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
tim
Jun 24, 2011

Wow. In one paragraph we learn that, because Jesus told a woman “go and sin no more”, that means that Jesus wants us to vote to raise our taxes and provide government health care for all humans within the borders. (Let’s overlook the not negligible error that Jesus wrote their “sins” in the dust; we actually don’t know what He wrote. Pulpit exegetes like to supply that detail because it heightens the drama of the scene — which itself probably was not in the original version of the gospel.)

So this one episode establishes, not only that we should forgive, but also that at a national political level it is unchristian — UNCHRISTIAN — to allow people to experience the results of their actions.

I await eagerly this theologian’s gloss on St. Paul’s directive to the churches about their own social programs: “If anyone won’t work, let him starve.”

Guest
rbaer
Jun 24, 2011

I don’t necessarily disagree with most of this post, but 2 seems to really go a little bit far in terms of denying personal responsibility.

How about taking the insurance approach:
medical coverage (regardless of who provides it) should involve a surcharge for all modifiable behaviors that are unhealthy and costly (or, if you want to give it a positive spin, a rebate for healthy lifestyles):
-obesity (you could for instance give people with a downward tendency the same rate as normal weight people)
-smoking
-excessive ETOH (I believe there is a lab test for average ETOH use over the last weeks, or you couldpenalize people with DUI tickets and/or multiple ER visits for intoxiation
-poor medication compliance for treatment of certain conditions (hypertension, asthma, diabetes)
The assessment would need to be independent from the PCPs discretion. As a side note, I believe that medical coverage should have a progressive component (i.e. the more affluent help the needy), but you can give incentives within that framework.

Guest
Jun 24, 2011

…and where do you stop?

– people deciding to have defective babies instead of aborting them (corollary: people who refuse prenatal testing)
– people who don’t floss every day
– people who have promiscuous or unprotected sex (or same sex sex?)
– people who don’t wash their hands often enough
– people who choose to place their babies in daycare
– people who choose/forget to get vaccinated according to guidelines
– people who didn’t get screenings in time so now they’re really sick
– people who did not change batteries on their smoke detector
– people who decided to strip old paint without protective respirators
– people who chose to play tackle football in the park with no pads
– people who drove without a seatbelt
– people who ignored the brake fluid light too long
– people who don’t use anti-slipping mats in their bathtub
– people who don’t ingest enough of a particular vitamin or mineral
– people who choose to eat out at cheap filthy restaurants
– people who go out without a sweater
– people who clean their own gutters

…. just scribbling in the sand….

Guest
Alice B
Jun 24, 2011

Excellent reply! It is equivalent to spitting into the wind – “you sow what you reap” is not a viable way of dealing with health care or the personal responsibility issue in any type of scenario…

Guest
rbaer
Jun 24, 2011

Well, I don’t think it’s a good reply. What I suggest is incentives/policy. All you do is trying to set up a strawman by exaggeration. If someone argues for universal coverage/right to health care, do you find the parallel claim “and where do you stop? Right to work? Right to live in a decent space? Right to happiness?” a valid argument?

And ironically, policies are already in place for some of the more important items (seatbelt, vaccinations, handwashing), while some of your ironic suggestions address issues of no proven benefit (daycare, vitamins).

Guest
Jun 24, 2011

rbaer,

The point here is that people are people and we all make trillions of tiny decisions, some bad some good, and having policy for all these decisions imposed by government or big corporations is not my cup of tea. It always starts with a “crisis”, that requires unusual measures, and it always ends with loss of little freedoms previously reserved for little people and it always ends some place other than what was originally intended.

I would love to have right to work and right to decent shelter and right to decent meals and right to happiness too, but we can’t afford all these things just yet. Perhaps we cannot afford universal health care, but considering every other developed country can and does, without resorting to “policies”, I believe we can do at least as well as they do, and probably a heck of a lot better.

All these “policies” are aimed at reducing utilization of services. I suggest we start by reducing the grossly inflated prices we pay in this country for same services and the insanely expensive bureaucracy and profiteering surrounding them (a.k.a. administrative costs, waste, fraud).

That is not to say that I am opposed to education and assistance for folks to make better choices, quite the opposite, but having health care for all OR freedom for all is not the choice we are facing, no matter how much kool aid is being dispensed by Big interests.

