J Jayalalitha, his protege, followed suit. And now we have Kamal Haasan and Rajnikanth in the fray. The money spent in Tamil Nadu on elections has also been a huge talking point, what with the state being the poster child of election season doles. The cash seized by the Election Commission of India's expenditure observers saw record levels in the last elections, with more than crore rupees seized from just Tamil Nadu. Whatever the case may be, Tamil Nadu politics can be maddening and fascinating at the same time.
Pundits and psephologists are desperate to spot a trend - any trend - that indicates what this politically aware but unforgiving electorate has in mind for May In a country where leaders of every hue promise utopian futures, the great land of the Tamils goes a step further, giving the lie to the fatuous claims of our politicians. Or, you know, they bought into the evocative oratory of their leaders entirely, but only ended up revealing the futility of following political leaders with implicit trust.
To paraphrase a slice of modern wisdom, if the service is free, you are the product. A strident atheism drives the politics of a land steeped in unapologetic religiosity; movie stars can transcend Tamil identity politics and inexplicably find success in politics; and freebies like TVs and laptops are a regular feature as politicians attempt to swing votes in one of the most urbanised and productive states in India. Tamil Nadu has no use for the big Amazon and Flipkart sales, apparently.
Which is fitting. There was a time, not too long ago, when Tamil Nadu seemed a frontier too far for national parties. The Congress party, despite regularly finding stalwarts from that state in its upper echelons Kamraj, Chidambaram etc. The BJP? Well, for a Hindu party, they were utterly non-existent in a state where the culture is inextricably interwoven with its Hindu origins. The reason for that is, in the main, the Dravidian movement. The saffron party is viewed, at least according to political rhetoric, as a clique of upper caste Aryans seeking to impose their will over Tamilians with their wily machinations.
Though, to be fair, machinations do have to be wily if they are to have any chance of succeeding. However, contrary to this mainstream narrative, it required more than promises of righting historical wrongs to win elections. Subsequently, the DMK government under Karunanidhi gave free spectacles, cycle rickshaws.
Even the MG Ramachandran government offered free dhotis and sandals to woo voters. In , it doled out free laptops and television sets. These establishments often carried the prefix Amma, or mother, a term often used for the former chief minister herself. For instance, Amma Unavagams or canteens charged Rs3 for a plate of curd rice; the Amma brand of cement, launched by the AIADMK government, cost Rs per bag while the price in the open market was, at the time, Rs per bag.
Cohen a. The remainder of this section surveys several proposals as to what beyond democratic citizenship and civil liberties should be distributed equally among the members of society and how equality and inequality in the distribution of these goods should be measured. The latter issue can be posed in this way: When various amounts of heterogeneous goods are held by different individuals, how can one measure individuals' overall holdings of goods so that it can be determined when people's overall holdings are effectively equal?
The Lockean rights approach is so named because an early prominent exponent of the doctrine was John Locke Locke It might just as well be viewed as a rejection of egalitarianism rather than as a version of it. Contemporary Lockeans are also known as libertarians see Nozick The Lockean view is that every person has equal basic moral rights—natural rights.
Natural rights are rights that one has independently of institutional arrangements, people's subjective opinions, and cultural understandings. A person's natural rights give her a set of claims against all other persons that each person absolutely must respect. Our understanding of a particular rights claim or type or rights claim increases if we can determine whether or not it is forfeitable, waivable by the bearer, and transferable. The traditional content of Lockean rights is roughly as follows: Each person has the right to do whatever she chooses with whatever she legitimately owns so long as she does not violate the rights of others not to be harmed in certain ways—by force, fraud, coercion, theft, or infliction of damage on person or property.
Each person has the right not to be harmed by others in the mentioned ways, unless she voluntarily waives any of her rights or voluntarily transfers them to another or forfeits them by misconduct. Also, each adult person is the full rightful owner of herself and each child person has the right to be nurtured to adult status by those responsible for her creation. It is generally supposed in the Lockean tradition that starting from the premise of self-ownership, under actual conditions on earth one can validly derive strong rights of private appropriation and ownership of land and moveable parts of the earth Nozick, Property ownership of a thing comprises a bundle of rights, the central ones being the right to exclude others from the use of the thing and to control its use oneself.
If I own my body, I can exclude others from using it, and I have the right to decide its movements and control what may be done to it. The Lockean supposes that in a world in which self-owning persons confront unowned material resources, moveable and immoveable parts of the Earth, all persons initially have an equal right to use the resources, taking turns if there is crowding.
