When I first arrived in Switzerland, I spent almost my entire first week filing paperwork. To get an apartment, I needed proof of assets. To have proof of assets, I needed a bank account. To get a bank account, I needed a phone number and identity card. And to get an identity card, I had to submit my biometric information to the Swiss government and make a few trips to the Foreigners Bureau. It was a huge rigmarole that was simultaneously boring and exhausting.
The Swiss pride themselves on taking responsibility for their own affairs. The hoops that I had to jump through to establish residence were designed, in part, to prove that at I too was a self-sufficient, responsible person who wouldn’t become a ward of the state. As such, I was also required to purchase several forms of insurance, some of which I hadn’t seen before. One type of insurance had the word “responsibility” literally written in its title: the “assurance responsabilite civile” in French, or “liability insurance” in English. This insurance covered costs associated with accidental damages to third parties. There was also fire insurance, climber’s insurance (for outdoor activities), traveler’s insurance, accident insurance, and, of course, health insurance.
Health insurance in Switzerland, unlike the U.S., is typically not associated with an employer. Instead, it’s purchased on the individual marketplace, similar to the one that Obamacare set up. The key differences are that insurers are not allowed to make a profit on the basic coverage, that compliance with the mandate is virtually universal (since the penalty involves garnishing of wages, not a few hundred dollar fee), and that the Swiss government does a much better job of regulating prices of drugs and medical procedures, thereby keeping premiums low. At the time, though, I chafed at the mandate. I was a healthy individual, and I thought to myself, “Why should I pay $250/month towards healthcare that I’ll never use?” (I had chosen the highest deductible plan, so I had a strong incentive not to consume care).
I suppose the answer to that question comes back to this idea of responsibility. What is our responsibility as members of a society? Is it simply to take care of ourselves, or is it to take care of others as well?
The Swiss government, by and large, was good to me: it paid my salary, it subsidized my transportation, it made the trains run on time, it salted and cleared the sidewalks when it snowed, and it kept the streets clean. And, I conceded, I should be good to it, too, by not only taking care of myself, but also by paying for the care of other people – Swiss citizens –, despite the fact that many of them didn’t like me (and the feeling was mutual). Of course, I would have complied regardless of my feelings towards the law – hard mandates like the Swiss mandate tend to have that effect – but my feelings themselves changed as I understood Switzerland and its core values better.
We don’t have the same sense of societal responsibility in the U.S., and it’s a shame. This is a multifarious problem. First, our government often fails to meet its obligations to its citizens (the trains certainly don’t run on time here), and we have at least one party committed to keeping it that way. There is the ever-present specter of race looming over conversations of “responsibility”: if we feel that the government provides for “those people” and not us, we will be less likely to support societal programs and more likely to adopt a “personal responsibility” ethos. And there is also the immovable fact of poverty and deprivation: that many uninsured people show up at the emergency room seeking care for a preventable condition not because they want to be irresponsible, but because they couldn’t afford not to be. In Switzerland, premiums are capped at 8% of income and the poor are given subsidies if they cannot afford to buy insurance. In the U.S., we had to win a historic majority in the House and Senate to achieve just that.
The most durable social programs in U.S. history have instilled the feeling of mutual responsibility: the idea I help my brother in times of surplus and he helps me in times of dearth, and that my taxes are going to something that I will use at some point, not to a special program for special interests. There’s a reason that the Ryan plan attacks Medicaid and not Medicare: it’s a much easier target.
A lot of politics can be seen as a battle between the centripetal forces attempting to imbue societal responsibility, and the centrifugal forces encouraging its fragmentation. If there is an idea at the core of the GOP, it is this: that you are responsible for your own life, and that the only person taking care of you should be yourself. You are on your own, no matter what depredations life assaults you with.
Don’t believe me? Let’s remember back to the status quo ante: the era before Obamacare. It’s the period Republicans clearly preferred (or else they would have voted for Obamacare). One of the big changes wrought by Obamacare was a ban on discriminating against individuals with pre-existing conditions, and a ban on rescinding coverage from individuals who failed to report minor pre-existing conditions. Here’s one such horror story, from 2009:
Robin Beaton found out last June she had an aggressive form of breast cancer and needed surgery — immediately.
