Punishing the Poor, Again

January 14, 2018
Posted by Jay Livingston

The Republican approach to Medicaid seems designed not to improve the health and lives of the poor but to bolster other people’s feelings of righteousness. That’s why these policies focus on punishment for the “undeserving poor.” (See the previous post.)

The same preference for punishing sinners rather than solving problems pervades the anti-abortion movement. If the goal is to reduce the number of abortions, it would seem logical to reduce unwanted pregnancies. But most anti-abortion groups and politicians also want to restrict birth control.

Abortion opponents should also, logically, promote policies that make motherhood easier, but they don’t. Instead, as Michelle Oberman in today’s New York Times (here) points out, abortion opponents typically focus on making abortion more and more difficult or even punishing abortion-seeking women. These policies fall hardest, of course, on women with little money.

The price of motherhood is set by our government’s policies. It will, at some level, always be cheaper for a woman to have an abortion than to have a baby. But if anti-abortion campaigners truly want to decrease the numbers of abortions, rather than passing laws designed to drive up the costs of abortion, they would do far better to invest in the kinds of economic supports that make becoming a parent a realistic possibility for struggling women. Consider the medical needs of the women living at Rose Home: access to health care, substance-abuse and mental-health treatment, food and housing. Each has a price tag. Yet rather than offsetting the high price of motherhood, recent anti-abortion laws drive up the cost of abortion by closing clinics, forcing women to travel farther, and to wait longer before ending their pregnancies. The abortion war, with its singular focus on law, distracts us from the economic factors entwined in a woman’s decision to terminate a pregnancy. In a world of true choice, whether a woman walked into a Planned Parenthood or a crisis pregnancy center, she would learn that society cared enough to provide her with the resources she needs, regardless of her decision.

Oberman refers to “focus on law” in that last paragraph, but the laws she’s talking about, much like the Medicaid work-requirement rules, are designed not to help pregnant women but to make life more difficult for the unrighteous. The message these laws send is not that we want you to become a mother but that we want to see you suffer for having an unwanted pregnancy. For abortion opponents, having their morality engraved into the law the allows for rejoicing in righteous victory, but as Oberman says, it doesn’t do much for poor women or for their babies.

Last week, a New York Times op-ed about Medicare had a title that characterized the Republican approach: “You’re Sick. Whose Fault Is That?” The same idea applied to abortion would give us “You’re Pregnant. Whose Fault Is That?” It’s a great question if you are interested in assessing blame. The payoff comes in the currency of feelings – guilt (for those with illness or unwanted pregnancy), pride or righteousness for the healthy and virtuous. But if you’re interested in effective policy to improve people’s health or reduce abortion, “whose fault?” is the wrong question.Why not ask, “How can we help?”

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* Policies like this play well in the US. Where other countries see problems and search for effective solutions, Americans tend to see moral wrongdoing that should be punished. This tendency is especially strong in the area of sexuality, especially female sexuality, and not just when the issue is abortion. 

Nine years ago I wrote (here) about a Pennsylvania district attorney who was threatening to prosecute 15-year old girls for “sexual abuse of a minor.” The minors? Themselves. Their crime? A year or two earlier, they had taken cell-phone photos of themselves that showed them from the waist-up wearing only a bra. If convicted, they could be sent to prison and forced to register as sex offenders.

GOP Medicaid – It’s About Righteousness, Not Health

January 11, 2018
Posted by Jay Livingston

In yesterday’s post, I concluded that the principle goal of the Republican approach to Medicaid was not to improve the health of poor people but to punish their unvirtuous behavior. Today, the Centers for Medicare & Medicaid Services pretty much confirmed that. They issued guidelines allowing states to force Medicaid recipients to get a job, or failing that, to volunteer or participate in job training.  Here is the tweet from Seema Verma, director of the Centers.

Verna assumes that forcing poor people to work or volunteer improves their health. It doesn’t. At the Upshot (the New York Times’s data-heavy sector, here) Margot Sanger-Katz reviews the evidence.

It is not at all clear how much work or income alone improve health. In fact, there’s quite a lot of evidence that causality can move in the opposite direction . . . .“Having the medical coverage helps people to get a job,” said LaDonna Pavetti, a vice president at the liberal Center on Budget and Policy Priorities, who has studied work requirements extensively. . . . The earned-income tax credit, a program established specifically to raise the incomes of low-wage workers, wasn’t able to find any clear health benefit.

Sanger-Katz links to an article by Robert Rector of the Heritage Foundation, a right-wing think tank. Even he doesn’t think that the new rules will improve the health of the poor. And because people without Medicaid will wind up going to the emergency room (far more expensive that regular treatment), work requirements won’t save the government any money. Heritage published the article last March with the headline, “Work Requirements in Medicaid Won’t Work . . .”

