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Acts of Corporal Charity

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I once wrote a short story by this name.  It appears in an anthology called  Like A Charm that Karin Slaughter edited.  If you’re used to my novels, it may not be your kind of thing.  I’m a lot darker in my short stories than I am in my books.

But the reason the phrase occurred to me today is that I’m still thinking about that health care bill, and I’ve come to the conclusion that if there’s a single good reason to reject not only it, by any move to a public system in the US, it’s this:  the people who want to make absolutely sure that the public system does not cover illegal immigrants are right.

This is going to take a little explaining, so let me get to it.

To the extent that we operate health care as a public utility–which is largely what public systems do–the problem of free riders becomes acute.  We need everybody who is capable of paying into the system to pay into the system, because otherwise the system will go broke or be forced into rationing of a kind most Americans would not, and should not, accept.

Depending on the country involved, this may or may not necessitate taking a hard line against illegal immigrants.  Some countries don’t have very many, so that accommodating the few there are puts no strain on the system and can be done without large scale cost to the population at large.

The United States, however, has something like one and a half million illegal immigrants a year–okay, a guess, but you see what I mean.  We have lots of them.  I’m told that in some of the border towns of the southwest, the flood of such immigrants from Mexico overwhelms existing hospital facilites and sometimes public school systems as well.

And that’s without a public system.

Some of this problem could of course be addressed by stricter enforcement of existing immigration laws, and by accepting the need in such enforcement for an unflinching resort to deportation–but that particular policy tack makes lots of people very squeamish, and I think there’s good reason for that.

The country at large seems to have no trouble with the idea that we should deport people who have come here illegally–except, say, in cases where they brought their children when their children were four years old or so and now the kid is getting ready to graduate from high school and never even knew that he was here illegally and…

I didn’t make that up.  That’s a real case–in fact, more than one.  It doesn’t represent a huge number of cases, but I’d be willing to bet that if you went out into the country you could find dozens of such children and teen-agers, brought here by their parents so long ago they weren’t of an age to remember, who not only consider themselves Americans but who are Americans to the bone in every way but the official.

There are other kinds of cases, too:  the families of soldiers who have been in Iraq and Afghanistan; the families who have been here for decades and built businesses that emply “real” Americans and paid their taxes and all the rest and still do.

Americans tend to dislike the idea of illegal immigration a lot more than they dislike illegal immigrants, especially the ones they know in their own communities.  When it turns out that Carlos who does our lawn is illegal and the latest incarnation of the INS wants to deport him and his wife and children, we tend not to cheer on the deportation but to take up a collection to get him a good lawyer to fight it.

Immigration has done the United States more good than harm over time, and we tend to be very good at turning immigrants into Americans.  We do it through the public schools, yes, but also through our popular culture.  For all the yelling and screaming about large scale Hispanic immigration at the moment, the fact is that the Latinos show every sign of behaving like all other waves of immigration–the second generation speak both Spanish and English badly, the third generation speaks enough Spanish to swear effectively and figure out where the Christmas presents are hidden, and the fourth generation doesn’t speak Spanish at all.

In the bilingual education wars in California, for instance, the vast majority of the state’s Latinos were on the side of abolishing it and going for English immersion instead. 

Large, comprehensive welfare states tend to make it more difficult for countries to accommodate immigration and to assimilate immigrants.  There are a number of reasons for that.

One of them is that the success of such welfare states depends on a tacit acknowledgement of a tacit contract between all the members of a society–that is, on our all accepting certain base rules of conduct.  Sweden, for instance, did quite well with the most comprehensive welfare state on the planet as long as immigration was nonexistent to low, because all native born Swedes shared certain assumptions (state aid should never be asked for except in the last resort, for instance, and working hard and saving and keeping personal expenditures low was the only decent way to conduct a life, and government was good and not usually corrupt and therefore to be trusted and respected). 

Once Sweden started to take in large numbers of mostly Muslim immigrants from the Middle East, who saw government as essentially corrupt and in existence only to rip off the people, and therefore fair game to milk benefits from, the welfare state started to have significant problems, and the projection is that the problems are only going to get worse.

This is not to say that the Muslim immigrants were somehow immoral while the Swedes were moral.  Most of them came from countries where the governments were in fact corrupt, and not usually democratic to boot.  Their understanding of a citizen’s relationship to his government is the result of very real experience.  They have no reason to think that the government of Sweden will be any different from what they’re used to, except that it will be richer, and more willing to hand out stuff.

But you don’t need something as deeply significant as this to cause friction in a welfare state with a diverse population.  Think of the kinds of things that go on in families.  Bob and Sally are indignant that Johnny went out and bought those books today–he’s declaring bankruptcy!  Books are a luxury!  But Johnny, of course, doesn’t think books are a luxury.

