The myth of merit

Have you ever been on the outside, looking in?  Have you ever measured yourself, in financial, career, or social status, against other people?  Have you ever experienced a moment when you say to yourself,  “Why do they merit that when I don’t?”

If you haven’t, then you’re the exception to the rule, because so many of us have been shaped in so many ways by a great American myth: that we are a meritocracy and our place in society is determined by character, talent, and effort. There’s a lot of good to this myth, in that young people who believe it learn to strive, tend to do better in school and sometimes take more risks and realize more opportunities in life.  But then, I’ve seen plenty who make it on timing, luck, and even good looks, too.

The belief that one controls one’s own destiny is very powerful and, in many circumstances, is the key to unlocking a happy, productive, and meaningful life. But in other circumstances, it can send a very depressing message:  You have what you have because you aren’t good enough, you’re not worth it, and, try as you will, you may never be.  

Results of a study involving a 2008 Medicaid lottery in Oregon may better explain my point:  When health results for 6,000 winners of the lottery that provided them with Medicaid coverage were compared to 6,000 of their still-uninsured fellow citizens, they were found to have a 30 percent reduction in the incidence of depression—a major improvement in their overall mental health.

Though the study’s authors wouldn’t speculate on the cause for this change, I’m not afraid to do so. But let’s start by considering what Medicaid access could not do:

• Given qualifying requirements, it certainly didn’t boost anyone’s net worth.
• It didn’t make a big difference in their physical health, at least for the study period.
• It didn’t change their access to jobs or education.
• It didn’t change their housing or put more food on the table.

So, what could having just the access to health insurance have done? 

• Maybe it eased their worry about what might happen to themselves or their families
• Maybe it made them feel like they could save and plan ahead, without the fear of financial ruin
• Maybe it made going to work — or looking for work — a little less stressful
• Maybe the fact that they could make and pay for a doctor visit like most anyone else gave them a little dignity or peace of mind.

I’m awfully happy to have health insurance, which I get through my employer. And, I know my parents were happy to have it on a snowy January morning in 1981 when, following a longer-than expected surgical biopsy on a swelling in my neck, we learned together from a family physician that I had Hodgkin’s Disease—a form of lymphoma. In the utter shock of that moment, I felt the floor of my life open. I reached out as I began to fall, but was steadied by the clasp of my mother’s hand.  

Finances were the furthest thing from my mind at that moment, but they could not have been far from my father’s mind. I was the fifth of their seven children, nearing age 20, and in the old hospitalization plans of that time, he was on the hook for 20 percent of the cost of my care. And that care would take nearly six more months –of scans, biopsies, and tests; of more surgery and inpatient recovery; and finally, of two and a half months of radiation treatments.  

For years after I left the Cleveland Clinic on June 9, 1981 after my last treatment, I have wondered what all that treatment cost. Even 30 years ago, the bills were big – many zeros. Even with good health insurance paying a sizable share of the cost, the remainder certainly was very costly for my family. Being without health insurance – a relatively rare occurrence at that time – would have been depressing for any breadwinner, even one as optimistic and hardworking as my Dad.

So, as I live the 33^rd year of my own “recovery” of sorts, the Affordable Care Act provisions to expand insurance and Medicaid coverage, though quite imperfect, feel about as reassuring as my mother’s hand, then and now. And I must admit struggling to understand those who, for whatever reason, maintain that access to healthcare insurance - and the dignified, practical access to care that comes with it – ought to be limited based on any perception of individual merit or value.