A Doctor’s Case for a Universal Basic Income
By Vishal Khetpal (he/him) • June 21, 2021 • Vol. 01 No. 07
Illustration by Jay Davis (she/her)
Editor’s Note: Last week, the Affordable Care Act survived its third major legal challenge as the Supreme Court rejected the latest Republican attempt to overturn the law. Now that the existential threats to the law have likely subsided, the United States can finally look ahead to new policies that could strengthen its deeply flawed healthcare system. In this essay, Vishal Khetpal, a resident physician at Brown University, argues that the best way to improve the health of Americans is not through reforming the byzantine healthcare system but rather by giving cash directly to people.
The month before we met, Jorge suffered two heart attacks.
We sat together in a crammed exam room—he on a faded, burgundy exam table, me on a lab stool, positioned next to a pull-out desktop computer that was mounted onto a beige-colored wall. On speakerphone, a Spanish interpreter translated our conversation, our words muffled by surgical masks and respirators.
We were in a primary care clinic on the south side of Providence, Rhode Island, where I spend most of my Monday afternoons seeing patients. Our clinic is staffed primarily by resident physicians like me—doctors who recently graduated from medical school and are early in their careers. Jorge was one of my first patients ever.
It was a meeting of firsts in more ways than one: Before his heart attacks, Jorge had never seen a doctor before. He remembered being told once, at a community health fair, that his blood pressure was high and that he might benefit from losing some weight. But he wasn’t sure how to find a doctor or how he could get time off from his job in construction to see one. Besides, being in his mid-30s, he thought that seeing a doctor wasn’t urgent.
All that changed one day when, while at work, Jorge started to experience a crushing pain, pointing at the center of his chest. As he recounted his story, I followed along through the notes in his electronic medical record. With his chest pain, Jorge felt sweaty and short of breath, prompting him to go to an emergency room a few blocks away from where we sat. The doctors there, he told me, were concerned about his blood tests and the electrical tracings of his heart—his electrocardiogram (EKG). On a stretcher, they whisked him away to a cold room, where more doctors and nurses explained that they had to remove a clot in a blood vessel next to his heart. After snaking a wire toward his heart through his hand, the medical team wheeled him to a patient room. In his chart, I saw that he was started on a generic blood-thinning medication called clopidogrel to help keep his blood vessel, which was being held open by a stent, free of clots.
Jorge’s second heart attack came a few days later, while still recovering in the hospital. One morning, he felt the same waves of pain that overcame him not too long before. His EKG showed the same concerning pattern, and his medical team took him back to that cold room and found that Jorge’s stent had clotted. It turned out that Jorge’s body didn’t respond adequately to clopidogrel—an issue that about 5% of all people with heart attacks encounter. Jorge would have to take a different medication to keep his blood vessel open. Even with insurance, the new medication required significant out-of-pocket costs for Jorge. Between rent at the end of the month and his lost wages from time off from work, he and his family were quickly running out of money to afford his new prescription. Not taking that medicine, I told him, could be fatal.
In my line of work, I meet people like Jorge every day and see the effects of deep poverty on the lives of my patients. In our hospitals, I’ve met patients with diabetes—left uncontrolled by a diet of fast food or by skipping an expensive insulin prescription—on the verge of death with a condition called diabetic ketoacidosis, where the body is paradoxically bathed in glucose but starving for nutrition. In my clinic, I’ve had patients miss their appointments and fall behind on health screenings because of the cost of gas or a bus ticket, or because they can’t afford to skip a shift at work. Aware of my own privilege, I’ve often wondered in my brief encounters with patients if the best thing that I could do for them is open my wallet, only stopping after convincing myself that this strategy is not sustainable—nor is it ethical for me alone to decide who is and isn’t deserving of financial assistance.
Accessing the benefits that social safety-net programs provide can be a formidable challenge of its own—compounded by language barriers, literacy issues, and endless paperwork.
