Guest Post by Daniel S. Goldberg
Several weeks ago, Representative Jason Chaffetz (R- Utah) found himself the target of some acid criticism in multiple news outlets for attempting to justify some of the provisions in the AHCA by stating that ‘people may have to choose between iPhones and health care.’
Predictably, a storm of controversy erupted. Opponents of Rep. Chaffetz’s perspective pointed out the basic functional significance of a smartphone for more marginalized groups, including taking the time to note how smartphones were important for disease management, family and community care, public health, etc. This matters a great deal because the vast majority of health care services (by volume) actually happens outside of inpatient settings, and frequently outside of clinical settings at all. There is little doubt that smartphone access is material to the informal caregiving that places such tremendous demands on the resources of caregivers and intimates. There is no reason why more disadvantaged groups would be excepted from this assessment.
But it was not the merits of the opposition that animated me. Rather, I was irritated by what I perceived as its technocratic nature. The intellectual framework driving Rep. Chaffetz’s statement was not one cast in the metals of 21st c. technology and smartphones. Rather, it seems obvious to me that Rep. Chaffetz was invoking an old tradition in the West, one saturated with important intellectual, political, social, and moral implications: the issue of dessert, especially as it relates to social welfare.
What do we owe each other? What do we owe those who have less than us? And if we choose, as a social order, to pay in to create some kind of welfare apparatus to support those who are less able to provide for themselves, how do we regulate that decision? Where are its limits?
These are grand, difficult questions, but my point is an utterly practical one, suggesting the significance of intellectual history for understanding contemporary social policy: ideas are social actors. That is, acting in concert with a variety of social and political forces, ideas can form the key impetus to all forms of social action. Ideas move people. They help animate organization, investment, and activity in all manner of social and political practices. This most certainly includes policymaking, as intellectual historiography on policy history makes abundantly clear.
So, what ideas help us understand Rep. Chaffetz’s statement about ‘difficult’ choices between iPhones and health care? The answer, of course, is Western and/or peculiarly American ideas about social welfare and its connections to concepts of desert. Via processes of public reason, societies may well come to some kind of collective agreement that some form of welfare apparatus is worth establishing. Yet, there is always an apparent need to establish eligibility for the benefits of the scheme. Who is to be granted access to the largesse of the welfare state? And in a world where humans are born to sin, there will inevitably be those ne’er do-wells who seek such access even if they do not deserve it according to social norms, legal strictures, or both.
This is the point, then: the effort to distinguish the deserving from the deserving poor is at least 400 years old in the West. It is literally core to the Elizabethan poor laws. But some of the important ideas I argue animate Rep. Chaffetz’s perspective may be quite a bit older: anxiety over feigned illness or “malingering” (a modern term) can be located in medieval sources. They appear again in early modern sources such as Paolo Zacchia’s intensely interesting Quaestionum (itself concerned with legal proceedings, where the adjudicative function – what is the truth of a person’s illness? – is of special relevance).
What do we owe each other? And how can we be sure the people we help via welfare structures truly merit the assistance we grant them?
We do ourselves no favors, in terms of understanding political discourse and the grit and grime of policymaking by thinking about Rep. Chaffetz’s statement solely in terms of the merits of a particular piece of technology (which I in no way deny!). Rather, as a powerful political figure at the center of a raging national contest over the appropriate nature of the U.S. welfare apparatus, Rep. Chaffetz’s statement is best understood as manifesting the intellectual frameworks noted above — the most important task, apparently, is to discern merit or desert. Those who make wise choices amidst their straitened circumstances are those to whom help will be given. Those who choose poorly — who select shiny new technologies — will bear the full social consequences of their own decision.