The Lockean supposes this free use regime is provisional. Nozick interprets this Lockean Proviso as follows: One's appropriation and continued holding of a part of the Earth as one's private property is morally permissible provided that all persons affected by this claim of ownership are rendered no worse off by it than they would have been if instead the thing had remained under free use Nozick , chapter 7; compare Simmons , chapter 5.
A different account will need to be given for intellectual property, property rights in ideas. Lockean rights do not single out a state of affairs, that in which everyone's rights are fully respected, and hold that all people are obligated to act in whatever ways are needed to bring about this state of affairs. Each person's right generates a duty to respect that right on the part of every other person.
Rights are constraints on what each individual may do, and do not set goals that all are together obligated to fulfill Nozick , chapter 3. A more egalitarian variant of Lockean rights doctrine combines the right of self-ownership with skepticism about the Lockean account of the moral basis of private ownership rights. Instead the left-wing Lockean asserts that each person is the full rightful owner of herself and each adult person has a right to a per capita share of ownership of the unimproved land and resources of the Earth.
In short, this version of Lockeanism combines robust self-ownership with an egalitarian account of world ownership. There are several variants to this doctrine. Critics explore whether or not the doctrine is normatively stable: Do any plausible grounds there might be for denying Lockean private ownership of the world also generate grounds for denying individual self-ownership?
Do any grounds there might be for insisting on individual self-ownership also generate reasons to insist on Lockean private ownership of the world? See Steiner , G.
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Cohen , Vallentyne and Steiner a and b, and Van Parijs The nature of the dispute between the right-wing and left-wing Lockeans emerges into view when we consider justice across generations. Suppose at one time the Earth is unowned and persons alive then appropriate all valuable land. On the next day, new people are born.
What natural rights to land do they have? The left-libertarian holds that the doctrine of ownership must provide for fair treatment of each successive generation, and this requires that each new person has a right to an equal share of the value of unimproved resources or to some similar entitlement. The right-libertarian holds that the Lockean Proviso fully accommodates the legitimate claims of new persons. On this view, there is no fundamental right to an equal share in any sense. Luck plays a legitimate role in the operation of a natural rights regime.
Granted, it is bad luck for me if I am born uncharming and lacking in good lucks and others are not voluntarily willing to enter into romance or friendship with me, but my distressed condition does not tend to show that my rights have been violated. And granted, it is bad luck for me if I come late on the scene and those who came first happen to be far better off in material wealth prospects than I, but the fact that there are unequal prospects does not tend to show that my rights have been violated.
Provided the Lockean proviso is continuously satisfied and the appropriations by others leave me no worse off than I would have been under continued free use, my being worse off than others gives me no moral complaint against their property holdings. The Marxian tradition in political and economic thought urges the desirability of eliminating some of the inequalities associated with the institutions of a capitalist market economy.
Interpreting Karl Marx as an egalitarian normative theorist is a tricky undertaking, however, in view of the fact that he tends to eschew explicit normative theorizing on moral principles and to regard assertions of moral principles as so much ideological dust thrust in the eyes of the workers by defenders of capitalism.
Marx does, of course, have an elaborate empirical theory of the evolution of moral principles corresponding to changes in the economic mode of production. This norm can be regarded as defining an equal right, but like any such right, it is defective. One defect is that some individuals are naturally more able than others, and so the amount of one's labor contribution will vary depending on factors that vary by luck beyond one's power to control.
For this and other reasons Marx asserts it will be desirable to discard this norm when a higher phase of communist society is attained. Then society can move beyond the sphere of bourgeois right altogether and operate according to the norm, from each according to his ability, to each according to his needs. Despite Marx's disclaimer, he seems to be proposing a principle of equal right: Each has the right to receive economic goods that satisfy her needs to the same extent provided she contributes to the economy according to her ability.
But Marx would resist the description of this norm as a principle of justice or moral rights. One consideration in his mind may be that moral rights ought to be enforced, but when it is feasible and desirable to implement higher-phase communist distribution, the implementation can be carried out successfully without any legal or informal coercion, and hence should not occur through any process of social enforcement.
Or so Marx thinks. See Marx , Wood , Cohen, G. In modern societies with market economies, an egalitarian is generally thought to be one who supports equality of income and wealth income being a flow, wealth a stock. Respecting this usage, this entry considers an egalitarian in the broad sense to be someone who prefers in actual or at least non-exotic circumstances that people should be more nearly equal in income and wealth and favors policies that aim to bring about such equality.
