What About Personal Responsibility?

What About Personal Responsibility?

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A reader writes to ask: What about personal responsibility? “I see no movement afoot to require the public to accept or meet norms of behavior that would reduce the need for medical treatment—smoking, excess drinking, use of drugs, over weight, etc. What ever happened to ‘You reap what you sow’?”

Good question. I answered:

Thanks for writing. This is a common concern. It’s often expressed something like, “Why are we paying for all this healthcare for people who won’t take care of themselves?” This seems, at first blush, an obvious question with an obvious answer. After all, as I constantly point out in what you read, vast amounts of healthcare dollars are spent to correct what we might call “self-inflicted lifestyle damage.” Why should the rest of us pay for that? Where is the responsibility?

On inspection, the question is more complex and the answer is not so obvious. Let me try to parse it out. I can think of four related aspects of the question.

1. Their health affects ours. My wife and I had a lovely dinner at a very nice French restaurant on the waterfront here in Sausalito last night. The staff was all French, with those endearing accents. The busboy who set our table, poured the water, took away dirty plates and all that, was Mexican. I talked with him a bit in Spanish about the nice weather. I have no way of knowing his immigration status. Now, if I had my ‘druthers, just as a customer, would I rather that he have good access to healthcare and healthcare advice, be up on his flu vaccinations, be aware of the importance of washing his hands frequently, or would I rather he be a seething mass of communicable disease, compounded by ignorance?

 

Similarly, why should I wish the best outcomes for the Yakima Valley Farmworkers Collective? Because I drink beer. Ninety percent of the hops in the U.S. come from the Yakima Valley area. Sick and injured farmworkers do not help make hops cheaply and reliably available. In many ways, private health is a public concern. Wanting everyone to be as healthy as possible is not just a nice, charitable feeling. It is a public health concern, as well as an economic concern.

2: Assumptions about will and information. “You reap what you sow” is a very American thought. We like to think that people are completely responsible for their actions, have the ability to change them, and the knowledge that they need to identify what they are doing that is wrong or stupid, and to identify how to correct those actions. And of course in some sense we are, but that sense may not be as universal as we would like to think it is. My wife, Dr. Jennifer Flower, Ph.D., is a psychoanalyst, and we were discussing this just the other night, in the context of an article in the NY Times about Congressman Anthony Weiner. The article asked the question everyone has been asking, “What was he thinking?” They talked to various experts on neurophysiology, compulsive behavior, addictions, and the like, about the changes in the brain and mental patterns that lead to bizarre and obviously stupid behavior like that. That “Jackass” actor presumably knew that getting blind drunk and driving his car at 140 miles an hour was stupid and dangerous and would get him killed. Yet he did it anyway. Repeatedly, to a predictable end. People like that make being on the highway far more dangerous than we would like it to be.

We can now assume that people who smoke have heard that it is bad for them, but many of them don’t really know how they could stop. You and I might think that they should know, but they don’t. Most people who are obese don’t like being obese, don’t know how they got that way, and don’t really see a realistic path to losing all that weight. Again, we might think that we could tell them what to do, but they don’t actually know what to do (and most of the time, we would be wrong about what would actually work).

Assuming that people with behavioral problems could just correct them is not a realistic or fruitful way to frame the thought.

3: Ability to correct behaviors of others. So what do we do to correct those people’s behaviors? History shows us in multiple ways that simply telling them to shape up doesn’t work. Prohibition doesn’t work. Shame doesn’t work. Even good information by itself doesn’t work. The only thing that works is good information, combined with good attention, conveyed in language and modalities that they can hear it, delivered repeatedly by people whom they trust. What it takes is total engagement.

Short of that, changing those folks’ behavior is a pipe dream. The way you and I think they “should” live is completely irrelevant. Our opinions change nothing. “Requiring the public to accept or meet [our] norms of behavior” is a non-starter.

4: Just let them die? What would be the logical result of taking “you reap what you sow” as the driving dictum of the healthcare system? If you have a problem caused by your behavior, you’re on your own. Just suffer and die. This is, in effect, making stupid behavior a criminal offense. Some obviously is, such as drunk driving. But I’m picturing trials before you get treated at all to determine whether your lung cancer came from your smoking or the effluent of the refinery that you lived near; whether your obesity was willful or not.

