- BIOETHICS FORUM ESSAY
Belief in a Just World: A Case Study in Public Health Ethics
Why did portraying a married, working, loving, family-oriented, and religious couple with a disabled child bring out consistently negative reactions among the public toward allowing this family access to government-subsidized health care for their children? The answer may lie in a study by the National Center for Children in Poverty entitled “How Belief in a Just World Influences Views of Public Policy.” Those who believe in a just world believe that, basically, people get what they deserve and deserve what they get.
A recent news article in The Atlanta Journal-Constitution profiled a working-class married couple, Connie and Michael Post, whose children were enrolled in PeachCare for Kids, a health insurance program for children that is Georgia’s version of the State Children’s Health Insurance Program.1 The Posts were having a tough time making ends meet, and they depended on PeachCare for health care for their three children (and a fourth on the way at the time the series appeared). Michael had recently left his $42,000-a-year job as a full-time pastor to work as a freelance minister, supplementing his income with odd jobs and house painting. Connie had taken a job at a local horseshoeing school for $25,000 a year. Their take-home pay was about $850 per week, and their monthly expenses (mortgage, car payment, auto insurance, health insurance premiums with high deductibles for the parents, food, gas, electricity, water, cell and telephone service, clothes, credit card payment, life insurance) averaged around $2,883 a month, leaving little left over for extras. Living paycheck to paycheck, they seemed nonetheless a happy and stable family.
PeachCare for Kids lets families earning less than 235 percent of the federal poverty level get free health insurance for their children up to age six, and to pay a modest premium for health insurance for children over that age. The benefits include doctor visits, immunizations, hospitalizations, and emergency room visits. PeachCare is widely regarded as a successful preventive health program for children in low-income families whose earnings put them above Medicaid eligibility levels. The Posts would likely have been completely insolvent had not PeachCare been paying their children’s medical bills. Their middle child, Cadence, was disabled with autism, and she needed two $135 therapy sessions every week on an ongoing basis. An older child had sensory problems but had improved with once-a-week, $135 therapy sessions and no longer needed them.
“You can imagine how grateful we are for PeachCare,” Connie told the paper.
Readers’ reactions to the story were almost uniformly negative—which was particularly striking because the newspaper has a reputation for balance and even-handedness in printing reader responses.2 Readers consistently complained that the Posts were irresponsible. Some criticized the parents for their employment choices. “[They] have deliberately chosen to limit their income by giving up a high paying job—yet they continue to have children and shift the responsibility for their medical care to the taxpayers,” wrote one reader. Another thought that Connie, with a degree in English, should have become a public school teacher with medical benefits. A third observed: “While reading this story, my blood pressure spiked. . . . Whenever you reward bad behavior, that behavior will continue. This is why we need to cut these programs for all but the truly needy. These people aren’t needy, they are lazy, and PeachCare simply encourages said laziness.”
Almost all readers criticized the Posts for having too many children, and especially for being pregnant with a fourth child. “Unfortunately, it appears that the Posts do not themselves believe in being responsible,” wrote one reader. “[P]erhaps without multiple children they could not afford to provide for, they would be doing just fine.” Another commented, “as the story progressed my feelings turned to disbelief and then anger when I learned that ‘another child is on the way.’ . . . The responsible thing for this couple to do would be to practice some sort of birth control.”
Michael Post offered a defense of his family in a column a few days later.3 He wrote that he and Connie had also felt “disbelief” at news of the latest pregnancy, “since we had employed the same birth control method that had produced unfailing success the previous 2 ½ years. Once the shock wore off though, we embraced the reality that we would once again be given the opportunity to provide a loving home for another person. . . . [O]ur autistic child will have another sibling to help provide care to her, making sure that she will not be a burden to the state long after my wife, Connie, and I are gone.”
Michael also wrote that his shift from full-time to freelance minister had nothing to do with the decision to enroll their children in PeachCare. For the previous four years they had been grossing about $48,000 annually, but neither his nor Connie’s employer had offered health benefits, and as a minister he was considered self-employed and had to pay full Social Security and Medicare taxes without an employer match. He had not been tempted by PeachCare to quit his full-time job, for even with his prior full-time employment, their income for a family of five had been modest enough to meet eligibility for PeachCare. “[W]e would have to make at least $125,000 a year to cover all the expenses of raising our middle child who is autistic,” wrote Michael. “PeachCare is especially crucial for families with special needs children.” He ended with a plea for understanding: “We are not looking for a hand-out but rather affordable health care. Being the daddy of a beautiful autistic daughter had taught me that sometimes a little help is needed. Trust me, it has been a humbling lesson to learn.”