Many of my patients benefit from social safety-net programs such as the Supplemental Nutrition Assistance Program (SNAP) and Social Security, as well as public health insurance programs like Medicaid. Accessing the benefits that these programs provide, however, can be a formidable challenge of its own—compounded by language barriers, literacy issues, and endless paperwork. And although health insurance is vital for navigating the U.S. healthcare system, it still comes with cost-sharing that can be too much to bear. Far too many Americans confront the difficult calculus of deciding between necessities—like a brand-name blood thinner and groceries for the next week.
Through my clinical practice, I’ve become convinced that expanding our current social safety net—for instance, by delivering Medicare for All—would still not be enough to address the problems confronting the most vulnerable among us. What they need is a basic income. As the United States begins to recover from the worst public health crisis in a century, the best way to repair a broken social contract is distributing regular cash transfers to all Americans. It is an idea with roots in our country’s past—and undoubtedly has a role to play in our future.
A Brief History of the Universal Basic Income
The idea of a universal basic income is not new. It was first proposed by a Renaissance humanist named Juan Luis Vives in the 16th century, who argued that it was both a moral and pragmatic way for governments to give back to their citizens. Since then, universal basic income has made unexpected cameos throughout history. Experiments have been conducted around the world, from rural Kenya to upstate New York. Governments of all sizes have implemented forms of it, including an 18th century village in England, the Eastern Band of Cherokee Nation in North Carolina, the state of Alaska, and the country of Iran.
In the United States, a form of basic income for older Americans—Social Security—is the third rail of our politics. But a basic income, expanded to most adults, has historically been sidelined to the political fringes, finding only pockets of support across ideological camps. At our nation’s founding, a basic income—called a “citizen’s dividend”—was proposed by Thomas Paine, to be paid for by land taxes. In the past century, it has been backed by a group of politically-strange bedfellows—figures such as Huey Long, Martin Luther King Jr., Buckminster Fuller, Milton Friedman, and others. It nearly became law under the administration of Richard Nixon, passing the House as part of welfare reform legislation, before failing in the Senate.
The movement behind an expanded basic income, both in the United States and elsewhere, has ebbed and flowed over the years. Proponents often use basic income as a tool to advance specific political agendas, such as libertarians who aim to dismantle the social safety net. But among the U.S. public more broadly, basic income seems to emerge within political discourse in times of significant social change. Just two years ago, Andrew Yang—a social entrepreneur with no political experience—mounted a grassroots campaign for president driven by an argument that a basic income is desperately needed to confront an ongoing Fourth Industrial Revolution, in which millions of jobs are being displaced by new technologies and automation. Public interest in basic income, however, perhaps reached its peak during the Great Depression, when Francis Townsend, a doctor, wrote an extended letter to the editor in the Long Beach Telegram-Press outlining a basic income scheme for older Americans—after watching three elderly women scavenge for food in trash heaps in front of his home. Townsend’s letter, in its day, went viral and inadvertently created an organized national movement of over two million people. That movement was central in pressuring the administration of Franklin D. Roosevelt to enact Social Security.
It comes as no surprise, then, in this moment of profound social disruption, that basic income is getting a closer look. Both in the United States and abroad, direct cash transfers are now in vogue, as governments have stepped forward to provide basic income support for their citizens. Looking ahead to post-pandemic life, Spain’s central government has announced plans to experiment with a basic income for segments of its population, while other countries are exploring this option too. On the back of a successful basic income program for young adults, the leader of the populous Gyeonggi Province in South Korea, Lee Jae-Myung, is mounting a bid for president. In the United States, dozens of cities have announced basic income pilot programs, in hopes of finding a policy that may address the profound social and structural inequities unearthed by COVID-19.
Over the course of 2020, many Americans came to believe that the social contract is broken. They’re not wrong. A universal basic income could renew the social contract for the first time in a generation.
Over the course of 2020, many Americans came to believe that the social contract is broken. They’re not wrong. The last time that contract was truly revisited, one might argue, was more than 50 years ago, in the administration of Lyndon Johnson, whose Great Society aimed to end poverty and to achieve racial justice through programs such as Medicare and Medicaid. A universal basic income could renew the social contract for the first time in a generation, affirming both of the Great Society’s goals, and bolster a social safety net stretched far too thin.
