The Affordable Care Act and the Death of Personal Responsibility

The Affordable Care Act and the Death of Personal Responsibility

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I was a chubby kid, which brought with it all manner of slights, both real and imagined.  My predicament was worsened because I came from an immigrant family, and my father was tormented by unrelenting and untreated bipolar disease.  When he was lucid, however, he taught essential lessons that neither he nor I knew at the time would become my life’s cornerstone: don’t trust the professions too much; advance your own cause through limitless learning; and, use exercise — all forms of it — as an irreplaceable lever for personal betterment.  My dad may have been out of it more often than not, but he swam, did calisthenics, played tennis, and boxed, and he walked vigorously right up until the end of his life.  I saw, I learned, I did (and still do).

Imagine, then, my chagrin at how the Affordable Care Act (ACA) effectively shears away the concept of personal responsibility and mastery of lifelong wellness skills  from the pursuit of actual health.  It was a huge missed opportunity to teach Americans about what’s first in the line of responsibility for good health.

Instead, the ACA’s philosophical foundation ignores the power that individuals have to impact their personal health trajectory, and it compels Americans to accept lifelong roles as patients in a system that many of them not only don’t want any part of but that they distrust and don’t understand.  It is exactly the opposite result that something called “health” reform should have produced.

The ACA’s obtunded vision of wellness is especially problematic.  The ACA seeks wellness through sickness by facilitating, for example, employer-sponsored intrusion into people’s health lives — particularly through the clinically meaningless and hopelessly cost-ineffective twins of health risk appraisals and biometrics, which literally create illness by over-diagnosing people with things that they don’t have.  This is both daring and appalling: turn more people into patients by convincing them that in order to become well they must first become sick, even though what they suffer from most are things that more medical care cannot fix: economic dislocation, fractured families, and jobs they hate.  That we are not the only Western society dealing with this issue is small comfort.

The AMA’s recent categorization of obesity as a disease is an aiding and abetting of the ACA’s sleight of hand.  Telling obese people that  they’re now all sick (even though many are healthier than their normal weight peers is inviting people who deserve better into a medical Twilight Zone.  It is a judgment that supports the ACA’s impetus to treat people like Pavlov’s dogs, hoping to induce behavior change through highly coercive incentives instead of through greater autonomy and mastery of essential lifelong health promotion skills.  The former cements authority-subject relationships while the latter builds self-respect and independence and reshapes the patient-provider context to create an environment in which interactions can be more limited and bounded by clear, understandable, and achievable expectations.


We have set ourselves up for a long-term worsening of health status by not framing health reform primarily in the context of how people can keep themselves from becoming patients.  By positioning the health care system as prescient and omniscient, we invite its eventual undoing because it cannot conceivably solve for us all the problems it has been tasked with at emotional and fiscal prices that we can afford.  It is like prescribing an antidepressant to someone whose life has left the rails.

I, for one, am not waiting for Washington to awaken.  As my father passed along vital health lessons to me, I am repeating the process with my son, now 9.  His preternatural devotion to learning and exercise is already obvious in academic performance, his persistently happy demeanor, and his asthma control.  In fact, his fitness has improved so much over the past two years that his medication usage is down by 75%, and he has not had a physician visit for asthma in three years.

Ivan Illich, the radical Catholic priest who wrote Medical Nemesis, really was prescient, as the ACA actually animates his prophetic vision of the rise of a medical state that diminishes and injures individuals in pursuit of its own enrichment and empowerment.  Who would have ever believed that almost four decades after publication of Nemesis, another radical, Barack Obama, would be the one to breathe life into Illich’s medical demon?

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

Vik thanks his friend and colleague, Al Lewis, for his very helpful comments on, and contributions to, the development of this post.

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126 Comments on "The Affordable Care Act and the Death of Personal Responsibility"


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Mia
Jan 24, 2014

For those of us that take care of our health, there will be no changes. But just because there is an ACA does not mean that these people will stop. There will always be that junk food junky with bad bones and high cholesterol, the over salter with hypertension, but there is also Aunt Judy with RA and HTN that does all that she can to be healthy but it doesn’t work, nor can she afford to go to the doctor.