But the self-defense only fueled the public’s anger. Readers again complained about the Posts’ irresponsible choices. “What I do object to is Michael Post’s appalling sense of entitlement. . . . When are we going to stop burdening future generations with the consequences of our own actions?” demanded one reader, who further advised: “There are methods of birth control that are 100 percent effective, and Post and his wife should schedule a visit with a physician who can enlighten them on these methods.”4
At the time the article appeared, the Georgia General Assembly was considering changing the PeachCare program to tighten eligibility guidelines and restrict enrollments to families earning less than 200 percent of the federal poverty level ($34,340 for a family of three).5 The Journal-Constitution’s portrayal of the Posts seemed intended to put a sympathetic face on the PeachCare program. But if the newspaper’s editors, who supported PeachCare, had thought the article profiled a poster family for retaining the current guidelines, then they sorely misjudged their audience.
How could that be? Why did portraying a married, working, loving, family-oriented, and religious couple with a disabled child bring out such consistently negative reactions among the public toward allowing this family access to government-subsidized health care for their children? Why did this family represent, in public opinion, proof that PeachCare was being abused?
Belief in a Just World
The answer may lie in a study by the National Center for Children in Poverty entitled “How Belief in a Just World Influences Views of Public Policy.”6 Those who believe in a just world believe that, basically, people get what they deserve and deserve what they get. The NCCP study suggests that this belief influences opinions about whether women who have trouble making ends meet deserve public assistance. Who is and who is not perceived as “deserving” of public aid was a focus of this study.
The study surveyed public opinion about providing public assistance to a hypothetical woman, Lisa, who is the mother of two children and is having trouble paying her family’s basic expenses. Telephone interviewees responded to various vignettes about Lisa, which randomly varied according to Lisa’s demographic characteristics (for example, whether she is married or divorced), her employment status, and how much she does to improve her situation (for example, skipping a meal so the children can eat, looking for a job, seeking a better job, or going to school).
The study tested how a strong belief in a just world might affect people’s judgment about “deservingness” to receive public assistance when those in need try to improve their situation. Respondents were asked to assess how deserving Lisa was to receive public aid in the various vignettes. For respondents who had a strong belief in a just world, the more Lisa did to improve her situation, the less deserving they found her to be to receive public assistance. It was the opposite for respondents with a weak belief in a just world: the more Lisa tried to improve her situation, the more deserving they found her.
The report drew some interesting conclusions. One was that the strength (or weakness) of a person’s belief in a just world is connected with that person’s attitudes toward a financially unsuccessful individual. “The results suggest that the belief system is challenged for people with a strong Belief in a Just World when they are presented with women who make efforts to improve their situation but still can’t get ahead. In order to protect their belief system, people with a strong Belief in a Just World will devalue and blame the victim.”7
Another conclusion was that to gain public support for efforts to prevent poverty and to improve low-income families’ lives, advocacy groups should take care not to threaten people’s belief in a just world. “Common descriptions of low-income families would increase support for aid from both groups if the threat to the general Belief in a Just World is reduced. Perhaps the best way to do this would be to highlight the systemic problems that lead to persistent economic struggles, rather than to portray the plight of individuals.”8 The hypothetical Lisa faces a systemic problem if she lives in an area of high unemployment; her difficulty finding a job is then not just an individual problem. Other research conducted by the NCCP found that support for government assistance increased when Lisa’s circumstances were described this way.9 This reflects the researchers’ overall conclusion that “support for social welfare spending is increased when poverty is framed as having a social, rather than individual, cause.”
Support for PeachCare
Georgia has proven to be a laboratory for testing these conclusions. A month after the news article and readers’ responses appeared in the paper, the University of Georgia published a research study funded by the Healthcare Georgia Foundation to measure public support for PeachCare.10 The research was based on telephone interviews conducted during the month in which the Post family saga had been publicly aired. But rather than describe a particular family whose circumstances would make them eligible for PeachCare, the survey asked more general questions about respondents’ knowledge of and support for PeachCare and health insurance for children in low-income families. The study found that of the five hundred respondents:
over 97 percent thought PeachCare for Kids is a “very important” or “somewhat important” program,
over 96 percent agreed that “all children should have the health care they need to grow and learn,”
over 93 percent agreed that “investing in children’s preventive care now, to avoid costly emergency care later, is a smart way to invest in our state’s future economy,”
over 85 percent were in favor of “investing more in the PeachCare for Kids program so that it can cover more of Georgia’s uninsured children,”
over 80 percent were in favor of “expanding the program so that every uninsured child in Georgia can get health care coverage,” and
over 65 percent thought “even more money [should be put] into the program so that more of the uninsured children in Georgia can get health care coverage.”
In short, the respondents were highly supportive of providing PeachCare to families eligible under the current guidelines and even of expanding the program. Our Georgia case study—the Post family story and this survey—illustrates the NCCP’s conclusion that the “face” and the “context” given to a government aid program can impact the public’s support for it, either negatively or positively.
