Job guarantees for the disabled

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It took me a while, but it has now dawned on me why job guarantees might be very popular in the U.S., even among the sick and disabled. The clue is in this response to a tweet from Nathan Tankus:
Here in the U.K., access to healthcare is not dependent on being gainfully employed. But in America, it is. If you aren’t working, your access to healthcare can be very limited. Thus, sick and disabled people who are unable to work can lose access to healthcare. The very people who need it most are denied it.

But there is a fatal flaw in the notion that a job guarantee could compensate for lack of universal healthcare, even temporarily. No job guarantee scheme can possibly ensure that absolutely everyone works. There will always be people who are too ill to work, or too disabled to work, or whose caring responsibilities make it impossible for them to work, or – since advocates of Job Guarantee schemes usually insist that the schemes must be voluntary – simply don’t want to work. What about them?

Clearly there would have to be federally-provided healthcare insurance for these people. But how do you decide who should benefit from that insurance and who should not? If someone doesn’t work, but receives federally-funded healthcare insurance, while their neighbours work to receive employer-funded healthcare insurance, how do you think those neighbours are going to feel? I say this about federally-funded healthcare insurance, but the same applies to any form of benefit or income that enables people not to work. Not all disabilities are visible, and some sicknesses carry a stigma; mental health problems, in particular, are often regarded as “skiving”. Public perception of benefit fraud is far higher than the reality, because ordinary people are very bad at discerning true need. Everyone has a story about someone they know who is gaming the system.

And as for the notion that job guarantees could be voluntary – dream on. The very reason why the UK now sanctions benefit claimants who don’t look for work is that working people resent paying taxes to fund the lifestyles of those who (in their view) can’t be bothered to work. A job guarantee scheme might be voluntary to start with, but it would inevitably succumb to popular pressure to make the lazy bastards work for their benefits. Indeed I have already heard exactly this from one prominent Job Guarantee advocate. In his view, if someone refuses a guaranteed job, they should receive nothing – no basic income, no healthcare insurance, no food stamps. I pointed out that a scheme which presents a choice between work or starvation is hardly voluntary, but this didn’t bother him. In his view, someone who refuses to work doesn’t deserve society’s support. His view is no doubt unusual among Job Guarantee advocates, most of whom seem to think that people would not be deprived of the means to live if they refused guaranteed jobs. But it is anything but unusual among the general public. Unless welfare benefits and services are universal, political reality means job guarantees inevitably become workfare.

Admittedly, “he who will not work, shall not eat” appears to be an unusual view among Job Guarantee advocates. Most say that there would be basic income and benefits for those who are unwilling or unable to accept guaranteed jobs. But the job guarantee wage, plus benefits such as healthcare insurance, would be higher, to ensure that there was a financial incentive for people to work.

Thus, a job guarantee scheme that ensured it was worth people’s while to work would necessarily be harsh towards those who – for whatever reason – did not work. In the U.S., such harshness might include restricting access to healthcare insurance, since this is a valuable benefit which creates a considerable incentive to work. And this brings us back to the sick and disabled again. Why should those who are unable to work through no fault of their own be condemned to a lifetime of poverty? Surely the richest nation on earth can treat its vulnerable better than this.

Of course, those who could prove they are genuinely unable to work could qualify for a higher level of benefits. But what does “unable to work” really mean? And who should decides whether someone is capable of work? We have seen again and again what the consequences of attempting to distinguish between the deserving and undeserving poor can be. Currently, the U.K.’s “work capacity assessment”, which attempts to determine who is capable of work and who is not, is feared by sick and disabled people up and down the land. Those who are deemed “fit for work” lose their enhanced sickness and disability benefits. The decisions are often wrong: more than half are overturned on appeal. The human consequences are frankly terrible. There have been cases of terminally-ill cancer patients being deemed “fit for work”, mentally ill people found “fit for work” starving to death after their enhanced benefits are cut, seriously ill people forcing themselves to attend “fit for work” interviews for fear of losing benefits.

The U.S. is showing signs of heading down the same road as the U.K. Don’t do it, America. It is unnecessary brutality.