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social determinates of health
Dec 11, 2013

This post and his responses clearly indicate the need for the ACA – since he probably developed his obesity in respond to the stress of his Father untreated mental illness as the result of not having any coverage..

In fact it is hard to see any logic in his argument since he lacked health insurance and still got fat therefore it would seem to indicate that it was the lack of health insurnace as a child that lead to either his obesity or his lack of control?

Most research shows that adverse childhood events have a dirct link to adult health problems.. But I guess if we just hold kids accountable for being born into poor neighborhoods with mentally ill parents we could prevent that?

Clearly the editorial board needs to review this type of post

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Al
Oct 7, 2013

Aquifer writes: “you are the one to deny “liberty” – how can one be free when one has no access to health care?”

I won’t even comment on this as it is so foolish it speaks for itself. You would probably be happier in a fascist state where liberty is compromised, but the government says it will take care of your needs.

You mixed up two different arguments when you added the dumping of toxins to your liberty argument. You will have to live within your state of confusion. At this point you can no longer be taken seriously. Bye.

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Aquifer
Oct 7, 2013

Ah yes – nothing like complaining about mixing up arguments from someone who apparently has only a one sided view of “freedom” –

That’s OK, Al – I’ll accept your concession :)

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Al
Oct 7, 2013

Aquifer writes: “Declaration of Independence -” right to life, liberty and the pursuit of happiness” – (funny, it doesn’t mention property – that’s John Locke you’re thinking of, not Thomas Jefferson) ”

Once again you seem to have a problem. I placed property in parenthesis for exactly that reason. Jefferson replaced happiness with property.

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Aquifer
Oct 7, 2013

No, Jefferson replaced property with happiness ….

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Al
Oct 7, 2013

Aquifer writes: “Are you confused?”

No, but apparently you are.

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Aquifer
Oct 7, 2013

I wasn’t confused about where the replies go so why did you find it necessary to “change venues”?

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Al
Oct 7, 2013

Aquifer writes: “PS – and precisely how does the Constitution define “general Welfare?”

Simple, the powers granted to the federal government are delineated in the following articles. If the “general Welfare” clause was to open the doors for the federal government regulating everything there would have been no need to limit its responsibilities in the following articles.

Admittedly many people that wish the Constitution to be treated as toilet paper errantly turn to that clause, but really don’t understand its meaning. Politics seems to trump the Constitution. If one wished the federal scope to be broadened there is always the Constitutional Amendment which would be totally unnecessary if one thought the general welfare clause meant one could do whatever they wanted.

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Aquifer
Oct 7, 2013

The Fed’l gov’t has the power to promote the General Welfare … There are 2 main principles of construction used in construing laws 1) whatever is not forbidden is allowed 2) whatever is not allowed is forbidden – you appear to adhere to the later, but where does it say that the “the general Welfare” is limited to whatever you claim it is? That is your construction – but you are not on the SC and they are the ones who “construe” ….

A Scalia fan? Hey, you like Thomas, too?

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Al
Oct 7, 2013

Aquifer writes: “Ah so it’s a one way street, you have no objection to my limiting my liberty to safeguard yours, but you have no intention of returning the favor …”

You create straw-men where none should exist. I want you to have the same choice with regard to your liberty as I have with regard to mine. You are the one willing to deny liberty to another.

How can mandating an obligation to another promote liberty?

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Aquifer
Oct 7, 2013

Terrific! ISTM you are the one to deny “liberty” – how can one be free when one has no access to health care? I am the one who would restore that liberty …

Well, let’s see – mandating that you have an obligation to not dump toxins in my drinking water supply promotes my liberty to be free of toxins in my drinking water …

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Al Lewis
Oct 6, 2013

btw “Al” and “Al Lewis” are two different people

Guest
Oct 5, 2013

Al, you need to read closely. The choice of who runs is up to the parties and not the voting public. The public gets to choose between two candidates, maybe three, presented to them. The illusion when we vote one way or the other is that we’ve “chosen” and approve. It’s often a lot like your father asking whether you want a public flogging or a couple of weeks shut in your room to atone for your misbehavior. Your choice would be neither but you have to make a choice…..Congratulations on being chosen to speak for the founders of the nation, by the way. Impressed.