A work requirement would just make it less likely for able-bodied adults without dependent children, known as ABAWDs, to register for the program. The work requirement would reduce Medicaid enrollments, but Medicaid costs might well go up because the eligible ABAWDs would go to the emergency room rather than receive routine care elsewhere. . . . Suppose a Medicaid eligible ABAWD enrolls in Medicaid and then fails to do his work assignment (a very likely outcome based on experience with other work requirements). This individual then shows up sick in the emergency room or clinic. Is the government going to deny him medical care because he did not do his workfare assignment? Of course not. [Well, maybe and maybe not. A lot of Tea Party types would gleefully deny him medical care. At a debate during the 2012 GOP primaries, they cheered at the idea of allowing someone without insurance to die. See this post.]

As Sanger-Katz says, Rector’s rationale for work requirements is not medical, it’s moral. The goal is not to make people healthy but to make them virtuous, to make them “personally responsible.”  And the way to do that is to punish them for their lack of virtue even though that may bring sickness and death. After all, since health is a matter of personal responsibility, it’s what they deserve. 

The new rules may not be very good at improving the health of poor people, but they will be effective at making the rest of us feel morally righteous. And isn’t that more important?

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.

Norm-Breaking in Elite Cultures

January 8, 2018 
Posted by Jay Livingston

A couple of recent items had me wishing that we had more ethnographies of the wealthy and powerful.*

First it was the Republican leaders’ obsequiousness to Trump after they’d passed the tax bill – what journalist Martin Schram called “a gushing word-bath of praise.”

• Paul Ryan: “Something this big, something this generational, something this profound could not have been done without exquisite presidential leadership.”
• Mitch McConnell: “Mr. President … this has been a year of extraordinary accomplishment for the Trump administration.”

This despite Trump having insulted them on Twitter (“Our very weak and ineffective leader, Paul Ryan.” “Can you believe that Mitch McConnell, who has screamed Repeal & Replace for 7 years, couldn't get it done.”)

Trump has forced cabinet members and other White House staff to similarly grovel. I wondered how these leaders, public and important men, could fawn like this. Don’t they know what they look like? Don’t they know how others see them?

My sociological spider sense tells me to think about them the way we think about any small-group culture. American sociology, since its early days, has shown how groups develop a set of ideas about what they do, especially when what they do is seen by others as strange or wrong. Howie Becker’s essays on marijuana-using musicians in the 1940s may be the best known example.

Maybe these politicians create a culture that frames this fawning as “political efficacy” or something like that rather than as what it seems to outsiders – brown-nosing. Maybe someone has already written an ethnography of Washington insiders. If so, I’m not aware of it.

A week later, Vanity Fair splashed an article about Silicon Valley sex parties.

The quote in the title is misleading. It’s a moral statement  – about what’s right and wrong (though not precisely in those terms). The full sentence takes the sociological perspective. It’s not that something is right or wrong but that how it looks depends on whether you are inside or outside.

“Anyone else who is on the outside would be looking at this and saying, Oh my God, this is so fucked up,” one female entrepreneur told me. “But the people in it have a very different perception about what’s going on.”

It raises the same question implicit in Becker’s Outsiders and all those other studies of deviance in groups: How do you insulate yourself from the perceptions of others?

The author of the article, Emily Chang, gives a couple of examples of the ways that these men neutralize mainstream norms. For example, they see their sexual morality and behavior as “disruptive” and as “changing paradigms.” Both of these buzzwords carry a very positive charge these days, especially in the tech and business world. “Disruptive” companies “change paradigms” and along the way make a ton of money.** Also carried over from the start-up world to the world of sex parties is an anti-regulation ideology. These men see themselves as libertarians, not libertines.

Unfortunately, Chang is doing journalism, not ethnography. She does not show us the conversations that reinforce the ideas that neutralize conventional perceptions and judgments. One man she talks to has reached the interesting view that although it’s the men who organize the parties and supply the women with Ecstasy and other drugs, “it’s women who are taking advantage of him and his tribe, preying on them for their money.” My hunch is that the “tribe” of men help reinforce this idea. But the picture we get from Chang is that they have come by this ideology separately.

Many of the men offer another idea as both explanation and justification – that they are making up for all the sex they didn’t have when they were younger. Even one of the women Chang talks to agrees.. “Ava” is an entrepreneur, and while apparently she is not a regular at sex parties, she has dated several of these newly wealthy men. Her evaluation of the catching-up hypothesis is less charitable than that of the men, and it is based on more conventional views of adult relationships.

They say, “I’m still catching up. I lost my virginity when I was 25,”  And I’ll say, “Well, you’re 33 now, are we all caught up yet?” In any other context, [these fancy dates] would be romantic, but instead it’s charged because no one would fuck them in high school. . . . I honestly think what they want is a do-over because women wouldn’t bone them until now.

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* There is surely a market for these books, and they have the potential to cross over from academia to the trade lists. Rachel Sherman carved a 2300-word essay from her book Uneasy Street: the Anxieties of Affluence that ran on the front page of the Sunday Times Review section (here ). It got over 3000 comments.

** A famous quote from Steve Jobs succinctly combined the ideas disruption and paradigm shift long before those terms became fashionable. Jobs was trying to convince John Sculley, CEO of Pepsico, to come to Apple as a marketing executive. Said Jobs, “Do you want to sell sugar water for the rest of your life, or do you want to come with me and change the world?” Sculley went to Apple. According to Wikipedia, he “continues to speak and write about disruptive marketing strategies.”