If we are not going to just tut-tut disapprovingly and cast people who we think caused their own problems out into the cold, then we end up treating them. What’s the cheapest way to treat them? As early as possible. In fact, the absolute cheapest way to treat them is to prevent the behavior from causing a medical problem in the first place, by getting very engaged with them as early as possible, at the primary care level, and in the schools, in the workplace, and in the community. That’s how they essentially ended risky sexual behaviors among gays in San Francisco and across the nation in the late 80s and 90s. There are scores of other examples in the “Healthy Communities” movement.

So the answer to: “Why do we have to pay so much to take care of people who won’t take care of themselves?” turns out to be: Because we have been in denial about the problem. If we truly want to spend as little as possible taking care of bad-behaving people, we need to build better systems for engaging with them earlier, stronger, in their language.

A “nanny state?” What would the Founders do?

By the way, does this sound like a “nanny state”? No, because engaging with the system is still voluntary at every step. It’s a numbers game. There will always be those who can’t or won’t take up the challenge to change their behavior. But it can be clearly shown that you can change the landscape of bad behavior within a population by offering the right kind of help at the right kind of level.

You ask, “Did our founders ever envision a nation that would use the government in the way it has been re: provision of healthcare?” We actually know what the Founders thought. Healthcare of course was a much more primitive matter then, and far less expensive compared to people’s income. But it was a much greater problem for one part of the population that was poor but economically important. So the very first Congress established a single-payer, individual mandate system for them: sailors got a few dollars taken out of their pay every payday; when injured or sick they could go to the sailor’s hospital in any of the young country’s major ports. They took care of the problem.

What would Jesus do?

We also, by the way, have some sense of how Jesus would deal with people who behave badly. When he encountered the accused prostitute, he told her to change her ways: “Go and sin no more.” But first he invited those in the crowd who had never behaved badly to cast the first stone. Then he knelt and began writing in the dust the sins of the crowd, and they melted away. When we are quick to condemn those who behave badly, and try to withdraw our help from them on that basis, this is a lesson worth contemplating. Few of us are as free of bad behaviors throughout our lives as we would like to imagine. Most of us struggle to live a good life. Some of us have had a lot more of a leg up in doing that than others.

So economics, good systems analysis, and a sense of forgiveness at the core all drive us to the same conclusion: The way to drive down costs for people’s unhealthy behavior is not to withdraw services from them, but to get to them earlier with smarter, stronger engagement.

As a healthcare speaker, writer, and consultant, Joe Flower has explored the future of healthcare with clients ranging from the World Health Organization, the Global Business Network, and the U.K. National Health Service, to the majority of state hospital associations in the U.S. He has written for a number of healthcare publications including the Healthcare Forum Journal, Physician Executive, and Wired Magazine. You can find more of Joe’s work at his website, imaginewhatif.com.

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76 Comments on "What About Personal Responsibility?"


Guest
Jul 27, 2011

Everyone should have access to decent health care services – medical help should not be a privilege. Unfortunately you are always going to have people who don’t take care of themselves or take advantage of the system but what about the people who genuinely need help? I really believe that it is wrong to deny someone medical assistance no matter what the circumstances. I live in South Africa and there are countless stories of people being turned away from hospital emergency rooms because they don’t have private healthcare insurance / medical aid. It is very sad!

Guest
Jul 20, 2011

People might take wrong decisions in their lives thus affecting their health. The job of a doctor is not to judge, but to cure. Of course, I don’t agree or support careless people that do not take care of themselves. but sometimes sickness isn’t related to the a person’s lifestyle, but other factors.

Guest

This is a tough debate and something we talk about in class often. Mostly I’ve found that the vast majority of adults don’t know a thing about their body. When’s the last time anyone took a class on anatomy, physiology and pathology? Most of the students coming to our school don’t even know the proper anatomical terms of the body. This makes me wonder if there’s a HUGE disconnect in people’s minds between action and consequence when it comes to health. If people don’t understand how their actions are affecting the internal structures of their organs and systems, how will they make educated decisions to be pro-active about their wellness?

Guest
Peter
Jul 1, 2011

“It will take a group effort to change our culture.”

Sadly Margie it will take a cultural change to get a group effort.

“Politics though can make for some strange bedfellows.”

