Redistributed Vulnerability and the Unmaking of the Social Contract
For much of the twentieth century, the United States at least partially acknowledged a basic political reality: some parts of human life cannot safely be left to markets alone. The New Deal emerged from economic collapse, and its underlying logic was not charity but stability: a recognition that a society cannot hold together when survival depends on uninterrupted productivity, perfect health, or private wealth. Social Security, unemployment insurance, labor protections, disability systems, and later Medicare and Medicaid were imperfect attempts to build a floor beneath which people were not supposed to fall. The floor mattered because markets distribute resources according to profitability, not human need.
Over the past half century, that project was reversed. Collective obligations were recast as inefficiencies to be privatized, outsourced, or converted into consumer markets. Citizens became customers. Public goods became products individuals were expected to navigate and purchase for themselves. Retirement security shifted from pensions to individual accounts tied to volatile financial markets. Healthcare became mediated by insurers and conglomerates whose primary obligation is shareholder return. Disability systems became adversarial, requiring people to repeatedly prove incapacity in order to access basic support.
The result was not less dependency. It was redistributed vulnerability: risk moved off institutional balance sheets and onto individual bodies, with the heaviest loads landing on the people least equipped to carry them.
Competing Obligations
A system designed to care for people requires flexibility, redundancy, accessibility, and long-term investment. A system designed around profitability requires cost containment, efficiency, and financial return. When the same institution is asked to do both, one set of priorities eventually overtakes the other, and the conflict is resolved, predictably, by shifting cost and risk downward. The forms are familiar: more documentation for the person seeking benefits, narrower eligibility, thinner staffing, automated denial, labor reclassified to escape benefit obligations.
This is not a mood. It is measurable. In 2024, Medicare Advantage insurers processed nearly 53 million prior authorization requests and denied roughly 8 percent of them, according to KFF’s analysis of federal data. Enrollees appealed only about one in eight denials. But of the denials that were appealed, more than 80 percent were partially or fully overturned. A denial system whose decisions collapse under scrutiny four times out of five is not performing quality control. It is friction doing the work of rationing, and the low appeal rate is not a flaw in the design. It is the design. In Medicaid managed care, where enrollees have the fewest resources to push back, the HHS Office of Inspector General found denial rates double those in Medicare Advantage, with roughly nine in ten enrollees never appealing at all.
The same logic governs what happens when extraction reaches the bedside. A peer-reviewed study of more than seven million Medicare patient stays found that private equity acquisition of nursing homes increased short-term mortality by roughly 10 percent, implying more than 20,000 deaths attributable to ownership structure between 2005 and 2017. The mechanism was legible in the data: frontline nursing hours fell, antipsychotic sedation rose, compliance with care standards declined, and taxpayer billing went up 11 percent. Operating costs were shifted away from staffing, the thing that keeps people alive, and toward the fees that return value to the fund. Nobody decided that residents should die sooner. The incentive structure decided, and the incentive structure was the product being purchased.
Reform rarely disturbs this arrangement. A loophole closes; the incentive that produced it survives; the structure changes shape without changing purpose. The burden of navigating the new configuration lands, as before, on the individual.
Disability as Diagnostic
Disabled people are usually treated as an exception within this economy. They are better understood as its clearest readout. Modern economic systems tie legitimacy and stability to productivity, endurance, and continuous labor participation. Those who cannot reliably meet that expectation are managed less as citizens with needs than as liabilities to be contained through bureaucratic process. The containment systems built for them reveal the operating assumptions that govern everyone.
The containment begins with definition. To control costs, institutions construct disability as a set of narrow thresholds: visible impairment, total incapacity, easily measurable functional limitation. Lived disability rarely operates so cleanly. Conditions fluctuate, compound, and resist measurement. Many people remain technically “capable” of work while working at extraordinary physical, cognitive, and financial cost; others cycle between stability and crisis depending on healthcare access, caregiving support, and economic conditions. Administrative systems do not fail to account for this complexity by accident. Accounting for it would require more expansive and flexible support, so the complexity is defined out of existence and access becomes a continuous adversarial negotiation: documentation requirements, medical gatekeeping, reassessment cycles, work-hour limits, asset caps.
