If liberals believe in social equality, they’d better be looking for institutions that can guarantee it even in the face of rising income inequality (something that liberals, at bottom, have no clue how to stop). One such institution was the draft–but the draft has gone away, and even if it comes back in the less militaristic form of “national service” it’s unlikely to cover the whole population the way it once did (e.g., during World War II).
Without national service, it’s not easy to come up with new institutions that might help reconnect a nation being slowly pulled apart along class lines. Health care is probably the biggest candidate left. If rich and poor use the same doctors and hospitals, wait in the same waiting rooms, etc., it will be harder for some people to think they are better than anyone else–even if some leave by bus and others in Porsches. That’s the theory, anyway.
If you entertain this theory, as I do, Obamacare is a troubling solution to the health care problem. Yes, it more or less insures everyone, but at the price of assigning people to different programs based on their income. If you are upper middle class and uninsured, you can buy insurance on the Obamacare “exchanges.” If you are non-upper middle class (under 400% of the poverty line–about $90,000 for a family of four) your purchase will be subsidized, even heavily subsidized. But if you are poor–less than 100% of poverty–you can’t get a subsidy through the Affordable Care Act. You will probably be shunted into a different system, Medicaid, which many consider inferior.
It’s an implausibly stratified system. If Obamacare’s exchanges work, and provide decent, affordable care, why not have the poor get insurance there too? We subsidize the middle class on the exchanges but not the poor? It’s almost as if the poor were a stigmatized caste, the eta of medical consumers–banned by virtue of their incomes from participating in the system we pay their betters to use. I’m not even sure this setup is constitutional–imagine we had a system that subsidized lawyers for everyone under 400% of poverty, except that it denied the subsidy for those under 100%. Would that hold up to an equal protection challenge? Access to legal assistance is a “fundamental” interest, a court might say–not to be denied on account of income. Isn’t access to medical assistance pretty fundamental too? Many Obamacare backers offer paternalistic reasons for separating out the poor–“that population” requires special services, etc. This doesn’t make that separation any less toxic to social egalitarians. It makes it more toxic.
Comes now Arkansas Gov. Mike Beebe with a simple, dramatic solution: move Medicaid onto the exchanges. That is, let the poor buy health insurance the same way middle income Americans will buy it–indeed, let them go onto the exchanges and buy the same policies non-poor people buy. Just use Medicaid money to subsidize the purchase (instead of Obamacare money).
Beebe’s solution is expensive–insurance on the exchanges will probably cost significantly more than Medicaid (perhaps because it will be significantly better!). The Beebe plan creates some perverse side effects of its own–described by Adrianna McIntyre and Karan Chhabra. For example, it would only apply to new Medicaid beneficiaries–those added to Medicaid by the Affordable Care Act, which required states to cover up to 133% of the poverty line. Those who are already on Medicaid-typically families under 100% of poverty–won’t qualify. They might still be stuck in Medicaid or even be left uncovered.
But all of these problems seem soluble with money, maybe lots of money (many billions)–but, unlike say, education and crime, throwing money at it will do the trick. Let the “legacy” sub-poverty Medicaiders onto the exchanges too. Let everyone on! Subsidize where necessary. Ultimately, the goal should be to have Medicaid become simply another funding mechanism for Obamacare–and then maybe Medicaid could disappear entirely. Why do we want or need two health care systems, one for the poor and one for the non-poor? Especially if one is worse than the other–but even if they are “separate but equal”? If you are pursuing social equality–especially if you are ambitious enough to hope the health system could take the place of the draft as a “class-mixing” institution–separate-but-equal won’t do.**
**–The cost of bringing the poor into the common health care system is only one of the added expenses of erasing Obamacare-style stratification. You also have to make the common system (e.g., the insurance available on the exchanges) good enough so that only the very rich will be tempted to bail out. That will take money too.
You could call this extra expense the Social Equality Surcharge. I say it’s well worth paying. Or do you have a better idea for a new pervasive, common institution used by all Americans under conditions of equality? I don’t.