Guest
rbaer
Jun 24, 2011

Margalit,

I am not sure that I made myself clear … your argumentation was a classical straw man/slippery slope argument … we cannot do x because supposedly then we have to do y which is nonsensical, but without good reason why you need to do y when considering x.

Maybe you know from my previous posts that I am all for taking a lot of profit interests out of health care, and all for universal health care, and I am a member of a physician single payor lobbying group. So I don’t disagree with your aasertion that we can and should do better than the status quo … but you seem to be not aware of the epidemic of obesity/DM2 that will make the US population as a whole sick AND in need of extra health care billions (there are a lot of associated conditions incl cardiovascular ds and even dementia). A fundamental change is needed, and not even informed individuals like yourself seem to be aware that as whole, the US population is on track to bcome a public health disaster. see also
http://diabetes.niddk.nih.gov/dm/pubs/statistics/#Diagnosed20

Guest
Jun 24, 2011

rbaer,
I do understand the problem, but I disagree with the solution because it is poses an unprecedented intrusion into private life and because it will disproportionately affect those who are already vulnerable. I don’t believe you can regulate that people should be “good”. You can educate and create an environment where it is easier to be “good” than to be “bad”.

I read someplace recently that they have health care video games now, and that there are Wii games that are as good as working out by having kids standing alone in front of a TV screen and boxing or something like that. Are we insane?
Why can’t we have gym class in schools every single day? Why can’t we create gold stars or whatever for kids to join team sports? Why can’t we serve healthy food in every school to every child (not just the poor ones)? Why can’t we spend some of money from the HHS seemingly bottomless purse to create small social businesses to bring fresh produce, cool gyms and little leagues of all sports to every neighborhood?
There are probably hundreds and thousands of possibilities that are not punitive in nature and will work just as well if not better.

Guest
Nate Ogden
Jun 25, 2011

“but considering every other developed country can and does,”

Might want to check out those riots in Greece before you say this. Rumor has it England is in for some pretty prolific strikes comming up soon as well. I believe the Union boss has promised to bring the nation to a stop. Also check out those debt loads Euope is carrying.

Would you really claim someone can afford something just becuase they can borrow the money to pay for it today and clearly has no ability to pay it back later?

love the rest of what you said though

Guest
Jun 24, 2011

Joe, I would share a foxhole with you any time. The social contract between our citizens and the government and tax payers that they would like to fund their healthcare must be bilateral. People do change – often when they experience pain — pain in their chest or pain in their pocketbooks. We need a massive change management initiative in this nation to wean this generation off their sense of entitlement. When my father grew up in the Depression, he would rather die than take a hand-out. Ironically, society seemed more supportive and communities close knit.

We have a moral obligation to help others in a nation as rich as ours but it is perfectly reasonable to expect something in return. You want our freedom, be ready to defend it. We need people to agree to see a primary care doctor and understand their health status. We need to remove barriers to care ( by providing first dollar preventive coverage ) but then we need to distinguish between those who choose not to fulfill their end of the bargain and those who do not.

I would argue that there are other implications of chronic illness arising out of modifiable lifestyle risks such as the impact on America’s economy. We could do more to stimulate the economy by reducing the average waist size of the American male from 38″ to its average in the 1961’s of 32″. Those 6″ have probably cost us twice the amount that we are underfunded in medicare liabilities.

Margalit, the answer to your question is very simple. I draw the line where ever you are asking me to use my tax dollars. No social contract, no dinero. You have to play if you want me to pay.

However, the system only works if everyone is pulling their oar. Just wait until 2014 when the mandated young invincibles need to choose between paying a $95 fine or paying out of pocket to join an exchange. We will have a parade of uninsured twenty-somethings only choosing to purchase coverage when they blow out their knee playing basketball – or in Joe’s case with the busboy, after he has contracted and transmitted a communicable disease.

Get real. Personal responsibility is the implied social contract in an entitlement – except perhaps, if you are insane and unable to help yourself. We have places for individuals who need that kind of help too but don’t expect to be able to bring any sharp objects.