The more real diversity a society has, the more difficult it will find trying to operate an extensive welfare state, and the more extensive a welfare state a society has, the more difficulty it will have in accommodating diversity.

I’m talking about real diversity now, not the rainbow sprinkles kind.  Some people think of “diversity” as black and brown and white and yellow people who all run around wearing  pretty colorful costumes and eating exotic food but all think the same way.

Real diversity means living side by side with people who think everything you believe is absolutely wrong, and yet finding a way to be all Americans together.

So there’s the argument from diversity against expanding into a public health care system.  Americans actually like diversity, even if they get exasperated with it sometimes, and most of them are not willing to give it up.

But I think what bothers me most about the need to restrict such a public system in such a way that it will not “cover” illegal immigrants is that it’s simply wrong to deny medical care to people who need it.

I don’t think I’ve ever seen it stated that baldly, but I think it’s at the core of what a lot of our present US health care debate is about, and a lot of why so many people are furious at the insurance companies.

In spite of all of the professional policy rhetoric we all talk in these days, health care remains, in the minds and hearts of most Americans, not a public utility or a business opportunity, but an act of corporal charity.

It is a moral obligation we owe to our fellow human beings for no other reason than that they are human beings and we are too. 

Hell, most of us now feel that way about cats and dogs. 

Still, I’d guess that almost all of us feel that way about human beings, and almost all of us find it deeply repugnant to envision a situation where a woman comes staggering into the ER about to have a baby, or cut up by her boyfriend so that she’s nearly bleeding to death, or collapsing from undiagnosed and untreated cancer, and we run her through a data base and go:  nope, no treatment, you’re illegal.

And yes, I know, that isn’t what would happen even under strict rules about illegal immigrants.  But it’s the possibility of that happening that makes so many people ambivalent about such rules, and some people completely hysterical on the subject.

I could go on for some time here about the roots of this conviction, that it is a moral imperative that we treat the sick.  It’s most certainly a Christian imperative and its strength comes from a Christian understanding of the relationship of human beings to their fellow human beings.

But for the moment, it’s mostly important to me that the unstated, unelaborated moral conviction exists, because as long as it exists it forms a part of the health care debate that cannot be ignored, even though we all spend so much time trying to ignore it.

And since it’s one of those Christian principles I don’t want to see disappear,  I’d rather we didn’t ignore it.

It may, however, provide the death blow to any public system, and we’ll have to wait until this system to collapse–which it will–before we can formulate something saner.

Written by janeh

March 14th, 2010 at 8:41 am

Posted in Uncategorized

6 Responses to 'Acts of Corporal Charity'

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  1. All the material I’ve seen trying to sort out well-run countries–high literacy, low crime and incarceration rates, high overall life expectancy and such–wind up with lists of small to medium homogenous states. The recent work on civic participation in the US came to the same conclusion–whereupon the authors sat on it for years. Of course, in each case, “activists” dedicate themselves to destroying this homogeneity.

    But it could be the immigrants are just accelerating an existing trend on welfare. For a thousand years Swedes who didn’t work hard and save didn’t make it through the winter. It’s conditioned them. But now that’s no longer true, and it may just be a matter of time before young Swedes see the system much as the immigrants do.

    For myself, I believe even a nation as diverse as the United States can maintain long term a minimal welfare system. It would help, of course, if the Supremes reversed themselves on residency restrictions, and so permitted more local variations.

    But “minimal” is tricky. You can look a long time to find a legislator who has voted for a particular extension of the welfare state who is willing to say that a proposed next step goes too far. Most will admit that at some point the penalties for work and the benefits of not doing so flip incentives and the system goes into a downward spiral, but none will concede that the point is near or already past. You have to replace the politician instead, and we’ve gone to some lengths to make this difficult.

    And, of course, a politician or a government bureaucrats has a powerful incentive to make the machine bigger and more expensive.

    robert_piepenbrink

    14 Mar 10 at 2:05 pm

  2. Okay, I feel the present health care bill will allow a number of people who do not have health care access to it. I’ve not read the bill in its entirety, all 1400 pages of it. I have read summaries, opinions by both political parties and the accuracy of those opinions researched by Politifact. Opinions stated in this blog are opposite mine, so I could well be wrong. My daughter, 26, a college graduate who has a reasonably good job and is healthy for the most part, does not have health care, so I do have a personal reason for wanting the bill to pass. One of my reasons for being in favor of the bill, more visceral than anything else, is that Republicans in Congress are working so hard to defeat it. I agree that denying illegal immigrants health care is both unfair and wrong. Many of them work here for low wages and many pay taxes. Maybe the best thing to do would be to scrap the current bill and start over again but practically I can’t see that happening. Other presidents have tried and failed. I feel any more health care reform efforts during the Obama administration will die a painful death in Congress.

    jem

    14 Mar 10 at 6:15 pm

  3. Okay–first.

    Not having health insurance is NOT the same as not having health care. I don’t have health insurance, but I have all the health care I want. I just pay for it.

