The check arrives on the first of the month, like Social Security used to. Three thousand dollars. It doesn’t come with a letter from the President or a thank-you from a grateful nation. It comes with a notification, the way everything does now, and a small line of text noting that the dividend has been deposited.
I don’t work. Almost nobody does, not in the way we used to mean it. In the world I’m imagining, the artificial superintelligences do nearly all of the economic activity on the planet: the coding, the logistics, the accounting, the lawyering, the designing, and increasingly the building, as the robots come online. What’s left for humans is a thin layer of carve-outs, the jobs we’ve decided by law should stay human, and a much thicker layer of nothing in particular.
So we get paid for existing. And this, I’ve come to think, is where the American version of universal healthcare actually comes from. Not from a Medicare for All bill, not from a Bernie Sanders presidency that never arrived, but from the side door of a basic income.
The deal
In 2006 the conservative social scientist Charles Murray proposed something radical for a man of the right: abolish the whole patchwork of transfer programs (welfare, food stamps, housing assistance, Social Security, Medicare, Medicaid) and replace it with one cash grant to every adult. No caseworkers, no means tests, no bureaucracy deciding whether you deserve help. Just money.
Even Murray couldn’t make healthcare fit cleanly inside the check, though. His plan required people to put part of the grant toward catastrophic health insurance. He understood that a 50-year-old with a bad heart and a 25-year-old marathoner can’t both be handed the same envelope and told to sort it out.
My version of the deal is Murray’s, with two changes. The first is size. Murray’s grant was a supplement. In an economy where the machines do nearly everything, the grant has to be a living. Call it High UBI: around $3,000 a month.
It’s worth doing the arithmetic, because the number is huge. Three thousand dollars a month to roughly 260 million American adults is about $9.4 trillion a year. That’s on the order of a third of what the entire U.S. economy produces today. It only works if the economy is much, much bigger than it is now. That’s the whole premise: superintelligence makes the pie so large that a third of today’s GDP looks like a rounding error. If that premise fails, so does everything else in this essay. But if it holds, the check is affordable, and the check is how a displaced population keeps buying the things the machines are making.
The second change is that the state still pays for prescriptions and the other things individuals can’t price for themselves. Insulin, chemo, the drugs a transplant patient takes for the rest of her life. Cash covers the checkup. The government covers the pharmacy.
I’d take that deal. I think most Americans would.
What gets cheap, and what doesn’t
Part of what makes the deal plausible is that superintelligence collapses a large share of what we now spend on medicine. Diagnosis becomes nearly free. So does triage, and the paperwork, and the billing department that exists mostly to fight with another billing department. A machine that never sleeps, has read every paper ever published, and has seen ten billion patient records will be a better diagnostician than any doctor most of us have ever met.
But not everything gets cheap. Bodies are expensive. Surgery, nursing, hospital beds, the physical labor of caring for someone who can’t care for themselves: none of that becomes free because a mind in a data center got smarter. Not until the robots arrive, and I’ve written before about what it might mean to let them into the exam room.
Rent doesn’t get cheap either. Land is land. A $3,000 check in a world where everyone has a $3,000 check is a lot of money competing for the same number of houses near the same number of good hospitals. Some of the High UBI will simply flow through tenants to landlords, as it always does.
So the check pays for the cheap part of medicine. The state has to pay for the expensive part. That’s the logic of the carve-out.
The carve-out doesn’t stay put
Here’s my first problem with my own deal. Once the state pays for prescriptions, it has exactly the same argument for paying for the insulin pump, and then the dialysis machine, and then the hospital stay where the drug gets administered. Every line you draw becomes a lobby for the thing just past it.
That might be fine. Maybe the carve-out grows until it’s single-payer in all but name, and America backs into the system the rest of the developed world chose on purpose. But it means “UBI plus prescriptions” isn’t a stable resting place. It’s a starting point, and nobody will agree on where it ends.
Follow the pills
The second problem is the one that actually keeps me up.
In this world, who invents the drugs? Superintelligence does. Drug discovery is the field where these systems will shine first and brightest: protein folding, molecular design, running a million simulated trials before a single human swallows a pill. That means the patents, and the pricing power that comes with them, sit with a handful of ASI companies.
Now trace the money. The government taxes the ASI companies to fund the dividend. The dividend lands in my account. Then the government turns around and pays the ASI companies for my prescriptions. The money leaves the machine, passes through me, and goes back to the machine, minus whatever I spent on rent and groceries, much of which was also produced by the machine.
In a sense this is just how a dividend economy works. Alaskans get an oil check and spend it at stores that sell gasoline. Nobody calls it a scandal. But Alaska’s oil company doesn’t also write the check, set the price of the medicine, and diagnose the illness the medicine treats. When one entity, or a few, sits at every point in the loop, the loop isn’t really an economy anymore. It’s an allowance.
The check and the pills come from the same hand. I don’t know what to do with that, except notice it.
Meanwhile, elsewhere
This essay is about America, deliberately. But picture the day I fill my first state-paid prescription, the one invented by an ASI and paid for with an ASI tax.
That same week, Berlin is debating cuts to its health system. Europe built the welfare states Americans envied by taxing work, and work is gone. The profits that replaced it are booked in California and Delaware, out of reach. It’s an ugly irony: America may finally get something like universal healthcare at the moment Europe starts losing it, not because our system got better but because theirs ran out of money and the two met in the middle.
And in a village in rural Bangladesh, a woman is being diagnosed by an app on a cheap phone, better than any doctor within a hundred miles could manage, by a system owned by the same company that filled my prescription. The garment factory that used to employ her daughter closed years ago. Whether she gets a dividend of her own is a question I can’t answer, and one the company may not feel any obligation to.
Taking the pill
So here’s where I land. I’d take the deal: the $3,000, the prescriptions, the whole thing. I’m not principled enough to turn down free medicine to make a point about market concentration, and neither are you.
But I’d take it the way you take a loan from a relative who’s a little too generous. Grateful, and watching. Every month the check arrives, and every month I’ll be a little more dependent on the hand that writes it, and a little less able to imagine life without it.
The notification arrives. The dividend has been deposited. I go pick up my prescription. The pharmacist, a human, one of the carve-outs, hands me the bag and asks if I have any questions.
I have plenty. None of them are for her.