Nearly every day I go into the clinic or the hospital, I see evidence of why a basic income is sorely needed in the United States. It doesn’t surprise me that universal basic incomes have been associated with a range of positive mental and physical health outcomes. But the case for a universal basic income begins further upstream.
A Basic Income is Upstream Medicine
Rishi Manchanda, a physician and public health researcher based in Los Angeles, gave a talk nearly a decade ago on a subject in medicine that is too often ignored. He began the talk with a parable. Manchanda tells the story of three friends, watching a steady stream of drowning people in a river careening toward a waterfall, unable to save themselves. The friends step into action to try and save them. The first friend swims toward the waterfall, hoping to catch people before they plunge. The second friend builds rafts quickly from nearby tree branches, ushering people to safety onto the riverbank, before they reach the waterfall. The third friend notes that both approaches are saving lives, but that too many people continue to slip through beyond the waterfall. Seeking to find out why so many people are drowning in the first place, the friend decides to swim further upstream.
Throughout the rest of the talk, Manchanda makes the case for training and developing more specialists in what he calls “upstream medicine” (since giving that talk, Manchanda has also founded an organization dedicated to doing just that). In his analogy, he draws a comparison between the first friend and the critical care intensivist or the trauma surgeon, saving people on the brink of death at the front lines. The second friend is the primary care specialist, pounding the pavement of preventive care. The third, Manchanda argues, should be the “upstreamist,” tasked with understanding health outcomes beyond the exam room.
Medicine has tried to articulate the factors influencing this “upstreamism” as social determinants of health. These include factors like where people live, how people eat, how people cope with stress in their lives, and how people interact with one another in their environments. Our social policy, to some degree, targets those determinants. Public housing and rent controls, for example, work to address housing insecurity, while food stamps, through SNAP, keep thousands of Americans from starving. But among those determinants, poverty is arguably the most central. It is the determinant that weaves itself into all the others—serving as the backdrop for home evictions and job losses. Poverty affects who we are and how we navigate our world.
Poverty is More Than a Lack of Cash
Rutger Bregman, an advocate of universal basic income, has said that “poverty isn’t a lack of character; it’s a lack of cash.” The first clause of this quote is undeniably true. Poverty certainly has its roots in large, immovable factors, such as generational wealth and racial discrimination. In diving deeper into what causes poverty, however, the second clause is perhaps too simplistic. Poverty is propagated through social structures, both intentional and unintentional.
Take the “poverty tax,” for example. This isn’t a formal tax, levied by the government. Rather, it is a term that binds together a growing body of literature articulating the indirect and quiet costs of being poor in the United States. An early use of the term can be found in a report compiled by the Brookings Institution’s Metropolitan Policy Program, authored by Matt Fellowes in 2006. Across 12 metropolitan areas in the United States, Fellowes and his colleagues found that the poverty tax includes predatory lending, such as payday loans (and later, in the wake of the 2008 financial crisis, subprime mortgages), and increased costs for consumer goods like cars, furniture, and electronics. It also includes higher costs at the grocery store and more expensive home and auto insurance policies.
In the aggregate, these individual costs compound and affect communities and neighborhoods where poverty concentrates. For example, my drive to our clinic in South Providence, Rhode Island—where more than a third of people live in poverty—takes me past dollar stores and fast food restaurants on streets lined by cracked sidewalks. Our clinic is only a few blocks away from the Port of Providence, where industrial plants and oil refineries pollute the local environment with toxins like arsenic and benzene, and where the city sewage plant is located. The public schools, in this neighborhood and across Providence, underperformed benchmarks so severely that operations were taken over by the state in 2019.