    When Bill was uninsured, he got every single thing he needed to treat his cancer, including a place on the transplant list.

    The same with my sister in law who died this past fall–she worked as a “customer service representative,” her husband was self-employed, but they still had health care, and it was good enough to detect that cancer at its very initial stages.

    Most of the people who are uninsured are middle class. We don’t go to emergency rooms for care. We have regular doctors. We get regular check-ups and screenings. We just pay for them.

    I’ve been advised that things differ in different region of the country, but where I live doctors give discounts to those of us without insurance–and would give BIGGER discounts except that Federal law prevents them from charging anybody less than they get paid by Medicare.

    Hospitals provide payment plans and uninsured patient funds pools.

    People in the US get treated, now, when they need to be.

    Most of the people who go into bankruptcy during or after a catastrophic illness are doing one of two things:

    Either they’re deliberately arranging their finances so as to qualify for Medicaid, which requires a paydown before it allows you on OR

    They’re resonding to the crisis by playing ostrich and pretending the bills aren’t there. They don’t answer the phone. They don’t call the providers. They just hunker down unti somebody starts a law suit.

    When Bill’s insurance company dumped us, I got in touch with all his providers, as well as our regular doctor, our pediatrician, and every other medical person or facility we dealt with. I explained the situation. I set up plans and agreements.

    And when Bill died, I called everybody again and we made another set of agreements.

    Nobody in my family went without health care.

    And I didn’t go bankrupt or lose my house. Doctors and hospitals find themselves in these situations all the time. Almost all of them have methods of dealing with it so that everybody who needs to get treated, gets treated.

    That said, there’s no reason why this health care bill needs to include an individual mandate to buy insurance from the very companies that are ripping us off. In fact, Obama campaigned on a promise NOT to require that in any health insurance bill he signed.

    I find that I agree with the Republicans about one third of the time, with the Democrats about one third of the time, and with neither about one third of the time.

    There were good Republican plans for health insurance reform–for instance, giving everybody a $3000 MSA, reimbursable at fifty percent of what’s unspent at the end of the year, plus a catastrophic plan to cover the big stuff–but they haven’t been doing any of that this time around. They’ve just been kicking their heels up.

    But although I haven’t read the entire bill, I have read the summaries, and the summary the WH put out of what Obama wants, and I will guarantee you that it will result in even larger numbers of people uninsured than we have now.

    That’s because a lot of the estimate for how many more people it will cover make an assumption that is almost assuredly false–that is that if you mandate all employers to provide insurance, small businesses WON’T respond by cutting back on their workforces and highering fewer people.

    If the web site you looked at addresses that issue, I’d be glad to see it. But if you made it mandatory for me to pay every one of my employees $10K to $14K more than I’m paying them now–in health insurance premiums–I’d fire some people to make the math work out right.

    A lot of small business owners will have to do that just to stay in business.

    And as for immigrants, illegal or otherwise–the larger the benefits paid by your welfare state, the more you have to restrict immigration.

    Money isn’t infinite.

    janeh

    14 Mar 10 at 8:52 pm

  4. First, lest Jane be thought to be crazy about the negotiations/discounts issues. My sister, who lives paycheck to paycheck in Florida (well, until she got laid off, that is) had health insurance, but it wasn’t great health insurance. She ran up massive bills 2 years ago with pancreatitis, about $60,000 worth. My mom spent a lot of time on the phone, and got that reduced to about $3,000. That was paid. So it is doable, and you don’t have to be college-educated to do it.

    When I’ve been hospitalized and had to pay my $7000 deductible, each time, I called the hospital and got a reasonable payment plan set up, where *I* decided how much I could pay each month. I named the number, they said okay. In one call. No hassles. Then they sent me invoices each month to let me pay easily and see my payment progress.

    So people who don’t have insurance, but who need healthcare often say they don’t *have* healthcare because they’d rather not spend that money. But if they break an arm or something relatively minor, their total bills are likely to be less than a year’s worth of insurance would be. If they have a major occurrence, of course, then they are in the negotiation spot.

    I also get discounts from my optometrist, because I don’t have vision insurance. It’s cheaper just to buy my own glasses every two years or so.

