In fact, the majority of Americans say it is fair to ask people with unhealthy lifestyles to pay more for health insurance. We believe in the concept of personal responsibility. You hear it in doctors’ lounges and in coffee shops, among the white collar and blue collar alike. Even President Obama has said, “We’ve got to have the American people doing something about their own care.”
But personal responsibility is a complex notion, especially when it comes to health. Individual choices always take place within a broader, messy context. When people advocate the need for personal accountability, they presuppose more control over health and sickness than really exists.
Unhealthy habits are one factor in disease, but so are social status, income, family dynamics, education and genetics. Patient noncompliance with medical recommendations undoubtedly contributes to poor health, but it is as much a function of poor communication, medication costs and side effects, cultural barriers and inadequate resources as it is of willful disregard of a doctor’s advice.
A few years ago surgeons in Melbourne, Australia, were refusing to provide heart and lung surgeries to smokers, even those who needed the operations to stay alive. “Why should taxpayers pay for it?” said one surgeon quoted in media reports at the time. “It is consuming resources for someone who is contributing to their own demise.”
Though some were outraged by this stance — the Australian Medical Association called it “unconscionable” to ration services based on personal habits — many doctors agreed with it. Like the majority of Americans, they saw nothing wrong with patients paying for the consequences of their actions.
The problem is that punitive measures to force healthy behavior do not usually work. In 2006, West Virginia started rewarding Medicaid patients who signed a pledge to enroll in a wellness plan and to follow their doctors’ orders with special benefits, including unlimited prescription-drug coverage, programs to help them quit smoking and nutrition counseling. Those who did not sign up were enrolled in a more restrictive plan that, among other things, limited drug coverage to only four prescriptions a month.
The program, by many accounts, is failing. As of August 2009, only 15 percent of 160,000 eligible patients had signed up. Patients with limited transportation options were having a hard time committing to regular office visits. And experts say there is no evidence that restricting benefits for noncompliant patients has promoted healthy behaviors.
As a cardiology fellow, I once took care of a young man with severe congestive heart failure. We were supposed to start him on a blood thinner early in his hospitalization, but it got overlooked. Fed up with the delays in getting his blood sufficiently thinned, he left the hospital against medical advice. He said he had to go home to care for his toddler.
He came to the clinic a week later looking very embarrassed. He had left without prescriptions, so he had been taking no medications since he left, leaving him short of breath. To compound the problem, he had been eating cold cuts, cheap and readily available, which made his condition even worse. But the attending physician refused to give him prescriptions. She said that he had to go to a walk-in clinic. She said he had to learn personal responsibility.
Healthy living should be encouraged, but punishing patients who make poor health choices clearly oversimplifies a very complex issue. We should be focusing on public health campaigns: encouraging exercise, smoking cessation and so on. Of course, this will require a change in how we live, how we plan our communities.
“It’s the context of people’s lives that determines their health,” said a World Health Organization report on health disparities. “So blaming individuals for poor health or crediting them for good health is inappropriate.”
I must admit I often feel like my colleagues who grouse about spending all day treating patients who do not seem to care about their health and then demand a quick fix. I do not relish paying more taxes to treat patients who engage in unhealthy habits. But then I remind myself that we all engage in socially irresponsible behavior that others pay for. I try to eat right and get enough exercise. But then I also sometimes send text messages when I drive.
The whole point of insurance is to reduce risk. When people inveigh against the lack of personal responsibility in health care, they are really demanding a different model, one based on actual risk, not just on spreading costs evenly through society. Sick people, they are really saying, should pay more. Which model we eventually adopt in this country will say a lot about the kind of society we want to live in.