The asset cap is worth dwelling on, because it is so exact. A person receiving Supplemental Security Income may hold no more than $2,000 in countable resources, a limit unchanged since 1989. Indexed to inflation, it would exceed $5,000 today; pegged to its original 1972 value, it would approach $10,000. The Center on Budget and Policy Priorities notes that the limit is also the leading driver of erroneous payments and benefit churn, suspending people who drift a few dollars over and saddling them with overpayment debt. Read structurally, the rule is not a safeguard against abuse. It is a legal prohibition on accumulating the savings that would let a disabled person absorb a single emergency. The program does not merely fail to prevent precarity. It mandates precarity as a condition of eligibility.
This is the deeper contradiction of market-oriented social policy. Many support systems are designed less around enabling participation and flourishing than around determining who has become sufficiently economically nonfunctional to qualify for minimal assistance. Recognition is conditional on proving incapacity and suffering in forms legible to agencies and insurers, and it frequently arrives only after the person has already reached crisis. The system does not ask what people need to live. It asks whether they have failed completely enough to deserve help.
The Generalization of Precarity
What disabled people have navigated for decades is now becoming the general condition. More than 100 million adults in the United States carry healthcare debt, 41 percent of the adult population, much of it hidden in credit card balances, payment plans, and loans from family, according to KFF’s national survey. Employer-sponsored coverage grows thinner while deductibles rise. Wages stagnate relative to housing, care, and education costs. Public programs grow more means-tested, more bureaucratic, and more stigmatized, while the agencies that might constrain any of this are weakened by underfunding and capture. And public rhetoric continues to frame the results as personal irresponsibility rather than structural design.
When the resulting instability becomes politically intolerable, the standard response is to inject public money into the privatized structures that produced it. In a genuinely public-oriented system, that investment would build capacity: providers trained and retained, facilities modernized, caregivers supported, preventative care expanded. Routed through fragmented private systems whose primary obligations remain financial, it functions differently. The subsidies stabilize the institutions; the institutions adapt by finding new ways to narrow eligibility, add friction, and extract value; and individuals keep absorbing the risk. Public money ends up underwriting scarcity rather than eliminating it.
Normalization completes the cycle. When barriers become routine, people internalize structural instability as personal failure or unavoidable fact. Workers accept hours without benefits as standard. Chronically ill people adapt to denial and appeal as a way of life. Families absorb caregiving that public systems have quietly stopped supporting. Entire communities reorganize themselves around scarcity while being told no alternative exists. But these outcomes are not weather. They are choices: political and economic decisions that subordinate human need to market logic, renewed every year they go unexamined.
What Markets Cannot Price
None of this requires believing that markets are useless. Markets allocate according to willingness and ability to pay; that is not a moral defect but their operating principle. The consequence, however, is unavoidable: a life without purchasing power registers as low demand, and care for that life registers as cost without return. No internal market mechanism corrects for this, because there is nothing to correct; the pricing is working as intended. Markets can distribute luxury goods and respond to consumer preference. They are structurally incapable of assigning equal value to human lives, because equal value is precisely what a price system exists to avoid assigning.
The question, then, is not whether markets can produce innovation or efficiency in some sectors. It is whether survival itself can be ethically organized around systems whose primary obligation is financial return. The twentieth century answered no, imperfectly and under duress. The decades since have been a long experiment in answering yes, and the results are in the denial statistics, the mortality data, the asset caps, and the debt loads.
Disability is where the experiment registered first and hardest, because disability is where the system’s real question gets asked out loud: not what do you need to live, but have you become nonfunctional enough to deserve help. A society that organizes survival around that question has not eliminated dependency. It has only decided whose vulnerability counts, and how much it is willing to pay to avoid finding out that the answer, eventually, is everyone’s.