“Who sinned, this man or his parents, that he was born blind?” Asked of Jesus by the religious authorities of the day, this question haunts many conversations about social welfare and health policy. Self-reliance—that people should “get what they earn”—is embedded in America’s cultural mythology. In some subtle way, people in poor health must be responsible for their condition and simply have to pay when illness strikes.

This is the moral question underlying health policy: Who should bear the cost of caring for the sick? That we are neither wholly blameless or nor wholly guilty for the state of our health is the Gordian knot we labor in vain to untie. We know that smoking often causes lung cancer and obesity can trigger diabetes. But not all lung cancer comes from smoking and diabetes has other triggers. We’re not willing to deny care to victims of either disease. We admire self-reliance but also sense the injustice in “blaming the victim” for diseases and conditions that have no known link to personal decisions (and some that do). As the Republican Congress and the Trump Administration seek to unwind Barack Obama’s Affordable Care Act (ACA), this “who pays?” question takes center stage. Read more »