The collective effort that defeated the soda tax were not “strange bedfellows” at all but married partners engaged in what America does best, think and act selfishly. Everyone you named against the tax MG were just part of the same delivery chain that profits from soda sales at the cost of poor health. You are correct though that a larger regional/state tax is needed for this to work. The other aspect that creates suspicion among tax payers is what use is the tax being put to. All too often these “good intention” taxes are just dumped into general revenues as another source of revenue, not dedicated to the problem they’re attempting to solve.

Guest
Margie
Jun 30, 2011

“So what do we do to correct those people’s behaviors?” “What it takes is total engagement.”
Total engagement means supporting individual choices and valuing responsible behavior individually and collectively. It will take a multi-modal approach such as providing incentives for healthier lifestyle choices, improving school nutrition to partner with parents for healthier children, menu labeling along with education on healthy choices, altering food industry marketing practices to decrease the negative effects of advertising, and even the use of food taxes, though obviously controversial, to create healthier defaults. It will take a group effort to change our culture.

Guest
MG
Jun 29, 2011

We should tax soda or at the very least remove/greatly reduce the ridiculous subsidies that both corn/sugar get in the first place at the federal level.

The irony is that a potential tax on soda brings together a really odd coalition of people against it. Saw that play in Philly recently where you had the representatives from the large beverage companies team up with the bottlers and the Teamsters. Restaurants and grocery stores also came out against it. Not too often you can find a political issue where the Teamsters team up with a large multinational firm like Coke. They flooded city council with promises of cash and easy crushed the Mayor’s push for a soda tax to increase overall revenues. Politics though can make for some strange bedfellows.

The issue though with a soda tax in only a local is that it does really unfairly put certain local businesses at a notable disadvantage. Philadelphia County is tiny & most of the people who do work downtown live elsewhere. Unless you would enact a soda tax on a large regional basis, it does create an uneven playing field.

Guest
Peter
Jun 28, 2011

What has medical underwriting ever done for the social costs of alcohol consumption (taxed) or diabetes prevention?

“Now ther healthy person who drinks one soda pays as well as the unhealthy person who drinks three a day.”

You pay only for the amount you consume, if you don’t want to pay then don’t consume – same as cigarette and alcohol taxes.

Guest
Nate Ogden
Jun 28, 2011

The absordity of the unheatlhy tax would be comical if it wasn’t real and so frequent.

We use to have a very efficient and effective tax on unhealthy lifechoices, it was called Medical underwriting. It apparently worked to well becuase Obama outlawed, between community rating, age spreads and subsidies it no longer exist.

Before medical underwriting was even cold and buried now people are talking about a tax to hold people accountable, and this is ok……

Now ther healthy person who drinks one soda pays as well as the unhealthy person who drinks three a day. We also have the added fun of tax collection 20% fraud and avoidance.

Seriously what are you tax proponets thinking that you kill medical underwriting then advocate for its less percise and efficient cousin taxation?

Guest
rbaer
Jun 28, 2011

Barry,
the savings that I assume would be almost exclusively longterm, and I heard several times that most employers and insurance companies are not too interested in longterm savings due to employee fluctuation. Remember that the average type 2 diabetic is probably at best a decade with private insurance … and then comes medicare to pick up the tab.

Peter,
We would need to do several things at once. I would think that the approach I suggested may be more feasible and effective, but that’s of course unproven, and neither approach/suggestion will happen in the short- to midterm term anyway. But one word to medicare and medicaid: there is enough room for financial incentives in medicare. In medicaid, the thinking was and is in many states that there should be no financial steering (incentive/disincentive) such as copays etc. because the recipients are thought to have basically no money anyway. Let me tell you that there are in fact quite a few people abusing the system, for instance using the ER for UTIs, or scheduling appointments without good reasons (e.g. doctor shopping, no showing appointments). That is one of the reasons why many docs (probably including hellMD and determinedMD) are irritated by medicaid (the really poor pay is another reason). A lot of doctors want to be paid well, but almost all doctors want their expertise and efforts to be valued in some form. A lot of medicaid patients (and of course also some patients with other forms or coverage/payment) really lack respect to people, resources, efforts. Too bad.

Guest
Peter
Jun 28, 2011

“What’s so bad about a more feasible idea, namely giving people who are normal weight or are slowly loosing weight when they are obese an insurance break?”

Hows that going to work for Medicare, Medicaid, VA insurance, uninsured? You also don’t have to be obese to have high blood sugar, high cholesterol, high blood pressure. Much of poor health is cultural and I don’t think you change culture with small breaks in health premiums. Bad food is simply too cheap.

