Medicaid and Other Welfare Programs

Medicaid (health benefits for the poor) and other welfare assistance programs generally do not impinge on individual liberty directly. But both can do so indirectly by using taxation to transfer free choice in spending decisions from some individuals to others.

As stated a greater length under Social Security and Medicare, there may be compelling governmental interests that, under certain conditions, justify taking from some in order to give others. Probably the most prominent possibility in the case of Medicaid is that fact that the government is the provider of last resort—the only institution that can deal effectively with the social “net-negatives.” See The Problem of “Net Negatives.” That is to say, it is the only entity that can effectively act to keep various inevitably shared assets and facilities (such as streets open to public traffic) from dissolving into disorder.

People who cannot provide for themselves do not just “go away.” In order to have the kind of public environment and society that the vast majority of people want, some provision has to be made to deal with those who might otherwise be found starving or dying of disease in the streets. These who cannot provide for themselves but do not just “go away” can be dealt with humanely or (in nations so inclined) inhumanely, but the bedrock fact it that they must be dealt with. And no matter how they are dealt with, there is a cost.

The prevailing values of the times are, of course, what ultimately determine whether a government interest is “compelling” or not, and the interest in assuring a humane solution to the problem of economic “net negatives” is no exception. In our times it seems clear that assuring a humane solution to this problem is a “compelling” governmental interest.

It must be remembered, however, that the existence of a compelling governmental interest does not mean that any and all impingements on liberty become permissible. The restrictions must be narrowly tailored to serve the compelling interest and there must not be any less restrictive alternatives.

With these latter qualifications in mind, it is almost certain that Medicaid as it now exists and other welfare programs would have to be modified in order to accommodate a fundamental right to liberty.

As suggested in the case of Social Security, one possible approach would be to provide a “second track” for those who prefer to risk a less comfortable future in exchange for short-term advantage. They would be permitted to pay only a small fraction of the taxes needed to humanely deal with medical destitution and, in exchange, they would agree to settle for only basic sustenance and palliative care in case of medical need. The problem is that, while nearly everyone expects (or should expect) to get old, most economic “net-positives” have no reason to expect that they will suddenly become net negatives in desperate need of the social safety net. Thus, the temptation can be strong for them to “free ride” on what many, probably most, consider to be a shared social responsibility, like national defense.

But, again, the point is not to solve the problem here but to suggest that a fundamental right to liberty means that we should be ever on the lookout to discover possible solutions that consider, not just fiscal or political advantage, but the interest in liberty as a first priority.

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