Bad Idea of the Week: Poor People Have a Duty to Be Well

A century ago, governments began to assert their authority over poor people and immigrants whose bad behavior was supposedly spreading epidemic diseases like smallpox, cholera and typhus. Cops in Boston held down writhing workers to inoculate them, and authorities in New York City locked up “Typhoid Mary” for 30 years because of her refusal to follow their instructions. Today, when the top killers are non-contagious “lifestyle” diseases that are related to smoking, alcohol, junk food and other “bad” habits, politicians can’t stigmatize “problem” people as a physical menace. But lately they’ve been portraying those people as a fiscal menace.

Last week, the Associated Press reported that Arizona’s Governor, Jan Brewer, has proposed requiring that patients who are overweight, diabetic or smokers be required to follow a plan to improve their health—and those who failed to meet their targets have to pay an extra $50 a year. In 2007, West Virginia tried an even more draconian plan: It redefined many important Medicaid services (like getting more than four prescriptions a month, treatment for drug addiction, and quit-smoking programs) as part of a special “enhanced” package. This “enhanced” Medicaid would only be available to people who signed commitments to do things like control their weight and keep medical appointments. (So if you’re a drug addict who can’t keep appointments, this plan’s answer is to take away access to addiction treatment. That’ll teach you!) As Doug Trapp reports here, the West Virginia plan, because it affected kids, was finally gutted by Federal rules that require states to give all their children on Medicaid the same benefits.

The reason for these moves, of course, is that states are broke and Medicaid costs a lot, so they’d like to spend less on it. But the justification, in both Arizona and Virginia, was clothed in rhetoric about responsibility and public health. It’s an attempt to smack smokers and fat people with a stigma once visited on the carriers of infectious diseases.

“If you are a healthy person who is financially challenged—and you need help from the state—then you’re going to have some responsibilities to meet,” then-Governor (now Senator) Joe Manchin said last year, according to Trapp’s piece. In Arizona this month, a spokeswoman for Arizona’s Medicaid program told the Wall Street Journal, “if you want to smoke, go for it. But understand you’re going to have to contribute something for the cost of the care of your smoking.”

It sounds so reasonable—because a century of vaccination and quarantine powers have made us used to the idea that society has a “right to protect itself against an epidemic of disease which threatens the safety of its members,” as the U.S. Supreme Court put it when it rejected an anti-vaccinationist’s claim in 1905. (Yes, forced vaccination was once seen as a grave intrusion into private life. The term “conscientious objector” was coined for people who refused vaccines.)

But the analogy between fiscal danger and the physical kind is feeble. One reason was neatly identified by the medical ethicist Art Caplan: When we’re worried about people spreading smallpox, we can identify those people by testing them for exposure and contagiousness. That’s not the case when the fear is over people spreading the disease of costliness, and the plague of insolvency. In that case, we have no reliable way to measure who the financial Typhoid Marys are. A “duty to be well” is so general and vague that it can tar everyone. (That’s one reason totalitarian governments like the concept.) If the state is going to tax smokers for the extra costs they impose on society, Caplan points out, it should also tax jet-skiiers, rock climbers, and the live-free-or-die types who don’t wear helmets on their motorcycle trips.

The notion of a “duty to be well” lately has been denounced as a left-wing idea. But the people interested in punishing Medicaid recipients for their supposed lack of responsibility have been conservatives, speaking the language of fiscal restraint. That’s one thing that hasn’t changed in the past 100 years.

A century ago, “tramps,” immigrants and working-class people were the people blamed for spreading diseases with their bad habits. Middle-class people who objected to vaccination weren’t denounced or inoculated by force. (The man who brought the Supreme Court case, Henning Jacobson, simply paid a fine for refusing a smallpox vaccine.) Today the fiscal menace of supposedly bad habits is once again being blamed on the poor, who are more likely to smoke and be obese.

Chronic diseases have replaced infectious epidemics, and the fear of literal death has been replaced by fear of financial collapse. What has endured is an urge to blame society’s health troubles on poor people.

Illustration: Excerpt from a Nazi anti-smoking poster