There is so much more that could be said here, from a historical perspective. Perhaps unsurprisingly, the moralist tradition of social welfare so palpable in current US discourse is also powerful in the UK (past and present). For example, most public health stakeholders in the US erroneously attribute the Sanitarian movements of the 19th c. (both US and Great Britain) to a quasi-revolutionary imperative — a desire to relieve the immiseration of the poor, to address the ails of rigid class structures and 19th c. dislocations that caused so much suffering and deprivation. In fact, as Christopher Hamlin has shown in his stunning text, the principal architect of British 19th c. public health reform, Edwin Chadwick, was motivated by a desire to maintain existing class hierarchy. A political conservative, Chadwick was concerned that the deprivation of the lower classes juxtaposed with the concentration of wealth among the affluent would lead to revolution (Chronology matters here: Chadwick was operating in the 1840s, when European revolutionary foment was reaching a fever pitch). Chadwick believed that a welfare apparatus should be designed intentionally to be just slightly less unpleasant than unemployment and abject poverty itself. He believed that alms houses should be so horrendous that no one would willingly seek them out or stay there unless they literally had no other choice. Moreover, for Chadwick, the unpleasant nature of the alms house would spur its users to seek out employment, thereby ensuring that welfare users were not content to rely on the largesse of the welfare state.
Finally, Chadwick, like most of his Sanitarian colleagues, was a hygienist, which in 19th c. Anglophone parlance, had a strong and intentional moral valence. (Check out the historiography on Florence Nightingale for some excellent discussion on this). Hygiene was a means of purification as well as a demonstration of virtue and right living. Hygiene, as historians of public health have shown repeatedly, was distinctly moral. This has profound implications for the judgments and moralism we see saturating public discourse over welfare policy in the US, because questions of desert are necessarily moral questions — ‘what do we owe each other’ is simply another way of framing the fundamental question of justice.
Once we understand these intellectual frameworks and the way they shape contemporary public reason as to welfare policy in the US, the broader impulse underlining Rep. Chaffetz’s comments is evident. And we can test the validity of the framework by seeing whether it helps explain other statements and perspectives swirling around contemporary US discourse on welfare policy, especially welfare policy targeted at the poor.
For example, there are proposals, some of which have made it into draft form as bills in the US Congress, to attach labor or labor-seeking requirements to Medicaid policy. Medicaid is an arm of the US welfare apparatus that most directly benefits poorer and more marginalized groups. Where a principal question that animates US welfare policy is one of desert, desire to work is a fundamental marker of virtue and merit. Chadwick would most certainly approve, as would architects of the Elizabethan poor laws. Note also that such requirements might well be experienced by many welfare users as degrading or demeaning, which also fits the Chadwickian aim — to make the receipt of alms so upsetting that only the truly immiserated would willingly seek it out, and would also attempt to cease such receipt just as soon as possible. This latter point connects to the oft-stated desire among policymakers in the US to “disincentivize” welfare usage in the US, to ensure that welfare users are “properly motivated” to seek work.
Or, consider the increasing efforts by states to subject welfare recipients to random drug-testing. Despite the uniform evidence that welfare recipients use drugs and alcohol at rates no greater, and often significantly lesser, than the non-welfare population, and despite consistent evidence that such drug-testing programs are incredibly cost-ineffective, efforts to institute such regimes are increasing. In the face of a mountain of evidence suggesting the waste and inefficacy of such programs, states are redoubling their efforts to implement them, and the federal government is only to eager to facilitate such implementation. How can this be explained outside of the power of ideas regarding desert — the need to distinguish the deserving from the undeserving poor? It cannot (although of course I do not claim the power of such ideas is the entire explanation – only that it is a necessary one).
The temptation to read political statements solely on their own terms is obvious. And of course, the merits of statements like Rep. Chaffetz’s are entirely meet for independent analysis. But if we disconnect statements made in the storm of public reason from the deeply-rooted intellectual frameworks that animate them, we impoverish our understanding of those political and social contests, and perhaps even our ability to influence them. In short, ideas are social actors.
“Daniel S. Goldberg is trained as an attorney, a bioethicist, and an intellectual historian. As to the latter, he is a 19th-early 20th c. Americanist, focusing primarily on the history of chronic pain and the history of medical imaging (especially the X-ray). His work on pain implicates multiple issues in disability, policy, and welfare.”