Guest
Barry Carol
Jun 28, 2011

“What’s so bad about a more feasible idea, namely giving people who are normal weight or are slowly loosing weight when they are obese an insurance break?”

rbaer –

There is nothing wrong with it al all. Indeed, many employers, including my own, are doing just that or it’s equivalent in the form of financial incentives for everything from completing a health risk assessment to joining a smoking cessation program to getting a physical to controlling blood pressure, cholesterol and weight. When I asked the executive in charge of our health plan recently about our company’s utilization trend, he said it really hadn’t declined much if at all. Other companies have had more success, though, especially those with much younger workforces than ours. In terms of overall health system costs, wellness initiatives haven’t really moved the needle much as far as I can tell. As for taxation of unhealthy foods, I’ve said many times that if you can design a tax that can be fairly applied and efficiently collected and administered, sign me up.

Guest
MG
Jun 28, 2011

Sadly none of this is going to change any time soon as it is related to agricultural policy in this country. Even getting rid of the relatively minuscule $6B in ethanol subsidies has been stymied on the Hill.

Earl Butz decided to favor Big Agriculture and the large-scale industrialization of food production and distribution in this country back in the 1970s as Nixon’s Secretary of Agriculture. It has had some really great successes (e.g.., % of food expenses as % of overall American budget has until recently notably decreased and if you count being able to use American grain surpluses as a foreign policy cudgel) but it has had some real downsides too (e.g., rapidly increased the death of the small business man including the small farmer, independent rancher, and specialized butcher)

We aren’t going to fix the medical issues in this country until we address the agricultural ones but I see no indication we are going to see any substantial shift in agricultural policy anytime soon/

Guest
rbaer
Jun 28, 2011

I don’t think you guys are realistic with a lot of your proposals. You cannot tax single ingredients in food (e.g. We don’t even know how bad sodium really is) – you would need a panel to determine each products nutritional value.

Remember what happened with subway? There are offering OK meals, but people compensate simply by eating more, and subway follows the market (5 $footlong). Soda’s and some similar items could be taxed though. However, I believe that soda addicts will easily pay double or triple for soda, and still pay only like 3-5 bucks per 2 liter bottle.

What’s so bad about a more feasible idea, namely giving people who are normal weight or are slowly loosing weight when they are obese an insurance break? I never suggested having people pay their diabetes care OOP.

Guest
Barry Carol
Jun 28, 2011

Margalit –

Tomatoes are the only thing on your list of six items that I actually like. I used to tolerate grapes OK many years ago but haven’t eaten them since. I can’t stand strawberries or blueberries or oranges or peaches or pears and wouldn’t eat them even if they were free. Apples, cantaloupe and watermelon are fine though. That’s just me, of course.

Craig –

It wouldn’t be fair to tax soda but not other unhealthy food just as it wouldn’t be fair to tax oil companies but no other industries that earn significant profits. Soda has been around for a very long time but the sharp increase in obesity has happened mainly in the last 30 years or so and especially in the last 20. I think the main culprits are the proliferation of fast food restaurants, fewer people working in physically demanding jobs and more people, including children, sitting at computers for extended periods. Heck, we don’t even need to get off the sofa or chair to change the channel on the TV anymore. I don’t think unhealthy foods per se are the problem so much as taking in more calories than we are expending in physical activity. I can eat a couple of cookies or a scoop of ice cream or a small chocolate bar on a fairly regular basis and get away with it but not a whole box of cookies or a quart of ice cream or a giant chocolate bar. Moderation is the name of the game.

Guest
Peter
Jun 28, 2011

“What do we tax – calories, fat grams, cholesterol, sodium, sugar?”

Yes, all of them. Fresh fruits, nuts and vegetables and certain grains such as rice would not be taxed. Pretty much anything without added sugar, salt and precessed fat would not be taxed.

“How do we define what constitutes a serving of most foods and do we apply the tax to that?”

Well Barry, right now industry is determining what constitutes a serving if you look at the label. Industry also gives us the % fat, calories and sugar content. It won’t be perfect but it will help to bring in revenue to offset the cost of obesity, heart disease, diabetes and make people aware of the cost of poor eating habits as well as make industry create better food. This is a pay-as-you-go solution. Doing nothing will just drown us in health debt unless you accept the Ryan plan which is to cut off anyone not able to afford health care.