Implications for Public Health Ethics
Public health ethics is concerned with, among other things, the equitable distribution of health care and the elimination of disparities in health and health care access among different populations. Disparities in health and health care access along economic lines are well documented: people with low incomes have poorer health and less access to health care than their wealthier neighbors.11
But those who want to ensure a just distribution of health care to low-income families need to understand how differently “justice” may be perceived by different people. For people with a strong belief in a just world, justice may mean that an individual does not deserve public assistance if his or her efforts do not succeed in avoiding the need for public aid. Almost by definition, those efforts must have been the wrong ones because in a just world, you deserve what you get and you get what you deserve. In this view of the world, justice means not giving aid to those who do not deserve it, and you do not deserve it if you need it because your own conduct either appears to have created the need for it or was unsuccessful in eliminating the need for it.
Of course, we cannot be sure whether the angry newspaper readers held a strong belief in a just world. Their uniformly strong negative reactions to the Post family’s situation, however, suggest such a belief, and their reactions parallel the findings of the NCCP study. As one reader of the Post family newspaper story complained: “It is grossly irresponsible to bear children you cannot properly support—and it is a gross injustice to penalize me for other people’s irresponsible behavior.” Another reader asked, “Why is it my responsibility to pay for your poor personal choices?” Quipped a third, “Remind me again why we are supposed to feel sorry for these irresponsible people?”
Another reader of the Post story who seemed sympathetic to PeachCare in concept intuitively understood the core insight of the NCCP study. The reader pleaded, “Could the [newspaper] please spotlight a family that does not add fuel to the fire against PeachCare? Perhaps a family that needs the assistance based on something unexpected that has happened to them, rather than choices they have made and continue to make?”
This statement reflects some clear implications for how we present public health programs. First, children have no control over whether they receive health care. They are entirely dependent on parents or the state to provide it. Those who advocate for broader access to health care for children should highlight this innocent dependency. More broadly, public health advocates should attend to ways in which need arises from circumstances outside the control of the individual.
The lessons from the NCCP research study, the University of Georgia survey, and the story of the Post family reflect centuries-old debates about who the “deserving poor” are—and even older questions about whether the sins of the parents should be visited upon the children. Those who want to gain support for social programs to eliminate disparities in health and health care access among those in need should take care to portray the needy as also deserving. Of course, what aid one deserves depends on who or what is to blame for creating the need for aid. Was it individuals’ irresponsible behavior? Or was it circumstances beyond their control? As lawyers well know, the answer you get depends on the question you ask.
1. B. Hendrick, “The Faces of PeachCare,” The Atlanta Journal-Constitution, April 8, 2007.
2. Responses to “The Faces of PeachCare,” The Atlanta Journal-Constitution, April 15, 2007.
3. M. Post, “PeachCare Aid Also Humbling,” The Atlanta Journal-Constitution, April 17, 2007.
4. Responses to “PeachCare Aid Also Humbling,” The Atlanta Journal-Constitution, April 18, 2007.
5. See B. Hendrick, “Legislature 2007: Tighter PeachCare Gets Push,” The Atlanta Journal-Constitution, March 28, 2007; and B. Hendrick, “Senate Puts Its Own Limits on PeachCare,” The Atlanta Journal-Constitution, April 17, 2007.
6. L.D. Applebaum, M.C. Lennon, and J.L. Aber, “How Belief in a Just World Influences Views of Public Policy,” National Center for Children in Poverty, Columbia University, Mailman School of Public Health, October 2003; http://www.nccp.org/publications/pub_553.
9. M.C. Lennon et al., “Circumstances Dictate Public Views of Government Assistance,” National Center for Children in Poverty, Columbia University, Mailman School of Public Health, October 2003; http://www.nccp.org/publications/pdf/text_552.pdf.
10. Survey Research Center, University of Georgia Office of Research Services, “2007 PeachCare for Kids Survey”; http://www.src.uga.
edu/surveys/HGF_2007/. B. Hendrick, “Majority Oppose PeachCare Cuts, Survey Finds,” The Atlanta Journal-Constitution, May 16, 2007.
11. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Program Evaluation, “Overview of the Uninsured in the United States: An Analysis of the 2005 Current Population Survey,” September 2005; http://aspe.
hhs.gov/health/reports/05/uninsured%2Dcps/ (figure 2); and The Child and Adolescent Health Measurement Initiative, National Survey of Children’s Health, 2003; http://nschdata.org/DataQuery/SurveyAreas.aspx (Criteria = Survey Sections, Nationwide, 2003, Health and Functional Status, Overall Health Status—children/youth ages 0–17, subgroup Family Income).