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.