Guest
Sep 22, 2013

Hot Off the press this morning, inequality by segmentation..yes look at the big 10 health apps funded, most of them sell data…so sounds like that’s what moves a VC to shell out money as they want a return, and see how the marketing now is reflecting this with the Penn State wellness program fail with wanting to assess a penalty, follow the data and the money and you have your answer…Look at their demo model, all about changing behavior whether you are a problem or not but the marketing to sell it judges everyone from the start as “being a problem” they want that data to sell like I have been saying it’s an epidemic and money is big when you see Walgreens pulling in billion a year selling data. I’ve only been pointing all of this out for about 4 years now.

http://ducknetweb.blogspot.com/2013/09/10-biggest-mobile-health-investments.html

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ljj2
Aug 22, 2013

Al-

You are absolutely correct suggesting that if we value individual freedoms then the government should not impose obligations on free people period.

This present government is tampering with the Constitution by virtue of imposing the ACA because as Vik Khanna pointed out that the act removes the concept of personal responsibility by imposing lifelong rules in a system many do not want, or refuse to be a part of..

~ljj2

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Aquifer
Aug 22, 2013

We are the government ….

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Al
Aug 24, 2013

Thanks, ljj2.

@Aquifer: “we are the government…”

Why do you say that? Because the government is elected? Were you part of any of those nasty governments that were duly elected by the people. Do you think the people of Egypt are the government? How about the Copt’s of Egypt?

We are the government is truer when the government doesn’t impose obligations on people. The Constitution imposed a specified list of obligations and suddenly you take the preamble and add that to the list. I don’t follow your logic or your understanding of history or individual freedom.

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Aquifer
Oct 5, 2013

The government we have, for better or worse, was placed there as a result of decisions we made at the polls – if we don’t like the results of those decisions, we can make others …

Can’t speak for Egyptians, can you?

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Aquifer
Oct 7, 2013

Al,

Are you confused?

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Al
Oct 7, 2013

Comments at end of the blog to prevent confusion.

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Aquifer
Oct 7, 2013

Al,

PS – and precisely how does the Constitution define “general Welfare”? Somehow i didn’t notice a delimiting list …. and so you think that Medicare is “unconstitutional”?

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Aquifer
Oct 7, 2013

Al,

Ah so it’s a one way street, you have no objection to my limiting my liberty to safeguard yours, but you have no intention of returning the favor …

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Al
Oct 6, 2013

I didn’t forget the Bill of Rights, but based upon your rhetoric I thought you had.

How one interprets the Constitution is based upon one’s personal philosophy, but if the federal government was truly provided the right to do all those things then there would have been no need to delineate the powers of the federal government and there would have been no need to set up a system for Constitutional Amendments.

I have no objections to you giving up your liberty as long as it doesn’t affect mine.

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Aquifer
Oct 6, 2013

No, i don’t believe that 51% of the population can vote to enslave 49% – even if they wanted to, or have you forgotten the Bill of Rights and the courts – some wry for your pastrami …

Art 1, Sec, 8 – “The Congress shall have power to lay and collect taxes …. to ….provide for the ….general Welfare of the United States ….”

So who decides what is meant by “general Welfare”? Medicare has passed muster for decades, expanding it for all would make it even more “general” ….

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Al
Oct 6, 2013

@Aquifer: “Baloney! Sorry but that is the most appropriate response to your first sentence ”

Pastrami. I can’t help the way you express yourself so I will repeat what I said. “It appears that you believe 51% of the people should be permitted to enslave 49% if it occurs at the polls.”

“But they also said, Art 1, Sec 8, that …”

Then they went on to specifically delineate those things that were responsibilities of the federal government. I suggest you read a bit further and a bit deeper.