The built environment then becomes deterministic of poverty itself—locking it into place, by making communities less attractive for investment and less likely to grow in population. Poverty creates deserts of basic necessities found in healthy communities, such as hospitals and fresh food, and leaves public institutions vulnerable to demolition by private actors. In one case in Philadelphia, two years ago, the storied but financially crippled Hahnemann University Hospital was forced to close its doors after a takeover by a private equity firm, leaving thousands without healthcare at an institution they trusted.
Any intervention designed to lift entire communities and neighborhoods out of poverty would have profound downstream effects on health.
Any intervention designed to lift entire communities and neighborhoods out of poverty would have profound downstream effects on health. In a study published in Health Affairs in 2014, for example, researchers found that specific low-income ZIP codes in California were associated with higher rates of foot amputations—an expensive and debilitating downstream complication of uncontrolled diabetes.
In healthcare, poverty is described with medical slang like “frequent fliers” (for patients who show up to the hospital or the emergency room frequently), “no-shows” (for patients who skip their appointments), and “noncompliant” (for patients who skip their prescriptions). It engenders biases among frustrated doctors, often compounding those that are already present among racial lines.
In healthcare, the poverty tax throws people into the river that Manchanda describes in his parable. Poverty limits what we can do in medicine. Even with insurance, people living in poverty are much less likely to take their prescriptions because of an inability to afford them. They’re more likely to miss their doctor’s appointments, often because of the costs that come with missing a shift at work or finding child care. Most can’t afford to see a dentist for oral care, or a therapist for mental health issues. When they do access care, they tend to utilize safety net clinics that are already stretched thin on resources. If they’re without a primary care doctor, they may go to urgent care centers or emergency rooms, where they may be surprised by expensive medical bills, even if insured. Once in the hospital, they’re more likely to be admitted under medical observation rather than inpatient status, and may be stuck with footing the bill for most of their hospital stay that their insurance refuses to cover.
Poverty itself even changes the way in which we process information and make decisions. In a paper published in Science in 2013, researchers from Princeton University discovered, through behavioral health experiments, that poverty may decrease IQs by 13 points, and was similar in its impact on cognition as losing a full night’s sleep. Advocates of universal basic income have described this as a mindset of scarcity. It is with this impaired cognition that we then force individuals to choose between basic necessities.
Putting these pieces together, poverty builds an identity and becomes a label-generator, filled with negative connotations. In healthcare, poverty is described with medical slang like “frequent fliers” (for patients who show up to the hospital or the emergency room frequently), “no-shows” (for patients who skip their appointments), and “noncompliant” (for patients who skip their prescriptions). It engenders biases among frustrated doctors, often compounding those that are already present among racial lines.
In the bigger picture, poverty limits social mobility and one’s ability to take risks with any financial implication. To attend college, or even to take time off from work to meet with a social worker, means foregoing wages—and may be a cost too great to bear. It leaves people, like Jorge at the beginning of this essay, stuck in a precarious state of animation, vulnerable to unexpected costs or any change in their status quo.
It’s no surprise, then, that poverty alone is a risk factor for poor health. One aspect of this is related to poverty’s linkages to other social determinants of health, such as poor housing leading to asthma, and food insecurity contributing to type 2 diabetes in younger adults. But poverty alone may even have physical effects on the body. A study published in the Journal of the American College of Cardiology in 2019 found that people living in low-income neighborhoods had a four-fold increase in risk for a major adverse cardiac event (like a heart attack) compared with their counterparts in the highest-income neighborhoods—even accounting for variables such as access to health insurance, smoking, and obesity. Their findings suggest that poverty increases the body’s chronic stress response, dysregulating hormones and leading to an increase in inflammation across the body.
Unifying this story of poverty and health is a landmark paper led by the economist Raj Chetty, which showed that income is directly related to life expectancy. Chetty and his colleagues found that the gap between the richest 1% and poorest 1% in life expectancy was more than 14 years. This is ultimately what’s at stake in the future of poverty and economic justice in the United States. Although it is too early to tell, it is reasonable to expect that the COVID-19 pandemic will only further this gap.
A Direct Answer to Poverty
A basic income, with the right execution, is the natural answer to confronting poverty at its roots.
