Marmor and Mashaw on social insurance
Understanding Social Insurance: Fairness, Affordability, and the ‘Modernization’ of Social Security and Medicare
By Theodore R. Marmor and Jerry L. Mashaw
Health Affairs
March 21, 2006
In our view, the fate of Social Security and Medicare should be neither stasis because of political gridlock nor transformative change because of anxieties about the future. Both are crucial parts of the U.S. social contract and respond to deeply held notions of fairness and collective responsibility. But they should not be immune to sensible adjustment to reflect changed circumstances. To see why, we need to understand why basic social insurance arrangements have been so remarkably durable both in the United States and elsewhere.
The short answer is, first, that the core features of social insurance arrangements are both economically sensible and socially and politically acceptable. Social insurance is part of the essential social glue that holds an individualistic polity together and that makes the economic risks of a market economy tolerable. Second, however fundamental to the U.S. social fabric, social insurance programs have been and can be adjusted over time to meet fiscal, demographic, and technological challenges. They are not dinosaurs from another age, but evolving programs whose core principles can be expressed through a number of adaptations.
But some mutations are species-altering. In our view, much of the current enthusiasm for “modernizing” Social Security and Medicare has precisely that species-altering ambition. These reforms emphasize not protection against common economic risks in a changing world, but individualized risk bearing through increased responsibility and rewards for personal choice and increased “marketization” of social provision. We do not deny for a moment the value of personal choice, individual responsibility, and market competition. Indeed, supporting a society based on a viable vision of those values is the fundamental function of social insurance. But social insurance programs designed to maximize personal choice and promote market competition will simply not deliver adequate social insurance protections. To see why, we need to explore the basic structure of social insurance and its capacity to face contemporary challenges-that is, its capacity to modernize while continuing to play its fundamental social role.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w114
Comment: By Don McCanne, M.D.
Even if you are already an authority on social insurance, this article is well worth reading. Marmor and Mashaw provide an effective framework on which to have a rational dialogue on social insurance. You will not only be able to explain why we should and how we can preserve the social insurance roles of Social Security and Medicare, but you will also be able to extrapolate the principles and thereby be able to explain why we need a program of social insurance to cover health care for everyone.
Even if you are not a subscriber to Health Affairs, for the next two weeks this article can be downloaded free of charge. You should do so now.