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Aquifer
Oct 5, 2013

Kay –
It is because too many believe what you appear to believe that we are in the fix we are in – convinced that “TINA” to the duopoly because you have been told so, by whom, pray tell? There are other choices at the polls, choices that support the positions and programs that a majority of people support in poll after poll – but these positions are held by 3rd parties that folks have been brainwashed into believing “can’t win”. So they vote only for those who they have been told “can”. What a self fulfilling prophecy! Anyone who meets the legal qualifications for office and is on the ballot can win if enough people vote for him/her – that is a simple fact … Yes we have non-corp candidates on the ballot available to be chosen – why don’t you choose them?

Al,
Baloney! Sorry but that is the most appropriate response to your first sentence …

Well the founders also thought, apparently, that human bondage was legal and that slaves were 3/5 of a person. So they weren’t batting a thousand … But they also said, Art 1, Sec 8, that ” ,,,Congress shall have the power to lay and collect taxes …” Is that your definition of “slavery” – being taxed to support the “general Welfare” ? Which sections of the Const. do you pick and choose to emphasize?

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Al
Oct 5, 2013

It appears that you believe 51% of the people should be permitted to enslave 49% if it occurs at the polls.

I think that is foolish thought and so did the founders of our nation.

Guest
Oct 5, 2013

This discussion has strayed into the very odd……AQUIFER: Suggest you give up the illusion held by a great majority of this country.: “…decisions we have made at the polls” is the great lie. The rich produce two or three candidates and advertise/support them. They are not often the choice of the majority of the populace, left to choose between the lesser of two evils. Cannot be candidate without money or pledging puppethood to those with money and power.

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LJwalden2
Aug 4, 2013

Jon-

I agree an important discussion point would be to primarily you ask her what her concerns are about her health during that vista. I never meant to infer that I would assume anything beyond that, and b-r-i-e-f-l-y let her know her VS and weight, BMI, and actively listen when she speaks. Otherwise, she would follow-up on an as-needed basis. Great discussion, I encourage other readers to chime in~ LJ

Guest
Aug 4, 2013

LJ – If it is true that you really want to not “assume anything” – I would suggest not bringing up her weight unless she does and I would certainly not talk about her BMI – really invalid, misleading, unscientific marker for health – She already knows she is fatter than what our culture says she should be and you really have nothing to offer her in those regards anyway – if she does bring up her weight you can talk to her about the lack of efficacy of weight loss programs and introduce the concept of health-centered approaches to improving health – which is why it would be great for you to learn about Health At Every Size – Jon

Guest
Aug 4, 2013

Hi LJ – Think about it for a minute – do you really believe that this person – we will call her Dawn – needs you to tell her that she may be struggling with her weight or that she may weigh more than is healthy for her? Is there any scientific evidence that “confronting” her about her weight as advocated by Chris would possibly have a positive outcome? Do you or Chris or anyone else you know have any weight loss intervention you could offer her that has any evidence base in terms of efficacy – long term I am talking? Not in your hopes and dreams and desires, but in scientific reality? Of course, you know that the answer to all of these questions is a resounding no! So, where does that leave you? How about you ask her what her concerns are about her health, instead of assuming you know what they are and really listen when she is talking – If she is really, as you say, having her husband go out for her three times a day and always bring back the same thing – and, by the way, I am doubting that you are seeing more and more of this kind of behavior – it sounds pretty extreme to me – but lets just say this is what she is doing – do you really think that telling her this is unhealthy and trying to give her an exercise prescription or an eating plan is going to begin to even touch what may be going on here? How many of both of these do you think she has been given over the last decade or two? Truth is, you are at a grave disadvantage trying to even touch this issue (disease label or no) – if you have the 7-11 typical physician minutes with this or any other patient – the best you can do is try to establish a therapeutic relationship – the worst is hound her about her weight – Ask her – listen to her – suspend your judgement – see if you can get a sense of what is really going on – and then listen to her and she will tell you what she needs I know this may seem impossible in the ridiculously short time you are allotted – but given that our prime directive is first, do no harm, it is the only thing that makes sense. – I would suggest searching out and exploring Health at Every Size – glad to send you materials if you would like – Jon