In the current, means-tested system of social services, too much money is left on the table. Frequently, this is due to indirect costs associated with accessing benefits.
In the current, means-tested system of social services, too much money is left on the table. Frequently, this is due to indirect costs associated with accessing benefits. Among them are the time taken to learn about the welfare programs and their eligibility guidelines (the learning cost) and to collect the necessary paperwork and documentation needed to access them (the compliance cost). There’s also the stigma of accessing benefits themselves, forming a psychological cost. In a paper published in the Journal of Public Administration Research and Theory, Dr. Carolyn Barnes, a researcher at Duke University, recently coined the term redemption cost to refer to the difficulty that often arises in exchanging benefits for goods (in part because certain benefits are not interchangeable with certain goods, and in part because certain businesses do not accept certain benefits). Prevailing across the current welfare system are requirements that amount to structural racism. Historically, this has included tying benefits to work in the formal economy, residency requirements to access benefits, and propagating narratives such as the “welfare queen” of the Reagan era. Today, it presents itself in the form of practices like access to broadband internet, drug testing in certain states, and remote identity proofing, in which users must answer questions about their banking and credit histories to confirm their identity, placing those without organized financial records at a disadvantage.
These costs are starkly present in our current system. A private company called mRelief, working to simplify the process of applying for food stamps, estimates that over $13 billion in SNAP benefits go unclaimed every year. For the Temporary Assistance to Needy Families Program today, the TANF-to-poverty ratio, measuring how many families eligible for TANF are actually receiving it, is at its lowest point since the program began.
Other benefits, though present in theory, are scarce in reality. A prime example is Section 8 Housing—a system of housing vouchers that allow tenants to pay income-adjusted rent supported by local governments. In Providence, reflective of the national market, applicants can expect to wait between three and ten years for a voucher. In larger cities such as New York and Los Angeles, even the waiting lists are closed, and may only open for a few days every few years at most. Some welfare programs have incredibly strict income cutoffs, while others, like the earned income tax credit, require filing a tax return. Segments of the general population, particularly individuals without families, are often excluded. And virtually all means-tested welfare programs are subject to benefit cliffs, or points in the income ladder where a marginally higher salary could mean losing thousands of dollars in government benefits.
A basic income could have its most profound effects on mental health and stress—a risk factor, in turn, for a host of diseases.
By contrast, a basic income could be given to individuals unconditionally to use as they choose. It wouldn’t be subject to a benefit cliff, a bureaucratic hurdle, or an afternoon on the phone spent on hold with a government agency. It would instead serve as a birthright, flipping the script currently in place for people to access welfare benefits. Federal agencies and the government would be responsible for getting benefits to the people, rather than the other way around. Government would be compelled to meet people where they are.
Health and Basic Income
When put into practice, basic income stands to improve the health of its beneficiaries.
In terms of its physical health benefits, much of the uptick in studied health outcomes related to basic income relates to maternal and child health. In Alaska, for example, its Permanent Fund (a lump sum given to state residents annually from oil revenues) has been associated with increasing uptake in prenatal care, improving Apgar scores (used to assess the overall health of newborns immediately after birth), and reducing rates of childhood obesity. In practice, it wouldn’t be a stretch to suggest that basic income could have significant effects on other diseases interlinked with social determinants of health, such as high blood pressure and stroke, though this has yet to be systematically studied.
A basic income, however, could have its most profound effects on mental health and stress—a risk factor, in turn, for a host of diseases. The data and stories emerging from the ongoing basic income demonstration in Stockton, California, show this clearly. After one year in the pilot study, participants in the treatment group, receiving a $500 basic income per month, experienced improvements in overall mental health compared with their counterparts not receiving that income. One participant, in an interview, reported feeling much less anxious about finances, with income helping to stop the frequent panic attacks she was having about bills at the end of the month. Another shared that the income allowed him to participate in “the small social rituals that make life bearable,” like going out to a restaurant or buying his mother a birthday present, which are protective against poor mental health outcomes. Similar findings have been reproduced in a basic income pilot program in Finland.