Her insurance carrier precertified her for a double mastectomy and hospital stay. But three days before the operation, the insurance company called and told her they had red-flagged her chart and she would not be able to have her surgery.
The reason? In May 2008, Beaton had visited a dermatologist for acne. A word written on her chart was interpreted to mean precancerous, so the insurance company decided to launch an investigation into her medical history.
Beaton’s dermatologist begged her insurance provider to go ahead with the surgery.
“He said, ‘This is a misunderstanding. This is not precancerous. All she has is acne.’ … He said ,’Please don’t hold up her cancer surgery for this,’ ” Beaton, 59, said as she testified at a House subcommittee hearing on the terminations of individual health policies by insurance companies.
Still, the insurance carrier decided to rescind her coverage. The company said it had reviewed her medical records and found out that she had misinformed them about some of her medical history.
Let’s be clear: people with pre-existing conditions are potentially very costly to pay for. The reason that insurance companies don’t want to cover them is that they likely can’t make money from them. If we want these individuals to have medical care, the rest of us will have to pay for it. We’ll have to spend more money to help people we (likely) don’t know, just like I paid premiums in Switzerland to defray the cost of care for people I didn’t know.
When the Republicans railed against Obamacare, one of the things they were fighting against is this idea: that we should pay more to take care of the least fortunate of us. Here’s Betsy McCaughey (who helped inspire the “death panel” lie, among other things), talk about pre-existing conditions in an editorial:
In truth, ObamaCare discriminates against healthy people who have to buy their coverage in the individual market. ObamaCare forces them to pay the same price as the chronically ill, whose medical costs are ten times as high, on average.
She’s not alone. Paul Ryan claims that Obamacare is failing because “the people who are healthy pay for the people who are sick”. One GOP representative, John Shimkus, wondered why men should have to pay for prenatal care. (Before Obamacare, it’s worth remember, women were often charged more than men for the same coverage.) And one of the major changes in Trumpcare is that insurers will be able to charge even more to the elderly for healthcare.
It’s disgusting, isn’t it? Insurance should be made unaffordable for the sick so that premiums stay low for everyone else; subsidies should be slashed for the poor so the rich can have their tax cuts, women should have to pay for their own pregnancies so that men like John Shimkus don’t have to think about where babies come from, and people a few years away from Medicare should be forced to hold on for dear life so that I can save a few bucks on health insurance. What happened to our collective responsibility, to the idea that we, the healthy and relatively well-off, owe a duty to everyone else?
It’s not just healthcare, either. Republicans believe in the “right to work”, which means workers can contribute nothing to unions and receive the same benefits all the same. They believe in private and religious vouchers, so well-to-do parents no longer have to help fund the education of everyone else’s kids. (But don’t worry, the law, in its majestic equality, grants everyone “access” to Groton!) They believe in individual retirement accounts as a solution to the problem of retirement savings, and health savings accounts as a solution to the problem of paying for healthcare. The people with thousands of dollars to sock away in these accounts will make out handsomely after the tax deductions, and the remainder won’t have enough money to make them worthwhile. Ah, well. At least the successful will no longer be subsidizing the unsuccessful, right?
I was thinking about all of this while reading a remarkable article from the Washington Post about white working class voters in West Virginia. They are probably the most difficult people to defend from the liberal perspective, simply because they have taken so little responsibility for and interest in their own lives. One woman blames Obama for the prescription drug “donut hole” brought about by Bush’s Medicare Part D bill. Another only discovered the existence of Medicaid when she was taxed for not purchasing insurance by the individual mandate. Many have poor health habits that they show little interest in fixing.
But most voted for Trump. And a small part of me, the most malicious part, wants them to see where supporting the ideology of the Republican Party gets them. No more Medicaid, no more ban on pre-existing conditions, no more insurance, no more government-subsidized care. No more societal or civic responsibility, only the personal kind. Every man and woman for him or herself. And, hey, if they don’t like it, they can always move to Switzerland.