Skin in the game

a pound of flesh

Bernie Sanders’ proposals for medicare-for-all and universal student debt relief have fired up the wonks. Charles Lane recently wrote a column in the Washington Post that has some bad news for American democratic socialists: actually, Nordic social democracy isn’t socialism. And he has a JP Morgan Chase report to prove it.

These countries are generous; but they are not stupid. They understand there is no such thing as “free” health care, and that requiring patients to have at least some skin in the game, in the form of cost-sharing, helps contain costs.

The use of the metaphor “skin in the game” in private health care is rather grotesque, when you think about it, but it’s also weirdly appropriate, for reasons that will hopefully become clear. The phrase is an example of synechoche–using a part for the whole, in this case one’s skin for one’s self. The referent of the skin comparison, however, is an issue of some etymological controversy in the Oxford English Dictionary. The dictionary asks, inconclusively, whether we are meant to be “risking our skin,” our health and personal safety, or “laying down some skin,” i.e. putting down money, in which “skin” is somewhat old-fashioned American slang for a dollar bill. Related to this last is the metaphor of skinning as swindling, or “fleecing.” So there are three competing metaphors here: flesh, finance, and theft.

As for the first: “skin in the game” calls to mind the Shakespearean phrase “a pound of flesh,” that which is demanded by the usurious Shylock to settle Antonio’s unpaid debt in The Merchant of Venice. Shylock really means to collect literally on this debt, to Antonio’s surprise and distress. The metaphors are somewhat different–a pound of flesh is demanded, cruelly, by a lender, while skin in the game is said to be owed, fairly, by a debtor or stakeholder. But while Antonio eventually gets out of his flesh bond, we’re supposed to keep our metaphorically flayed skin in whatever game Charles Lane thinks we’re playing at the hospital.

The second two meanings are (also) financial–though as any reader of American news knows, politicians love to use it as a way of justifying austerity as a form of moral “accountability.” (Paying more fees for public services you used to get for free ensures that you have “skin in the game.”) The OED attributes the popularity of the phrase to U.S. business culture, where it refers to a financial stake in a venture. We might also think here of the “game” in the phrase–a card game, perhaps, like skin. Sample usage, from the autobiography of Rudolph Alexander: “The guys were always playing Skin and that was a game that I refused to play. In my opinion, winning was based on luck or cheating.”

And then there’s the confidence game. As William Safire wrote in his short discussion of “skin in the game” (what can I say; when you’re right you’re right), “the skin game throughout the 19th century was ‘a confidence game,’ and paper dollars taken from suckers were known as skins.”

So how do we bond these metaphors of flesh, finance, gambling, and theft to the argument about health care Lane is making? Well, firstly, he’s not making one; saying we should have “skin in the game” is an assertion that it is fair to pay for health care as a commodity, not an argument for why it is. And this is the function of phrases like this: to avoid scrutiny by generating, as a kind of ancient folk wisdom, an unexamined confidence in the way things currently are.

If for-profit health care is a game, winning it is mostly based on luck, the distinctions between who gets sick and who doesn’t, who has “good” health insurance and who doesn’t, who lives in the right zip codes and who doesn’t, and so on. In the case of health care, “skin in the game” makes almost literal the pound of flesh that is demanded of us as health debtors–what else do we have in the game of our own health but our skin?

On meritocracy and the Varsity Blues scandal

I was a guest on WNYC’s On the Media, direct from a recording studio in Lisbon (thanks Dizplay Soundlab!), to talk about the scandal of meritocracy. Meritocracy is a particularly strange keyword, because it was originally coined by Michael Young as a satirical mockery of a fantasy it has now come to earnestly represent: social mobility through education and innate talent. Instead of gaining access to wealth and power through an accident of one’s birth (as in an aristocracy), in a meritocracy you gain access to wealth and power through your access to the elite institutions that reproduce wealth and power. Which you mostly gain access to by an accident of birth.

Thus, paying $500,000 to cheat your kid into Yale the meritocracy.

As I try to say here, though, the real scandal of college admissions in the United States isn’t how it works when people are cheating. It’s how it works when people aren’t cheating. Access to the “meritocracy” is guaranteed in most cases not by breathtaking bribes to con artists, but through more mundane, perfectly legal advantages: being born in the right public school district, to the “right” parents, and with the “right” posture, skin tone, gender identity, accent, etc.: in short, all the other sorts of advantages that are in general rewarded by elite higher education.

In other words, when we’ve finished laughing at Aunt Becky, USC will still cost $50,000/year.

New Keywords review published

Thanks to Oliver Eagleton and Counterfire for this insightful review of Keywords.

I appreciated Eagleton’s serious engagement with the book, and for this critique in particular:

While Williams chose to analyse words which could be reclaimed for the left, his inheritor seem to think that ‘the new language of capitalism’ must be rejected wholesale. His introduction urges us to argue ‘for free time, not “flexibility”; for free health care, not “wellness”; and for free universities, not “the marketplace of ideas”’ (p.19), all of which sounds unobjectionable. But Leary loses something by simply pitting one vocabulary against another, or contrasting the old with the new. He ignores the extent to which the dominant lexicon can generate values and ideas which undermine its own foundations.

This was always a worry of mine, that the project would become a list of “bad words” or office jargon to avoid. But at the same time, I don’t know what good can come from reclaiming “flexibility,” given how insidiously it already preys upon a desire for freedom. Yet I also think Eagleton’s basic comparison with Williams’ project is correct: the original Keywords was a lexicon of modern society in its contradictions, and so it included words, like “city” and “labor,” whose political ramifications were either ambiguous or potentially socialist. In this way my Keywords is different: words like “wellness,” “flexibility,” or “innovation” are blockages, words we use when we really mean something else. When we say “human capital,” for example, what we are really describing is “labor.” And to get to the bottom of that word, we have Raymond Williams’ Keywords.