This brings me to Nathan Tankus’s original tweet, which I find every bit as disturbing as the response to it, though for different reasons. Tankus muses about the possibility that “full employment” of the disabled might improve health outcomes for them. There is indeed research evidence that people who are working have better physical and mental health than those who are not. This evidence was seized upon by the U.K. government to justify welfare-to-work programmes designed to force sick and disabled people into work.

But the interpretation of the research needs considerable care. People who are not working are more likely to be in poverty (and in the U.S, lack access to healthcare). Poverty and lack of healthcare worsen health outcomes. But this does not mean that lack of work causes poor health outcomes for sick and disabled people, still less that the solution to their poor health outcomes is work, as this piece (pdf) suggests, for example:
Employment increases household income and decreases economic hardship, both of which improve physical and psychological well-being. Numerous studies have demonstrated that poverty leads to poor health status (Thompson, Wells, & Coats, 2012).  Well-paying work provides individuals with the financial means to access heat, nutritious food, health care, and safe housing, all of which impact health directly.  The stress of trying to pay bills and feed and clothe a family on an inadequate household income generates psycho-physiological distress, malaise and susceptibility to disease (Montgomery, Cook, Bartley, & Wadsworth, 1999). People with higher incomes are more likely to have a regular provider of medical care and health insurance coverage. One of the most significant financial benefits of working (besides income) is health insurance.  A majority of Americans (60%) receive employer-sponsored health insurance (State Health Access Data Assistance Center, 2013). Individuals with health insurance are more likely to see their primary care doctor and dentist and receive routine screenings for blood pressure and cholesterol, and get preventive care.
This is a wholly illegitimate argument. If sick and disabled people are typically living in poverty and have limited access to healthcare, it is not work that they need, it is adequate benefits and universal healthcare. 

Additionally, if sickness and disability benefits are being systematically cut to encourage people into work, as is the case in the U.K. and may soon be the case in the U.S., then health outcomes for those who are not working will worsen as a matter of policy. Any research that does not control for the effects of benefit cuts on the health outcomes of those who are not working is deeply flawed. (And if you don’t believe that cutting benefits and healthcare worsens health outcomes, look at Greece (pdf).)

There is also the problem of survey selection: the more sick or disabled someone is, the less likely they are to be working, so the health outcomes of those who are not working are inevitably worse than the health outcomes of those who are. Furthermore, aggregate responses showing health outcome improvement for those in work may conceal worsening health among those who are forced to give up work, or who are doing unsuitable work. Movement in and out of work, and variations in the number of hours worked by sick and disabled people, need to be monitored too.

I am therefore wary of public policy that aims to achieve “full employment” of sick and disabled people as a means of improving health outcomes. “Full employment” presumably means that all those who want to work are working, and to the maximum that they wish to work (since many sick and disabled people don’t work full time). But if the primary reasons for poor health outcomes among sick and disabled people are poverty and lack of healthcare, then the priority should be improving welfare benefits and introducing universal healthcare, not job guarantees. And anyway, “full employment” never means that absolutely everyone is working. What about the health outcomes of those who are unable or unwilling to work?

This is not to say that a job guarantee scheme aimed at helping those sick and disabled people who want to work to do so is a bad idea. The U.K. had such a scheme, introduced back in 1946. Remploy successfully employed thousands of disabled people in its factories, many of them war veterans. it also placed disabled people in private sector jobs. But it became bureaucratic and inefficient, and eventually succumbed to the fashion for privatisation; its factories were closed, making thousands of disabled people redundant, and it became simply an employment support agency for disabled people, helping them find work in the private sector.

Remploy factories were an important public service, and many mourn their passing. But they were never sufficient. A modern job guarantee scheme for sick and disabled people would have to offer a much wider range of jobs and more flexibility about hours and locations of work. This would be quite a public policy challenge.

Personally, I think that a job guarantee scheme for sick and disabled people is nowhere near as important as universal healthcare (Medicare for All, in the U.S.), uprating of welfare benefits to provide a decent income, and the ending of all attempts to judge whether someone is deserving of support. We need to end poverty among the sick and disabled first. Without that, any job guarantee scheme will simply reinforce the harshness that has become the hallmark of our time.

Related reading:

The road to the workhouse
A very British disease
When the world turns dark
Generosity