Guest
Jun 24, 2011

Mike,
What entitlements are you talking about? Most people in this country pay premiums and pay/have paid into Medicare, so what is it that you feel you are paying for? Or are you only referring to Medicaid folks when you say “You have to play if you want me to pay”?

“No social contract, no dinero.” – Does this apply to “corporate personhoods” who steal my tax dollars and my health care dollars and a bunch of other dollars, or just to poor, disabled and sick people who don’t vote?

Guest
Jun 24, 2011

Medicare and Medicaid are both entitlement programs and are woefully underfunded. Medicare is under water to the tune of $ 38T dollars because of overtreatment, fraud, abuse and unrealistic expectations that access to healthcare equals quality. My children are actually going to be asked to finance the difference between the ” premiums” you say are paying for these coverages and the “actual cost”.

I actual endorse providing healthcare for anyone who is uninsured. I am willing to be subjected to means testing for Social Security and Medicare — if I make over a certain amount, I should either have to contribute more to the system or be entitled to less.

However, I want accountability for my tax dollars. I want to know people are trying to do their part to keep costs down. I did not realize that ” poor” people should be exempted from trying to eat healthier, exercise and make better life style choices like stay compliant if they are diabetic, just as anyone who now will be making up to 400% of the FPL ( $88k for a family of 4 under PPACA ) will need o demonstrate for me to feel good that the $ 940B being raised to pay for this is worth it.

Less than 40% of the country pays taxes. As for “corporate personhoods”, it sounds like you have a serious anti-business axe to grind. After reading Too Big Too Fail, The Big Short and a range of books on the credit default swap fiascos, mortgage securitizationscams etc…the bailout made most Americans sick. However, alot of ” corporate personhoods” use personal capital, take risk, make create jobs, pay taxes and are justiably concerned about being vilified by people who paint them with the same coat of paint as fat cats who swindled America.

The beauty of a democracy is those who feel a strong social need to redistribute wealth, make greater provisions for the poor and seek social justice can vote for candidates who will represent these values. Others feel that one’s idealism can only take a person so far and that the drum beat for social change must be at a proper cadence so you do not blow up the 30% that are paying all the taxes or create welfare state where rich entitlements – initially intended to be a safety net, become a hammock.

Being an Independent, I have loathing for the far right for its lack of empathy and the far left for its lack of fiscal realism. I get annoyed when people retreat from the facts and the facts are 50m uninsured need coverage but we need to find a way of paying for it so we will not bankrupt the nation. I could not imagine supporting any plan that affords people coverage and asks nothing of them in return. I guess I am old fashioned — If I offer someone a hand, I also want to see them try to help themselves up – or in this case, put their soda and french fries down.

Guest
steve
Jun 25, 2011

“Less than 40% of the country pays taxes”

You forget payroll taxes. They make up, now, nearly the same percentage of federal revenue as income taxes. Everyone who works, pays them. State taxes are also important and they are regressive.

“After reading Too Big Too Fail, The Big Short and a range of books on the credit default swap fiasco”

Excellent. I think we need to break up the big banks and regulate them strictly. However, we over regulate small business and, IMO, misregulate big business. You make a good point that we should not lump everything together.

To your broader point, I like accountability. Give people the tools and ability to know what to do, then if they do not comply, provide incentives, negative and positive to alter behavior.

Steve

Guest
Nate Ogden
Jun 25, 2011

not true Steve, tax credits can exceed payroll taxes. With the earned encome pay ya to have a kid crap low income people easily draw more out then they and their employer pay in, by far

Guest
steve
Jun 25, 2011

Absolutely they can, but when you ad in excise taxes and all, it is way more than 40% paying taxes. A little over half o median income and you are paying in. It has traditionally occurred at a lower income, but the extra credits passed since the recession bump it up.

http://economix.blogs.nytimes.com/2011/06/21/are-taxes-high-or-low-a-further-look/#

http://www.cbo.gov/ftpdocs/98xx/doc9884/12-23-EffectiveTaxRates_Letter.pdf

http://www.taxpolicycenter.org/taxfacts/displayafact.cfm?Docid=228&Topic2id=50

Steve

Guest
steve
Jun 24, 2011

Joe reminds of when I worked in West Philadelphia right after I got out of the Navy. The city paid local teens to come work with us during the summer. The kids were late everyday for the first two weeks. I complained and thought it was awful. How could they not at least show up on time. One of my coworkers, took me aside and told me that none of these kids had fathers. None of them had seen someone go to work everyday. They just didnt know. He told me to chill, that he and a couple other guys would work to get them to understand. By the end of the summer, they were better, not perfect, but better. Human capital really does matter. Some people dont know how to do stuff that seems obvious to most of us.

