The Republican replacement for the ACA (Obamacare) has been called many things, “mean,” “heartless,” and “an act of class warfare by the rich against the poor,” but I am going to add one more, the Republican healthcare proposal is unjust.
The proposal in question, currently the BCRA, is not a healthcare bill, despite the enormous effect on our healthcare system it is fundamentally a “budget bill,” a series of tax cuts on the wealthiest individuals and industries payed for by cuts to programs benefiting middle and lower-class Americans. The result will be 22 million more people left uninsured by 2026 and 200,000 people dead in the next decade to give $536 billion tax cuts for the wealthiest Americans including cutting $172 billion in capital gains taxes which are paid almost exclusively by the rich, at a much lower rate than earned income.
Consider the work of political philosopher 20th century political philosopher John Rawls whose magnum opus, A Theory of Justice, revolutionized political philosophy and revitalized social contract theory at a time when most political philosophy was based in a utilitarian moral foundation.
Concerned with the unfairness of society, Rawls derived a thought experiment. He realized that given the opportunity to make decisions on public policy, people act in a way biased towards their own interests making agreement difficult and frees those in positions of power and privilege from caring about the welfare of those at the bottom of society.
His solution is to ask readers to consider themselves from the “original-position, behind the “Veil of Ignorance” which blinds us to our own interests: our sex, gender, race, age, religion, tastes, skills, values, disabilities, street address, and our friends. By taking up the Veil of Ignorance we can enter the original position at any time and behind the Veil we can deliberate our positions and expect to come up with an agreeable solution that would feel safe to enter when you could be anyone in the society and want to be able to pursue your own conception of the Good. It is under these conditions that he derives the following Two Principles of Justice: “
1. Each person has an equal right to a fully adequate scheme of equal basic rights and liberties, which scheme is compatible with a similar scheme for all.
2. Social and economic inequalities are to satisfy two conditions: first, they must be attached to offices and positions open to all under conditions of fair equality of opportunity; and second, they must be to the greatest benefit of the least advantaged members of society.” — John Rawls, Justice as Fairness (1985)
Rawls’s first principle, known as the “Liberty Principle,” is enough to justify universal healthcare when one starts with the position of healthcare as a basic right. This view is consistent with liberalism in the post New-Deal where liberty is understood to entail the security to exercise ones rights rather than merely a lack of prohibition. Accordingly, the ACA granted many individuals the freedom to be self-employed when the cost of health insurance made it prohibitive before even though there were no laws prohibiting it.
Returning to the Original Position, under the Veil of Ignorance, it would be illogical to accept any solution in which you could end up sick and uninsured, driven into debt or deprived of life unnecessarily. Universal health care becomes a mandate making this situation impossible. The idea is catching on in America with a recent Pew Research poll finding that “60% of Americans say that the Government should be responsible for ensuring healthcare coverage for all Americans.”
The arguments made upon the Liberty Principle are consistent with the typical complaints against the proposal listing the numerous parties who will be injured by the bill to generate outrage over the denial of their understood “right to healthcare.”
It gets more interesting with Rawls’s second principle which is divided into two parts. The first, called the “fair opportunity principle” which specifies that inequalities be attached to “offices and positions open to all under conditions of fair equality of opportunity” is considered non-controversial in theory, but is far from being realized in practice in a country where money is considered speech. We have already seen how corporate influence influences our healthcare policy with the death of the public option and can expect to keep seeing this influence until true campaign finance reform is realized.
It is the second part that makes Rawls innovative and controversial. In his “Difference Principle” Rawls declares that social and economic inequalities in a just society are to be “to the greatest benefit of the least advantaged in society.” While it has long been clear that many social harms arise from economic inequality, plans to create equality have all been accused of creating a leveling-down effect which deprives the ambitious and talented from the rewards of their work and the incentive to provide it. If, however, their additional work which generates rewards for them produces a positive effect for society either directly or through taxes which support social programs for the most vulnerable in the society, the inequality created is to the benefit of the least well off and thus just.
While Rawls’s work was focused on the basic structure of society rather than individual actions, like Robert Nozick’s Wilt Chamberlain example, it seems self-evident that our healthcare system is a part of this structure. It is also clear that this bill will increase inequality by transfer of wealth from the poor to the rich and it is also clear that this bill will harm the most vulnerable in our society, thus it violates the Difference Principle and is provably unjust.
The proposal in question not only violates any right to healthcare that might exist, it is not only attached to offices and positions not available to all under equality of opportunity, it is antithetical to the Difference Principle: increasing inequality to the detriment of the least well off. Consider the original thought experiment; under the Veil of Ignorance you have no way of knowing if you will be sick or healthy, no way of knowing if you will have risk factors such as a family history of cancer or living close to a coal-fired power plant, no way of knowing if you will be able to pay for your healthcare out of pocket. When you have an equal chance of being any person in that society once the veil of ignorance is lifted fairness it is irrational to agree to any set of rules in which any individual is not covered. Taking single-payer off the table for the next four years for pragmatic reasons, no individual under the Veil of Ignorance could agree to the replace the ACA with the BCRA lest they find themselves one of the 22 million additional Americans who will become uninsured by 2026 or 200,000 Americans destined to die in the next decade should this bill pass. Thus, the BCRA is innately unjust and must be rejected at all costs.