Basic income can change the way in which people interact with their healthcare system, shifting the focus toward prevention rather than emergency treatment. In Manitoba’s Income Experiment, for example, beneficiaries were less likely to be hospitalized compared with those not receiving a basic income. It could stand to amplify the health benefits of primary care in synergistic ways. In rural Kenya, researchers are finding that combining primary care visits with micro-financing opportunities is lowering blood pressure for patients better than with office visits alone. A basic income would enhance the most reliably present benefit of having health insurance—lower rates of medical debt and decreased likelihood of enduring a catastrophic medical expense.
Beyond its direct impact on health, basic income carries spillover effects. Basic income, across multiple pilot programs, has been consistently associated with educational attainment, lifting people out of poverty with little to no impact on job market participation or local inflation rates, based on collected evidence from programs already in place. In situations of crisis, such as the COVID-19 pandemic, a basic income has been shown to help beneficiaries better absorb financial shocks. And as advocates have argued in the past, basic income offers a local economic stimulus with the capacity to change the built environments that lock people into poverty. A fixed infusion of income into a community, for example, could help sustain a new grocery store or gym in a neighborhood. In addressing economic justice from both the individual and community perspectives, basic income directly confronts the social determinants of health that reside upstream from our clinics and hospitals.
The Citizen’s Grant
For almost a century, the United States has had a form of basic income—Social Security. Further expanding a basic income to most Americans, as part of a separate program, would come with risk. Basic income, after all, remains untested at this scale. Doing so, however, would renew the U.S. social contract. It would represent an investment in the American people, for the sake of the public good and not meant to be paid back. One could even call it the Citizen’s Grant.
Like Social Security, the Citizen’s Grant would work best alongside, rather than in place of, the current social safety net.
Like Social Security, the Citizen’s Grant would work best alongside, rather than in place of, the current social safety net. Although it would be ambitious in scope, creating the largest welfare program in U.S. history, it would need to be designed with political imperatives in mind. Its financial contours would need to be realistic, and at least somewhat politically palatable to a legislative majority.
In that vein, the program would need to be targeted in its approach, at least initially. Rather than using an income threshold to achieve its targeting, it could utilize age-based criteria, in keeping with its goal of being an unconditional benefit. The Citizen’s Grant could start with children and adults under the age of 65, phased into place starting with our youngest. Including children at the outset would be consistent with the available data on child health outcomes associated with basic income and would directly address the high rates of child poverty in the United States. Unlike the child tax credit policy passed as part of the American Rescue Plan, the basic income proposed in this plan wouldn’t require a filed tax return. Working to include young and middle-aged adults acknowledges the frequency with which this group seeks welfare benefits in our current system. In tandem, the U.S. government could undertake reforms within the original Social Security program and Medicare to maximize benefits for seniors.
The amount of the benefit itself could be $500 per month to each beneficiary. Basic income experiments have not been consistent in the amount offered to beneficiaries in their demonstrations. According to data collected by the Stanford Basic Income Lab, most experiments in the United States and Canada have offered benefits between $300 and $1,000. The amount of $500 was used in the Stockton demonstration to good effect. More generous figures proposed for a basic income tend to implicate wholesale changes to, or even elimination of, the current social safety net. Five-hundred dollars would amount to roughly half of the federal poverty level for a single individual and would nearly meet the federal poverty level for a family of four in 2020. The benefit itself could be pegged to inflation to maintain its purchasing power.
A figure of $500 would work to preserve the social safety net. In doing so, it would enable both cash and in-kind transfers (benefits that are subsidized by the government, like health insurance and food stamps) to remain progressive in their income distribution—ensuring that the poorest Americans are still getting the most financial help.