Steve

Guest
Barry Carol
Jun 25, 2011

Those were great comments from both Michael and Steve.

One piece of the original post that I disagree with, though, is the notion that good preventive care saves money for the healthcare system. While it may in the short term and it would certainly help people to live longer healthier lives, which is a good thing obviously, the limited studies that I’ve seen show that it doesn’t save money over a patient’s lifetime. The reason is that unhealthy people, including smokers and the morbidly obese, die sooner. Even people who live perfectly healthy and disciplined lives can get expensive to treat Alzheimer’s, dementia, cancer and CHF in old age. All of those are very expensive to treat.

Since I’m a big believer in properly structured incentives, however, I would prefer to attack the problem through the tax system. High taxes on cigarettes drove the incidence of smoking in the U.S. from over 40% of the population in the 1960’s to about 20% today though it seems to have stabilized there. Now are smoking rate is the 2nd lowest in the world after Canada. Since the huge proliferation of fast food restaurants is probably one of the big contributors to the increase in obesity in the last 20-30 years, we should consider raising taxes there while subsidizing healthy food. Admittedly, it would be harder to design a tax that could be broadly applied, efficiently collected and fairly administered, but it’s worth considering.

One area where I agree with Margalit is the need for greater convergence between the U.S. and other countries in the prices paid for each service, test, procedure and drug. Tiered network and narrow network insurance products could be helpful here, along with robust price and quality transparency tools for both referring doctors and patients. To reduce utilization, my preferences are tort reform, including safe harbor protection from lawsuits for following evidence based guidelines, and a more sensible approach to end of life care.

Guest
Barry Carol
Jun 25, 2011

Oops. It should be our smoking rate, not are smoking rate. It’s early in the morning here.

Guest
rbaer
Jun 25, 2011

Barry,

There is at least one study that somewhat demonstrates econmic benefits of lifestyle changes … I should try to locate that one. But anyway, certain lifestylechanges seem – intuitevely at least – money saving (and, let’s not forget, health enhancing).
DM2 causes (greatly contributes to) obesity which leads to a variety of chronic conditions (CAD/MI, stroke, eye disease. dementia), and DJD from obesity is also a costly problem. It is likely very cheaper to have a life into senior age without these now commonly middle age conditions. Yes, you still have a rate of costly cancer- and end of life care, but you take a lot of chronic care (and joint replacement surgery) out of the equation.

As you point out, the tax solution seems to be complicated in the details. You basically have to tax certain foods/menu items, or is eg McDonalds absolved from higher taxes because they have some healthy menu items. In the super market, do you want to tax breaded chicken (or maybe include even oil and breadcrumbs) and grilled chicken is free? I think it is possible that with a tax solution, you just have steering away from certain foods/menue items to other unhealthy options. It might be more feasible to reward individualslifestyle) who are normal weight (or are on the track of loosing weight). And if one cares about liberty: it seems a somewhat illogical decrease of liberty to make fatty food or alcohol (that are not unhealthy with occ consumption) very costly, compared to incentivizing the outcome that is desired (healthy lifestyle). It’s a little like taxing rubber to disincentivize car travel and promote trains.

Guest
Barry Carol
Jun 25, 2011

rbaer –

I agree that a tax on unhealthy food would be extremely difficult to design and implement. I’m concerned, though, about the relationship between the explosion in the number of fast food restaurants in the U.S. and the increase in obesity rates over the last 20-30 years. We know it’s not a genetics issue given the relatively short timeframe over which the increase occurred and the much lower obesity rates that prevail in Western Europe and, especially, Asia. Also, unhealthy food choices have always been available in supermarkets. Remember too that McDonald’s was not even founded until 1955 while Burger King, Wendy’s, and Dunkin Donuts came later and Starbuck’s arrived much later. Given the concentration of the soft drink industry, it might be easiest to tax their products at the manufacturer level based on either calories or sugar content and apply an equivalent tax to the sale of concentrate used by restaurants and bars. They, of course, would complain about the unfairness of being singled out.

