Virtue and Public Policy

January 10, 2018
Posted by Jay Livingston

In the conservative view, poverty and its associated ills happen not because poor people lack money and living-wage jobs but because poor people lack virtue. Since the 19th century, conservatives have struggled with the question of how to instill virtue in the lower classes. Their answer is usually some scheme for punishing bad behavior. Those policies are consistent with the idea that behavior arises from individual morality.

The trouble is that public policies derived from truths about individuals often have little general impact, especially when those policies emphasize punishment as the path to virtue. At The Upshot section of the New York Times website today (here), Dr.  Dhruv Khullar looks at how virtue and its lack affect health. The headline says,

“You’re Sick. Whose Fault Is That?”

Not mine. People like me, we go to the gym, we spin, we do yoga, we try not to gain weight, we don’t smoke, we wear FitBits and eat kale for godssake – all in the belief that this will keep us healthy and extend our years. There’s some evidence that we’re correct. But does our virtue point the way to effective policies? The sub-head in Dr. Khullar’s article has the answer.

It seems sensible to encourage “personal responsibility,” and yet policies that invoke the phrase can make health problems worse. 

Dr. Khullar offers the example of Indiana. When Indiana expanded Medicaid under the ACA, it added some provisions to punish unvirtuous health practices among the poor.*

To get full benefits in Indiana, patients must contribute monthly to a “personal wellness and responsibility account.” If they fail to pay, they may have benefits cut or lose coverage entirely for six months. They must also make co-payments for certain services, and pay a fee if they use the emergency department  unnecessarily.

Dr. Khullar says that the program has had “mixed results.” It is certainly not as effective as the state government claims. (Jake Harper at  NPR  goes deep into the weeds to fact-check those claims.)

At the same time the Indiana government rejected a more obvious way to reduce bad health practices, namely smoking. Some legislators thought that Hoosiers would cut down on their smoking if the tax on cigarettes was increased by $1 a pack. Less smoking and its attendant ills, more money for the state to use for healthcare or highways. Sounds like a good deal. But Gov. Pence and the Republicans in the state senate opposed the bill, and it never passed.

These legislative choices seem consistent with two principles cherished among conservatives: first, conservatives really hate restricting individual behavior even if those restrictions promote the general welfare (this same principle justifies their aversion to taxes, even “sin” taxes); and second conservatives really like punishing unvirtuous behavior among the poor

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* The woman who ran this program for Indiana when Mike Pence was governer is now the Trump administration’s head of Centers for Medicare and Medicaid Services.