    That said, I do NOT understand people who say, “My wife died because the insurance denied her X procedure.” Excuse me? You knew there was something out there that would SAVE HER LIFE and you worried about money first? Gah. I don’t want to blame the victim here, people who are sick are not often able to think logically, that’s what family are for. What kind of decision-making is that? Bankruptcy is worse than death? You’re going to wait on time-critical care to see if someone else will pay for it? No. Treat now, worry about money later.

    This small business owner currently provides health care for two adults, one 62, one 55, for about $12,000 per year, for both. Obamacare is going to double that, I’m guessing. We frankly can’t afford it. Other business owners I work with are just as worried. I can’t exactly fire my husband, but they are certainly going to look at reducing the employee burden if it passes. So much for the economy.

    Is it any wonder much of the small business community feels that Obama *HATES* and I do mean HATEs business? Like he thinks taxes fall from the sky, and that there’s infinite amounts of money to be had, even if all businesses go bust.

    Lymaree

    14 Mar 10 at 10:19 pm

  5. I’m a bit confused. In your initial blog topic today you seem to be advocating a public option which would include illegal immigrants. What are you saying? Not trying to be argumentative, just don’t quite understand. Also, you are right that health care for the uninsured does vary from state to state. Unless you meet the qualifying income level for medicaid, meaning you make too much money to qualify, in some cases you are s.o.l. in Florida. My daughter has to pay a fair sum of money to see her doctor, which she does periodically to get a prescription refilled. But when she is ill she just toughs it out unless it’s serious. A friend of mine was in the hospital for a seizure and was treated quickly and released because of lack of insurance. There are pharmacies with very low costs for a list of generic medications but if there’s not a generic available then you pay a hefty cost. In Birmingham, AL where I lived most of my life there is one public hospital, Cooper Green, that treats people without insurance, working on a sliding scale based on the family’s income and size. If there’s a public hospital in Pinellas county I don’t know about it. Florida has an optional insurance–Cover Florida– for those who make too much to qualify for medicaid but who are not insured through their workplaces. This plan is very limited and limits lifetime cost for an illness to $50,000. There are 3.8 million in Florida without insurance. Are you saying that: a)we would be better off with the health care and insurance costs we now have b) that any health care reform that doesn’t include a public option does not serve the nation as a whole or c) that making health care insurance mandatory will result in unemployment for more people? I’m not trying to obstreporous about this. My apologies if it sounds that way.

    Some of the sites I looked at: http://www.politifact.com and another is http://www.factcheck.org/2010/02/health-care-summit-squabbles/ http://www.aarpmagazine.org/health/8_myths_about_health_care_reform.html and I read summaries of the bill in my local paper as well.

    jem

    14 Mar 10 at 11:28 pm

  6. There’s something that’s bothering me that I’ve been hestitating to mention because it’s based on gut feelings rather that logic. Two things, really, the more minor one (which applies to a lesser degree to single-payer systems) is, what if you don’t have someone to advocate for you and do all this negotiation? I probably won’t. I don’t, really, right now, although I do have relatives who are still alive, none of the ones able to do it live anywhere near me. It’s not something even a close friend can do.

    But there’s no real solution to that, other than digging up someone to give authority to, should the need arise at a point when there was still someone alive I felt I could trust to that extent and ask that great a favour of, or, more likely, depend on social workers and other strangers.

    My main points are is that I don’t think I could either bring myself to get something – medical care or anything else – that I knew I couldn’t afford, nor negotiate the price down to something that, just maybe, I could afford.

    I’m a really rotten negotiator, and I don’t think my skills would improve if I knew I was dying and this was my last chance at a few more years of life.

    And the first point – the signing up for medical care, life-saving or not, that I knew cost far more money than I have or would ever see even if I were healthy, and then, after I got it, saying ‘Well, let’s negotiate on the price’ – I don’t think I could do it. It feels dishonest. It’s like stealing a car from a car dealer and then going to the dealer and saying ‘Let’s negotiate. I’ll give you, say, 10% of the cost’.

    I’ve never done well with bargaining and I don’t like the idea of prices that depend on who the customer is. But even if I think the pricing system is unfair, I don’t want to take things I can’t pay for.

    I’ll take my chances here. I’ve been paying through taxes since I was 15, so I feel like I’m paying my way. I won’t be accepting something I have absolutely no ability to or intention of paying for. Maybe if I really were in the US and dying, I’d lose my qualms and try to game the system that way, but I’m glad I won’t be in a position to decide whether I should or not.

    Cheryl

    15 Mar 10 at 7:15 am

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