Money is a conventional medium of exchange. Given an array of goods for sale at various prices, with some money one has the option to purchase any combination of these goods, within the budget constraint set by the amount of money one has. What money can purchase in a given society depends on the state of its economy and also on legal and cultural norms that may limit in various ways what is allowed to be put up for sale.
For example, the laws may forbid the sale of sexual activity, human organs intended for transplant, the right to become a parent of a particular child by adoption, narcotic drugs, and so on. What money can purchase also obviously depends on what one is free to do with whatever one purchases—one may catch fish with the fishing rod one purchases only with a license and in accordance with rules issued by the state agency that regulates fishing. Leaving these complications in the background, one can appreciate that having money gives one effective freedom to engage in a wide variety of activities and experiences.
One has the option to purchase any of many commodities and do with them whatever is legally and conventionally allowed, up to the limit of one's budget. The ideal of equality of income and wealth is roughly the ideal that people should enjoy this effective freedom to the same extent.
This ideal is attractive to some and repulsive to others. One serious objection is that to bring about and sustain the condition in which all people have the same amount of money would require continuous and extensive violation of people's Lockean rights, which as standardly understood include the right to gain more property than others possess by gift or trade or hard work.
Another, closely related objection is that a regime of equal money could be maintained only by wrongful interference with people's liberty, because if money is distributed equally at one time people will choose to act in ways that over time will tend to result in unequal distribution of money at later times.
For the first objection, see Nozick , chapter 7, for the second, see Walzer Another objection to the ideal of monetary equality is that its pursuit would inhibit people's engagement in wealth-creating and wealth-saving activity, and in the not very long run would reduce society's stock of wealth and make us all worse off in the terms of the effective freedom that was being equalized.
Yet another objection is that people behave in ways that render them more and less deserving, and monetary good fortune is among the types of things that people come to deserve differentially. The advocate of egalitarianism in the broad sense has some replies.
Unless some substantive argument is given as to why Lockean rights should be accorded moral deference, the mere fact that equality conflicts with Lockean rights does not by itself impugn the ideal of equality. In the same vein, one might hold that the fact that continuous restriction of individual liberty is needed to satisfy some norm does not by itself tell us whether the moral gain from satisfying the ideal is worth the moral cost of lessened freedom. Some restrictions of liberty are undeniably worth their cost, and some ideal of equality might be among the values that warrant some sacrifice of liberty.
Equality might be upheld as one value among others, and increase in wealth or in wealth per capita may be included along with equality in a pluralistic ethics.
We may want more effective freedom of the sort money combined with goods for sale provides , and we may also want this freedom equally distributed, and then we would need to find an acceptable compromise of these values to deal with cases when they conflict in practice. Much the same might be said about the conflict between the achievement of equality of money and the distribution of good fortune according to people's differential desert.
Monetary equality can strike one as a misguided ideal for the different reason that it does not deal in what is of fundamental importance. The value of purchasing power, equal or unequal, depends on the value of what is for sale.
Imagine that the economy of a society is organized so it produces only trivial knick-knacks. Freedom to purchase trivia is a trivial freedom, and rendering it equal does not significantly improve matters. Critics of consumerism and consumer culture are moved by the idea that in actual modern societies, the economy, responsive to consumer demand, is responsive to demands for what is not very worthwhile and ignores many truly important human goods, that either happen to be not for sale or that by their nature are not suitable for sale on a market. Another concern about monetary equality is that purchasing power interacts with individuals' personal powers and traits, and real freedom reflects the interaction, which an emphasis on purchasing power alone conceals.
Consider two persons, one of whom is blind, legless, and armless, while the other has good eyesight and full use of her limbs. Given equal money, the first must spend his money on devices and services to cope with his handicaps, while the second may purchase far more of what she likes. Here equality of purchasing power seems to leave the two very unequal in real freedom to live their lives as they choose.
But the case of handicaps is just an extreme instance of what is always present, namely each individual has a set of traits and natural powers bestowed by genetic inheritance and early socialization, and these differ greatly across persons and greatly affect people's access to valuable ways to live. One response to the problematic features of the monetary equality ideal is to shift to the notion of real freedom as that which an egalitarian morality should be concerned to equalize.
Real or effective freedom contrasts with formal freedom. You are formally free to go to Canada just in case no law or convention backed by penalties prevents you from going and no one would coercively interfere if you attempted to travel there. In contrast, you are really or effectively free to go to Canada just in case this is an option that you may choose—if you choose to go and seriously try to go, you will get there, and if you do not choose to go and make a serious attempt to go, you do not get there.
