The Antisocial “Safety Net”

The “safety net” is not merely a catchall or shorthand but a metaphor with imagery that undermines an understanding of public health programs. The metaphor calls to mind a height-defying, independent subject who might unexpectedly and temporarily need rescue, priming the reader for an individualized, rescue-focused vision of the role of law in the public’s health inconsistent with much public health research. Where public health research emphasizes human interconnectedness, the safety net metaphor emphasizes individuality. And where public health research emphasizes the importance of social determinants and the value of prevention, the safety net metaphor reifies only programs that rescue, leaving upstream programs invisible. The first half of this article provides background on the origin, ambiguity, and past criticisms of the safety net metaphor in public health. The second half problematizes the inherent content of the metaphor.

Origin, Ambiguity, and Criticism of the Safety Net Metaphor in Public Health Discourse

Jack Kemp and Ronald Reagan originated the safety net imagery for US health and welfare programs in the late 1970s and early 1980s, borrowing the metaphor from the field of international finance. ¹ In the early days of his first term, President Reagan defended proposed cuts in New Deal and Great Society programs by explaining that “those who, through no fault of their own, must depend on the rest of us—the poverty stricken, the disabled, the elderly, all those with true need—can rest assured that the social safety net of programs they depend on are exempt from any cuts.” ²

Reagan’s conceptualization of a safety net for those with true need helped to diffuse criticism of cuts to existing programs while obscuring questions about which programs would be cut (and, in the case of entitlements, as to which beneficiaries). ³ Although members of the Reagan administration “carr[ied] the safety net around as a kind of security blanket,” ⁴ they were also inconsistent in identifying the programs composing the safety net. ³

The safety net metaphor has since seen widespread adoption in public and academic discourse as a catchall for health and welfare programs. Use of the metaphor in public health is ubiquitous, although various authors present the safety net as comprising various groupings of programs. These differing understandings of the programs included in the safety net can be roughly differentiated into 4 overlapping categories. In approximate order of breadth, these differing categories of programs in the safety net include (1) subsistence programs providing direct cash or in-kind support (whether only means tested or also morality tested) ^{5 -7} ; (2) subsistence programs and programs that reduce the likelihood that people who are not in poverty will become impoverished (poverty prevention programs) ^{8 -11} ; (3) all health and welfare programs, or all such programs relevant to a given topic or group (eg, safety net for workers), including programs that address social determinants ^{12 -14} ; or (4) in the health care arena, the discrete subset of health care providers who accept patients regardless of their ability to pay (ie, open-access providers). ^{15 -18}

This definitional ambiguity is confusing because it creates a risk of miscommunication. Two people might have an entire conversation about the safety net and its importance without ever realizing that they disagree about fundamental questions, such as whether safety net programs should be morality tested.

Scholars have, in a few instances, problematized the widespread adoption of the safety net metaphor. Law professor John Jacobi pointed out that labeling a group of programs as a safety net may lead policy makers to believe that other programs are unnecessary, even if that is not the intent of the label. For example, using the phrase “health care safety net” to refer to open-access providers willing to treat patients regardless of their ability to pay might suggest that the existence of such providers renders unnecessary other programs that many view to be important aspects of what they think of as the safety net, including Medicare and Medicaid. ¹⁹

Jones et al ²⁰ suggest modifying the imagery to the broader metaphor of a cliff. In this metaphor, a safety net “halfway down the cliff” (representing secondary prevention efforts) catches those who fall through a fence at the top of the cliff (representing primary prevention efforts), and social determinants interventions entail moving people further from the cliff so they do not fall in the first place. And historian Alice O’Connor, in published remarks from a panel discussion, lamented that “what we normally think of as the public safety net is in fact embedded in [a] larger system in which [various] forms of public social provision . . . are meant to benefit us all, and are meant to provide protection for the broad citizenry . . . against the vicissitudes of the market economy.” ²¹

The Loaded Imagery of the Safety Net Metaphor

The safety net metaphor’s definitional ambiguity is not the only challenge posed by the term. Even if it were used consistently and precisely, the term still carries loaded imagery that is inconsistent with some understandings of the function and purpose of public health programs. The safety net is a metaphor, not an empty catchall or acronym. Metaphors are tools of understanding that call to mind a particular image or story and invite listeners to use that story as a shortcut in building their own understanding of a complex or abstract concept. The story the safety net metaphor calls to mind makes it a particularly poor fit for public health.

The Independent Individual in the Safety Net Metaphor

The safety net metaphor first calls to mind a height-defying individual (perhaps climbing a ladder or walking a tightrope) who might come to fall alone. Although the occasional listener might have a different vision, generally speaking, people climb ladders, walk tightropes, and fall alone. But public health research emphasizes that individual health is not independent of family, neighborhood, race, or community. ²² Quite the contrary, the social-ecological model for understanding public health “places individual choices into their social context and emphasizes structural explanations for health behaviors and outcomes.” ^{22 -24}

The individualized worldview of the safety net metaphor has no place for many of the most important problems and interventions studied by public health. Virus transmission ²⁵ ; the water crisis in Flint, Michigan ²⁶ ; mental health education in public schools ²⁷ ; adverse childhood events ²⁸ ; and Good Samaritan laws to encourage overdose reporting ²⁹ are difficult or impossible to understand within the individualized safety net metaphor because such problems and interventions entail human interactions that have no place in the antisocial vision it calls to mind.

The Reactive State in the Safety Net Metaphor

Because the safety net metaphor mischaracterizes the problem addressed by health and welfare laws as the risk that an “individual” might in some sense “fall,” it is not surprising that the metaphor as often used also mischaracterizes the role of the state in solving that problem. ³⁰ Health and welfare programs described by the metaphor exist to rescue an individual should she fall and do not otherwise affect the individual.

Merely describing the role of the state in the safety net metaphor pinpoints a second way in which the metaphor undermines public health discourse. Public health research emphasizes the potential for health and welfare laws to improve health by affecting upstream social determinants, ³¹ just as feminist legal theory emphasizes the “webs of economic, social, cultural, and institutional relationships” surrounding personally identifiable crises. ³² This potential is present even for traditional means-tested financial benefit programs, including the Earned Income Tax Credit and unemployment compensation; public health research has seen these programs, too, as addressing social determinants of health. ³³ The safety net metaphor contradicts this emphasis by reifying laws to the extent they are involved in rescue but not to the extent they are involved in prevention. By conceptualizing law as present only to help a person who falls, the safety net ignores the law’s role in increasing or decreasing the likelihood that a person might fall in the first place or their resilience in the event that they do have a health or financial setback. This differential reification is present even in the careful cliff metaphor described by Jones et al, ²⁰ on which rescue programs take the concrete form of a safety net or an ambulance, and primary prevention programs take the concrete form of a fence, but programs focused on the social determinants are invisible (we see only their effect—people moved further somehow from the cliff’s edge). As a tool for promoting understanding of health and welfare laws, differential reification creates a challenge because it increases the salience of primary prevention and rescue but not of social and structural determinants of health and inequality.

Moreover, the implicit suggestion that state support is provided only temporarily to help a person get “back up” is inconsistent with the role of important programs widely understood to be part of the safety net. For example, Medicaid is the primary source of long-term care coverage in the United States, covering approximately 60% of nursing home stays. ³⁴ For these nursing home residents, the program is more akin to a platform at the other end of the tightrope of the market economy than the safety net hanging below.

Conclusion

Public health researchers and professionals should not use the safety net metaphor uncritically. The metaphor is descriptively confusing in that it means different things to different audiences, and the imagery it calls to mind is inherently problematic in the context of public health even when used precisely.