A benefit of this size would also be easier to pay for. In total, by my calculation (assuming a beneficiary pool of about 266 million Americans), the Citizen’s Grant would cost roughly $1.6 trillion on an annual basis. Although this would by far outsize Social Security and Medicare, it could be paid for on the back of a value-added tax (VAT)—a consumption tax used by many other countries to pay for social services—as well as a carbon tax. Using estimates from the Tax Foundation, a carbon tax of $50 per metric ton would generate about $180 billion in tax revenue per year. The Foundation also estimated in 2019 that a VAT could generate between $957 billion if set at a 10% rate, and $1.9 trillion if set at a 22% rate. The program could initially be paid for with the carbon tax and VAT set at 10%, with the VAT rate sliding upward annually as more people are added into the benefit pool to keep the program revenue-neutral. Further assisting its bottom line would be offsets generated by growth in GDP as it stimulates the economy.
The disbursement of the Citizen’s Grant benefits would be designed in ways that confront the indirect administrative and psychological burdens of accessing the social safety net. Distributing the benefit could be done at the same time and date in the month to keep it predictable (like the Stockton demonstration has done) rather than following a complex calculation involving birth date and age like Social Security currently does. Learning from the adverse effects of lump-sum distribution in the Eastern Cherokee experience with basic income, the program would distribute income on a monthly basis. The benefit could be directly sent online, loaded into government-issued debit cards sent via mail to every home, or sent to a designated post office for people without a permanent address to pick up, as is done for SNAP benefits. It wouldn’t require a proof of income, lengthy application, a current job, or drug testing, nor would it have lifetime benefit caps. Instead, it would be a guarantee that offers dignity, provides a common touchstone for the American experience, and serves as a new third rail in our politics.
Can it Happen?
Just over a year ago, Andrew Yang’s central campaign promise of a universal basic income generated buzz but was not taken seriously by the political establishment. Today, however, the world is different. COVID-19 has exposed deep social rifts and set the status quo on fire. It has rebalanced the risk-reward calculation for an expanded basic income.
Increasingly, the idea of a basic income feels possible. Earlier in the pandemic, two rounds of stimulus checks passed Congress with bipartisan support. On the ground locally today, 30 cities across the United States are now piloting basic income programs, with support from Mayors for Guaranteed Income. Even if the U.S. public isn’t quite behind the notion of a universal basic income, the stimulus checks have enjoyed wide support, regardless of political persuasion. And as Washington sets its sights beyond the pandemic, even conservatives are expressing an interest in giving money directly to the people. In the debate over the future of the child tax credit, Senator Mitt Romney proposed a bill that would eliminate it in favor of a child allowance plan distributed through Social Security as monthly payments. In doing so, Romney has struck a nerve among thinkers across the ideological spectrum, who see the current social safety net as far too complex and cumbersome.
Behind this air of possibility is a new presidency. Joe Biden has set his sights on becoming a transformative U.S. president. Already in his term, his administration has ushered through the American Rescue Plan, providing COVID-19 relief legislation and significant public investment in social welfare. On the horizon now are two more bills—the American Jobs Plan and the American Families Plan—both of which are poised to invest heavily in infrastructure, domestic manufacturing, and caregiver services, among other things. In remarks he gave in April, Biden compared these plans to grand innovations in U.S. history, such as the Space Race and the building of the Interstate Highway System. An expanded basic income would fit the mold of a grand American innovation, too.
Social policy has a habit of advancing dramatically in the face of tragedy. In a United States hobbling out of the Great Depression, tragedy resulted in the enactment of Social Security—inspired by a fervent doctor from California and his national movement. In post-war Britain, as civilians picked up rubble from Blitzkrieg raids, tragedy resulted in the creation of the beloved National Health Service. In a post-pandemic United States, what will our collective tragedy result in?
In one version of our future, it would mean revisiting the Great Society for people like Jorge and so many of my patients and making government work for them. It should mean enacting a universal basic income.
Vishal Khetpal (he/him) is a resident physician and essayist, currently training in the Brown University Internal Medicine Program. He earned his medical degree from Brown University in 2020 and his master’s degree in global health from the London School of Economics in 2016. His other writings are available at vishalkhetpal.com.
Edited by Eddie Fishman (he/him)