While I’m certainly a fan of personal responsibility, I can also understand that most of the morbidly obese especially cannot lose weight and keep it off to any significant degree through diet and exercise no matter how hard they try. This is why bariatric surgery is increasingly popular among this population. Poor people often don’t have safe places to exercise. They don’t have good access to healthy food and couldn’t afford most of it even if they did. Smoking is often one of the few pleasures that help to relieve stress in their chaotic lives. Financial incentives for healthy behavior are like high deductible health plans to encourage wiser use of medical resources. They both make pretty good sense for the middle class and the upper half of the income distribution. They don’t work nearly as well for the poor. While education can lead the horse to water, we can’t make them drink. We probably could provide more community health centers to provide basic care for the poor and take some of the pressure off of expensive emergency rooms.

Guest
Barry Carol
Jun 25, 2011

As the recently deceased Peter Falk would say, “There’s one more thing.” If it were up to me, I would require the poor and all the rest of us to carry a national ID card with a name, address, picture, finger print or other biometric identifier. Anyone who applies for taxpayer funded benefits of any kind should at least be expected to prove that they are who they say they are and that they are in the country legally. That goes for medical providers who bill Medicare and Medicaid as well. Maybe it would help us to mitigate some of the fraud that many of these programs are riddled with. Even the 9/11 Commission recommended it. It’s worth a try in my opinion.

Guest
Jun 25, 2011

Mike,

I don’t have an anti-business axe to grind, and I have not read those two books you mention. However, I do have an anti-Big-business axe to grind, and if you go back to Jefferson, Justice Brandeis, President Truman, etc., you can see that we have been digging ourselves into this particular hole for a very long time. Bigness is not good for the people and is not conducive to competition and is a threat to both freedom and liberty. Bigness is causing concentration of wealth, and power, into the hands of a very small fraction of people, and increasing misery for the rest.
The dreaded transformation of corporations into a special kind of aristocracy has come to pass in our times. We have now reached a point where we accept that big business is lobbying and paying politicians and swaying policy any which way it wants with no outrage at all. Justice Brandeis would be appalled if he were alive today, and so am I.
And Big business is not paying their fair share in taxation any more than those poor people who are supposed to pull themselves up by their bootstraps. And, like President Truman, I don’t really care that when reaching middle age, the captains of Big business, who pillaged and abused the resources this country freely gave them, including human ones, are building libraries or establishing charitable funds. It’s not good enough.

As to Medicare and Medicaid, I couldn’t agree with you more when you point out the excesses in over-treatment, fraud and abuse. Those must be addressed, and since I have children too, I have no desire to leave them a mountain of bills and a damaged Democracy as inheritance.
I believe we can cut a lot of expenses in these programs and even more in the private insurance programs without resorting to policing people’s refrigerators and dinner plates.

We don’t need to tax bread crumbs and oil, or chicken tenders. We need to stop subsidizing corn and sugar and wheat and tobacco, and we need to subsidize healthy foods and subsidize small businesses that bring those healthy, locally grown healthy foods to those who need them most. Health care, more so than medical care, is indeed local. We need thousands of local and small solutions, and small businesses are much better suited to do that than the giant feeding corporations who got us where are now.

Guest
Jun 25, 2011

I think you hit it on the head. Having been part of a very large oligopoly, it does bring with it considerable advantages due to size. In a Darwinian landscape, only the large survive and I also believe that is ultimately not good for the consumer.

I also agree that the subsidies for corn, sugar etc are a root cause and that the food industry has been amazingly excused from this national health debate. When I was CEO of my firm, I almost had a mutiny on my hands when I switched all the subsidized food in the cafeteria. Fried foods got a fat tax and greens and healthy foods received huge subsidies. Vending machines changed and rewards for healthy behavior through a credit based self-administered system along with credits received for engaging in certain preventive programs helped bring our medical costs down considerably. I was not popular but hamburger consumption dropped considerably while consumption of heart healthy foods and snacks increased. It starts at home, in the C Suite and in government.