One might lack formal freedom to do something yet be really free to do it, if one was able to evade or overcome the legal and extralegal obstacles to doing that thing. Another response to the problematic features of the monetary equality ideal aims to cope with the thought that freedom of purchasing power may not be of great importance.
The response is to characterize what we should be equalizing in terms that directly express what is reasonably regarded as truly important. Both responses are present in a proposal made by Amartya Sen in several publications beginning in see Sen and and the references cited in Sen Sen suggests that in so far as we should value equality of condition, what we should value is equal real freedom, and more specifically basic functioning capability equality. People may function—do or be something—in any of a huge number of ways. Consider all of the different ways that one might function variously.
Many of these are trivial or of little importance; set these to the side. Consider then basic functionings, functionings that are essential or important for human flourishing or valuable agency. Consider all of the packages of functionings that an individual at a time is really free to choose all at once; these are one's capabilities at a time. We may also consider an individual's basic capabilities over the life course. The proposal is that society should sustain basic capability equality. Care must be taken in identifying an individual's capability sets, since what others choose may affect the freedom one has.
One may have the option of choosing the functioning of attending college, but only if not too many persons in one's high school cohort make the same choice. Above that threshold level for each capability, differences in the level of capability that people can attain do not signify—they do not change the fact that everyone does or does not enjoy equal basic capabilities. To get equal basic capability for everyone would be to get each person at or above the threshold level for every one of the capabilities that are specified to be necessary for a minimally decent or good enough life.
The capability approach to equality can be developed in different ways depending on how basic capabilities are identified. Some theorists have explored the capability approach by tying it to an objective account of human well-being or flourishing. The aim is to identify all of the functionings needed for human flourishing. For each of these functionings, the ideal is that each person should be sustained in the capability to engage in every one of these functionings at a satisfactory or good enough level.
See Nussbaum , , and Another use of the capability approach ties it to the idea of what is needed for each person to function as a full participating member of modern democratic society.
Each person is to be sustained throughout her life, so far as this is feasible, in the capabilities to function at a satisfactory level in all of the ways necessary for full membership and participation in democratic society. See Anderson and Walzer It should be noted that the capability approach as described so far might seem to involve the assumption that anything whatever that reduces or expands an individual's real freedom to function in ways that are valuable should trigger a response on the part of a society or agency that aims to establish and sustain capability equality.
This appearance is misleading in at least two different ways. For one thing, Sen clearly wants to allow that one's capabilities can increase by virtue of gaining opportunities to function even though one does not get real freedom to accept or decline the opportunities. Consider the capability to be free of malaria, which opens many malaria-free life options, when the capability is obtained by public health measures beyond the power of the individual agent to control. Also, if what one embraces is basic capability equality for all, then by implication one is countenancing that there may be non-basic capabilities, providing which to all is not required.
But even if we amend our conception of capabilities to accommodate these points, one might still deny that every reduction or threat to an individual's basic capabilities poses a social justice issue while otherwise working within the capability framework.
One might distinguish aspects of a person's situation that are socially caused from those that are naturally caused. This distinction is evidently rough and needs refinement, but one has some sense of what is intended. That I am unable to run fast or sing a tune on key may be largely due to my genetic endowment, which in this context we may take to be naturally rather than socially caused. In contrast, the facts that given the talents of others and their choices to use them in market interaction, my running ability is nonmarketable but my singing ability enables me to have a career as a professional singer are deemed socially caused.
That I have a certain physical appearance is natural any of a wide variety of childrearing regimens would have produced pretty much this same physical appearance but that my appearance renders me ineligible for marriage or romantic liaisons is a social fact social arrangements bring this about and different social arrangements might undo it. Even if my natural physical appearance repels any marital or romantic partners I might seek, society might provide me charm lessons or cosmetic surgery or promulgate an egalitarian norm that encourages the charming and the physically attractive not to shun my company or institute some mix of these three strategies or some others.
However exactly the natural and social are distinguished, one might restrict the scope of an equality ideal to the smoothing out of socially caused inequalities. What this restriction amounts to depends on how one distinguishes socially caused from other inequalities. Suppose that society pursues policy A, and that if it pursued policy B instead, a given inequality across people would disappear. Does this fact suffice to qualify the inequality as socially caused or not?
The starting point of the capability approach is that the equality that matters morality or that we are morally required to sustain is equality of freedom of some sort. This starting point is open to challenge. Freedom is no doubt important as a means to many other goods and as something everyone cares about to some considerable extent. But why confine the concern of equality to freedom rather than to achieved outcomes? Suppose that we could supply resources to Smith that will expand her freedom to achieve outcomes she has good reason to value, but we happen to know that this freedom will do nobody any good.
