance, is a kind of work, one that we don’t reward with wages. Why should men and women who find child-rearing more meaningful be coerced into the labor market?
In the case of health care, we’re tilted way too far to the pro-work side. Health isn’t just one good among many; it is one of a few basic goods (like food and water) that every person must have to do literally anything else. There is no life without health, and judging by numbers around the world, providing universal access to insurance doesn’t fatally undermine the work incentive. Denying access to it, however, is one of the more extreme versions of work coercion imaginable in a free society. You don’t have to be Van Parijs to see that some means of coercing people to work really should be out-of-bounds.
The response to these arguments from smart conservatives like Douthat has been to skip over the philosophical argument and argue that, even if liberals are right, that Obamacare is a bad way of providing for people’s basic health needs — one that wastes money and creates unnecessarily large disincentives to work.
There’s certainly a debate to be had between Obamacare, a more expansive system like single payer, and preferred conservative alternatives that focus on providing catastrophic care only. But that’s not the debate on Capitol Hill, where you have folks like Sen. Ted Cruz (R-TX) answering the rhetorical question “Can’t you just tweak Obamacare?” with the charming line “Yeah, with a nuclear bomb!” When even the now-moribund Republican alternative health plan would have the same effects on the labor supply as Obamacare, it’s really a question of whether you think people should be forced to choose between health and work or whether they shouldn’t.
If access to health care really is critical to freedom, then denying it in the name of the “dignity” of work (as Paul Ryan implies we ought do) is perverse. The very idea of work’s dignity is that there’s something essentially empowering about providing for yourself and/or your family, with your own two hands: that earning your own keep makes you the master of your own destiny. That’s all well and good, but if you’re being forced to work, that critical element of agency is fatally undermined. You’re not choosing to earn your own keep in a job you love and are invested in; you’re being forced to do someone else’s bidding to stay healthy. And there is no dignity in coercion.