We call them “entitlements,” the big three: Medicare, Medicaid, and Social Security. They’ve been in the news a lot lately. We’re told that they need to be ‘fixed’ and that is scary. It’s scary because they are huge systems, huge not just by one measure but by many: huge in scope and complexity, huge in benefits conferred, huge in social consequence, huge in their impact on the federal coffers.
The entitlements possess centrality. They are a source of political and economic vulnerability, yet their future is of momentous social importance. What happens to them represents, to some extent, what will happen to us, both as individuals and as a country.
Will Americans discover the means of prudence while continuing in their commitment to providing needed medical care to the ill who are poor and elderly? Will aged Americans be guaranteed a subsistence in their 80s and 90s, or will they be draining the resources of their families, or on the street begging? Will the government sensibly modify its social-welfare programs, or will it fudge on its responsibility to “promote the general welfare,” one of the purposes of federalism evoked in the preamble to the Constitution?
Moderation and broad vision are the keys to determining how best to effect the changes these massive programs need. The crisis of social welfare is not just national but global; it follows from a long historical trajectory. The interactive graphics that Gapminder puts together furnish a global longitudinal perspective on our current situation—on our great achievement and our difficulties.
The entitlement programs of today were part of a great historic initiative that altered human life in the 20th century. In the late-19th and early-20th centuries, many countries of the world created various sorts of social-welfare programs. As populations worldwide shifted from the countryside to cities, nations saw their citizens becoming newly vulnerable to hardships that living on the land in extended networks used to ease. As humans became more divorced from the land, they became cut off from a natural subsistence and more vulnerable to the shifts in fortune that market economies caused.
Nations were also moved by a humane desire to apply life-saving medical advances to the cruel diseases and conditions that cut short all too many lives, both here in the US and globally. Just imagine: in 1900, the average life expectancy for an American man was just 46.3 years of age; for a woman it was 48.6. Click the play button on this page to see how dramatically life expectancy for many peoples of the world has changed since then.
The creation of so-called safety-nets played an important part in improving both the health and wealth of developing nations. The graphic above suggests the strong relationship between these two qualities, with wealthiest countries of the world also enjoying the greatest life expectancies. While some countries are wealthier than the US, and others are healthier, the United States enjoys the distinction of being the largest mass society to enjoy both health and wealth to such a high degree. Wealth, especially when widely shared, is an important contributor to public health; conversely, public health is a crucial asset in determining what a nation can achieve.
Of course, many factors contribute to life expectancy: culture, environment, and genetic inheritance as well as living standards and public policy. The case of Russia, which continues to have a remarkably low life expectancy despite its considerable resources and size, shows how a nation can be dragged down when all these elements ill combine. On the other hand, the elite group of countries enjoying the greatest health and wealth include all the Western European countries, with their Cadillac safety nets, as well as many former imperial possessions of the U.K.
Now, however, the very success we have achieved in promoting health and long life is contributing to a crisis being felt worldwide. We can see it in our own country, where entitlement spending is a major contributor to our ballooning federal deficits, but it also appears in the massive debts that European governments are accruing, as well as in the sometimes violent struggles over “austerity,” pensions, and public health insurance retrenchments in countries such as Spain, Italy, France, the UK, and Greece. The underlying connections among these crises are a reminder that the problems we are facing are by no means unique. Shaped by the same historical factors and the same demographic trends, the same problems are bedeviling many other nations.
At the same time, the historic role of these programs in helping nations secure greater blessings for their people argues for their continuing importance in an increasingly competitive and precarious world. Countries that demonstrate the most prudence and creativity in reshaping the social guarantees they extend to their citizenry are those most likely to flourish and dominate in the future. The worst paths for the US and other countries are those defined by extremes. Preserving our entitlements unchanged or gutting them mercilessly are alternatives equally foolhardy. Acknowledging the great social advances we have achieved with the aid of entitlements should go hand-in-hand with discovering creative and discriminating ways to move ahead.
Click on the image to enlarge, or check out the pdf version from Gapminder.