She will neglect it and it will be wasted. In these circumstances, why supply the resources? If provision of freedom for its own sake is morally of first-priority importance, then the fact that freedom in this instance will do nobody any good would seem to be an irrelevant consideration. If this fact seems highly pertinent to what we should do, this indicates that freedom may not be the ultimate value the distribution of which is the proper concern of an equality ideal.
A version of this objection can be lodged by advocates of any type of doctrine of equality of outcome against any type of doctrine of equal opportunity for outcomes. Another feature of the capability approach as elaborated to this point is that it does not appear to register the significance of personal responsibility as it might appropriately qualify the formulation of an equality ideal Roemer and A simple example illustrates the difficulty.
Suppose society is dedicated to sustaining all of its members equally at some level of basic capability. Society provides resources fully adequate for sustaining an individual at this level of basic capability, but he frivolously and negligently squanders the resources. The resources are re-supplied, and squandered again, and the cycle continues.
At some point in the cycle, many people would urge that the responsibility of society has been fulfilled, and that it is the individual's responsibility to use provided resources in reasonable ways, if his lack of adequate basic capability is to warrant a claim to equality-restoring social intervention. The capability approach could of course be modified to accommodate responsibility concerns. But it will be useful to turn to consideration of the resourcist approach, within which the aim of integrating equality and responsibility has prompted various proposals.
A third feature of the capability approach that has elicited criticism is the idea that knowledge of human flourishing and what facilitates it must inform the identification of an adequate equality norm. The worry in a nutshell is that in modern societies that secure wide freedoms, people will embrace many opposed conceptions of how to live and of what is choiceworthy in human life.
These are matters about which we must agree to disagree. At least if an ideal of equality is being constructed to serve in a public conception of justice that establishes basic terms of morality for a modern democratic society, this ideal must eschew controversial claims about human good and human flourishing such as those in which the capability approach must become embroiled. Martha Nussbaum explores how the capability approach to social equality might function appropriately as a public conception of justice Nussbaum Charles Larmore argues that it is wrong for government to impose a policy that could only be justified by appeal to the claim that some controversial conception of the good is superior to another Larmore and ; for criticism of the neutrality requirement, see Raz and Sher In response it might be urged that a conception of human capabilities might be controversial but true and, if known to be true, appropriately imposed by government policy.
The ideal of equality of resources can be understood by recognizing its primary enemies. These enemies comprise all manner of proposals that suppose that in so far as we should care about equality of condition across persons, what we should care about equalizing is some function of the utility or welfare or well-being or good that persons attain over the course of their lives.
There is a complication here, because the resource-oriented approach also opposes the capability approach, which so to speak stands midway between resources and welfare. This raises the question whether the capability approach is an unstable compromise see Dworkin , chapter 7.
This issue surfaces for discussion eleven paragraphs down in this section. John Rawls offers an especially clear statement of the animating impulse of the equality of resources ideal. For it does not look behind the use which persons make of the rights and opportunities available to them in order to measure, much less to maximize, the satisfactions they achieve. Nor does it try to evaluate the relative merits of different conceptions of the good. Instead, it is assumed that the members of society are rational persons able to adjust their conceptions of the good to their situation.
Resourcist ideals of equality of condition are non-welfarist. Several thoughts are intertwined here. One is that equality of condition must be developed as a component of an acceptable theory of justice, intended to be the basic charter of a democratic society and acceptable to all reasonable members of such a society, who are presumed to be disposed to disagree interminably about many ultimate issues concerning religion and the meaning and worth of human life Rawls We must seek reasonable terms of cooperation that people who disagree about much can nonetheless accept.
If there is anything that people cannot reasonably be expected to agree about, it is what constitutes human good, so introducing a controversial conception of human good as part and parcel of the ideal of equality that is to be at the core of the principles of justice is a bad mistake. Another thought is that responsible individuals will consider themselves to have a personal obligation, which cannot be shifted to the government or any agency of society, to decide for themselves what is worthwhile in human life and what is worth seeking and to fashion and refashion as changing circumstances warrant a plan of life to achieve worthwhile ends.
So even if the true theory of human good could be discovered, it would offend the dignity and sense of responsibility of individual persons for some agency of society to preempt this individual responsibility by arranging matters so that everyone achieves human good understood a certain way to a sufficiently high degree. Individuals should take responsibility for their ends. See Rawls , Rakowski , Dworkin , and for a different view, Fleurbaey Another thought that motivates the family of equality-of-resources ideals is that society's obligations by way of providing for its members are limited.