If the GOP want Chris Christie to run for office, he better lose a few lbs…

Guest
Jun 25, 2011

…and to use the Peter Falk adage of “one more thing”, don’t you find it ironic that Walmart who brought Twinkies and other packaged sugary fat, to every village and every hamlet, is now a health care provider, bringing cheap care to the same people it made sick?

Guest
Nate Ogden
Jun 25, 2011

no ax to grind? I was eating twinkies decades before I ever step foot into a Wal Mart. To claim Wal Mart made people sick is a joke, the school cafteria has about 50 year head start on them.

Guest
Nate Ogden
Jun 25, 2011

I remember doing 2-3 churros a day at lunch in S CA which was a good 10 years before I ever saw the inside of a wal mart. Pizza and Taco’s with white sauce(poor mans watered down ranch) picked that up in High School in Vegas before Wal Mart even sold groceries.

Guest
rbaer
Jun 25, 2011

Margalit, Barry,

I agree with a lot of your suggestions – the corn subsidies for instance have to go – but you both seem to argue: I feel strongly about B (healthy food subsidies, stop of corn subsidies, increasing availabilitiy for healthy food and exercise) THEREFORE I don’t like A. It may be that a multimodal approach works best. Healthy lifestyle implies also a cultural change, and don’t get me started about the fact that we are a sedentary keyboard- and car society, much more so than all other industrialized countries, and that we should try to start changing that.

However, that does not contradict that personal responsibility is not important and that health status based incentives may not work. And I believe that this was one of the main thoughts of the OP.

“I can also understand that most of the morbidly obese especially cannot lose weight and keep it off to any significant degree through diet and exercise no matter how hard they try. This is why bariatric surgery is increasingly popular among this population. Poor people often don’t have safe places to exercise.”

I want to comment that exactly this attitude (it’s only the society’s fault) fosters a procedure that is – at least for some – very unhealthy and for a small minority lethal/crippling. I am not sure that we will ever have good numbers re. long term outcome, as observation periods need to be long and randomization is not possible.
Moreover, while obesity is associated with poverty, it is by no means a problem of the poor only. There are enough middle class people who are obese, at least in the midwest where I reside.

Guest
Jun 25, 2011

rbaer, I do agree that obesity is a problem that cuts across financial classes (I live in the midwest too), but here is the problem I see. We stack the deck against people with weight problems and then ask them to be better than thou. You wouldn’t treat heroin addiction by placing the addict in the midst of a shop selling heroin for pennies, strategically placing little vials everywhere he may go and constantly showing him happy and sunny adds of beautiful people shooting up.
Yet this exactly what we do with unhealthy food. We are all exposed to a constant barrage of clever advertising for the unhealthiest fare, practically from birth, we have candy and sodas strategically placed at checkout counters even in sporting goods stores and gyms, you cannot watch more than 15 minutes of TV without seeing some blond skinny kid wolfing down a big Mac, can’t drive more than 20 miles without a billboard showing a larger than life ice cream cone or “refreshing” soda can, etc. etc. etc.
We cannot do anything to curb this perverse and constant messaging because it would infringe on big business right to free speech. The solution? Punish the individual who should know better. Heck, make them all go get bariatric surgery, but keep Big business rights intact….
If you don’t want to exclude A in favor of B, then how about not excluding C (cut this insane and blatantly false advertising down) either?

Guest
DeterminedMD
Jun 25, 2011

Was just checking at another thread and saw this one had 21 comments in just one day, so offer this that I have not read above yet:

“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.”

Isn’t it just pathetic we are so dumbed down and insensitive that shame and pain do not impact on people’s choices and behaviors these days. I think a sizeable factor is this very medium we are commenting on, as not having the one to one interaction, the face to face discussion just minimizes acceptance of consequences. And we have political representation that just reinforces this erroneous mentality, as our politicians truly reflect what we are as a culture: entitled, selfish, and devoid of responsibility for poor actions and choices.

Oh, and as I said before, we live too long as a collective culture. Sorry, there is no reasonable and fair rebuttal to why we should live to be in our 80’s onward in sizeable numbers when the majority are destructively dependent in the end.

Yes, I see the 800 pound gorilla, wave to it and keep my distance while respecting it’s presence and potential!