A just and egalitarian society is not plausibly held to be obligated to do whatever turns out to be necessary to bring it about that their members attain any given level or share of quality of life. The reason for this is that the quality of life the degree to which one attains valuable agency and well-being goals that any individual reaches over the course of her life depends on many choices and actions taken by that very individual, so to a considerable extent, the quality of life one reaches must be up to oneself, not the job of society or some agency acting on behalf of society.
Along these lines, the actual course of an individual's life and the degree of fulfillment it reaches also depend on many chance factors for which nobody can reasonably be held accountable. Justice is a practical ideal, not a Don Quixote conception that aims to correct all bad luck of any sort that befalls persons. A reasonable morality understands the social justice obligations of society as limited, not open-ended and unbounded.
So if equality of condition is part of social justice, it too must reflect an appropriately limited conception of social responsibility. Equality of resources fills this bill. See Daniels and chapters 3 and 4 of Buchanan et al. The trick then is to develop an appropriate conception of resources that can serve in an ideal of equality of condition. Resources can be external, material goods, such as land and moveable property. One can also extend the domain, and consider traits of persons that are latent talents or instruments that help them to achieve their ends as also included within the set of resources to be equalized.
Extending the domain in this way will introduce complexity into the account, because personal talents are attached to persons and cannot simply be transferred to others who lack talent. What one can do is take people's variously valuable personal talents into account in determining how material resources should be distributed so as to achieve an overall distribution that should register as sufficiently equal. If Smith lacks good legs, this personal resource deficit might be offset by assigning Smith extra resources so he can buy a wheelchair or other mobility device.
Notice that in elaborating equality of resources, it is assumed that a population of individuals with given traits, generated by genetic inheritance and early socialization, is present, and equalization is to proceed by adjusting features of the individuals' environment or by altering features of the individuals, say by extra education.
But of course, moral questions may also be raised about the processes by which individuals come to be born and given early socialization so as to endow them with certain traits. With genetic information about an individual made available to prospective parents before the individual is born, a decision can be made about whether to bring this child to term. In the future, genetic enhancements may be available that can alter the genetic makeup of individuals, and again a morality must consider when enhancements should be supplied and by whom.
Raising these questions makes it evident that just assuming an initial population of individuals with given traits takes for granted matters that are very much morally up for grabs see Buchanan et al. For the purposes of this entry, this complication is noted only to be set aside.
How can resources be identified and rated? We want to be able to say, given two persons each with different amounts of resources, which one has more resources overall. The literature to date reveals two ways of confronting the question. Rawls suggests that the conception of resources to be deployed in a resourcist ideal of equality is primary social goods.
These are defined as distributable goods that a rational person prefers to have more rather than less of, whatever else she wants.
A variant conception identifies them as goods that any rational person would want who gives priority to her interests in 1 cooperating with others on fair terms and 2 selecting and if need be revising a conception of the good and a set of life aims along with pursuing the conception and the aims. In , Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average.
The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns. The explosive trend in American medical costs seems to have occurred here in an especially intense form. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control.
Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.
One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it.
I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease.
Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them. Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H. El Paso County, eight hundred miles up the border, has essentially the same demographics.
Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.
Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods.
We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery. I was impressed. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers.
At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies.
The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average. Nor does the care given in McAllen stand out for its quality.
Medicare ranks hospitals on twenty-five metrics of care. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.
I gave them the spending data from Medicare. People can be seen faster and get their tests more readily, he said. Others were skeptical. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere. That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. There is overutilization here, pure and simple. Before, it was about how to do a good job. Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere.
Yes, they had more technology. The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder. Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment.
A surgeon has to provide reassurance people are often scared and want to go straight to surgery , some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate.
The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars. I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago? Send her home, they said.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care. The Medicare payment data provided the most detail. Between and , critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period.
In and , patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes.
They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.
In a study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received.
If anything, they seemed to do worse. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In , doctors performed at least sixty million surgical procedures, one for every five Americans.
No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes. To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician.
They got more of the stuff that cost more, but not more of what they needed. In an odd way, this news is reassuring. Policymakers have worried that doing so would require rationing, which the public would never go along with. Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. Unless we figure it out, health reform will fail.
I had what I considered to be a reasonable plan for finding out what was going on in McAllen. The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. Truth be told, her office seemed less churrigueresco than Office Depot.
She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.