What About Personal Responsibility?

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.

76 replies »

  1. 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!

  2. 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.

  3. 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?

  4. “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.

  5. “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.

  6. 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.

  7. People should buy the care they value. The government should not rob me to pay for your healthcare for the benefit of Anthony Weiner.

  8. 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.

  9. 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?

  10. 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.

    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.

  11. “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.

  12. “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.

  13. There is a huge difference between abandoning care for those with garden-variety chronic diseases as suggested by ‘MD as Hell’ and needlessly prolonging largely futile end-of-life care.

    Since when does this only apply to ‘liberals’ either? I always thought it was more a religious element to it that life should be prolonged as long as possible.

    So people should live less than 80 years? Should we institute a ‘Soylent Green’ program where we just have the state perform mandatory executions on those who reach 80 years of age? Ranting comments full of nonsense largely add little to the overall conservation.

  14. It is interpreted as callous and ridiculous because people in this country can’t handle reality, and unfortunately people in power are those with the least grasp on it!!!

    MD as HELL is one of the few people besides me with the guts and persistence to call it as it is. We can’t save and maintain lives that are not meant to be prolonged. And what I can’t stand are the family members who are trying to appease their guilt and shame by not asking, but demanding fullcourt presses to prolong a parent’s or grandparent’s life because the kids or grandkids have had their profound revelation that the person in the bed is dying and they did not spend enough quality time to now to be in good graces with someone.

    And don’t tell me I am off base in this interpretation, I have seen it since medical school to now, and it is pathetic to keep someone else alive to satisfy a third party’s conscience. If you sad sack liberal do gooders can’t understand the absurdity to this twisted logic, then you deserve the representation in your states and DC who are going to start cutting back end of life interventions anyway if Obamination Care survives the efforts to terminate it.

    Having politicians allegedly solve health care problems without letting the participants have a prominent say in the process is ridiculous in expecting positive and responsible results. And as I have said before, I am not looking to conservatives for answers either, as they are just the opposite polar extremes in poor ideation as well.

    Face it, people are not meant to live 8 or more decades of life, or your culture will be negatively impacted by having a sizeable percentage of dependent citizens to be cared for. Ask Japan if I am so off base!!!

  15. 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/

  16. This is one of the more callous and completely ridiculous things I have seen posted on here. You wouldn’t have a viable workforce if you followed this absurd advise.

  17. 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.

  18. 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.

  19. “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.

  20. I wish to reiterate: Public health approaches do the most good, for the most people, for the least amount of money. Therefore, the USA spends the least time and effort on public health. Go figure.

  21. Soda pop is acid and sugar. The acid gives indigestion, the sugar gives obesity, and all the stuff that comes with it. A bottle of the stuff once or twice a week won’t hurt you, but many of my patients drink it as their main source of liquid. This is bad. We as a society need to discourage this, as it costs us a ton. Think how much insurance companies could save in claims if their customers took better care of themselves. While it is true that I have no love for insurance companies, if their customers are healthier, I am happier.

    Moderation in all things. We need to get back to this.

  22. At my supermarket:

    1 lb of tomatoes – $2.99
    1 red pepper – $1.50
    1 lb grapes – $2.99
    1 lb of blueberries – $7.00
    1 lb strawberries – $4.99
    1 loaf whole grain bread – $3.50

    Cut it in half…. subsidize local farmers that grow healthy fresh food. Maybe if tomatoes didn’t travel 2000 miles and tasted like rubber and were cheap, people will eat more of them on their own accord…..

  23. What is wrong with singling out soda pop?

    What makes soda pop unhealthy? Are you taxing any carbinated beverage or just those high in sugar? If your going to tax them are you going to outlaw home brewing now? Is soda unhealthy or is drinking to much soda unhealthy? Can I avoid the tax buying my soda from the indian smoke shop? Do you tax manufacture or sale? What are you going to do about the black market?

  24. @Barry,

    What is wrong with singling out soda pop? That would be a good place to start. Add chips, Twinkies, cookies, ice cream, and Hot Pockets as well. I love them all, but should have to pay more for them. Make fresh fruits and veggies dirt cheap. This is not too difficult to figure out. Yes, they taste great. But too much of them is bad for you.

  25. “Not with a bar code system. We’ve never tried it so how do we know.”

    Peter –

    What do we tax – calories, fat grams, cholesterol, sodium, sugar? How do we define what constitutes a serving of most foods and do we apply the tax to that? Even a healthy diet needs a certain level of all of those. Taxes on cigarettes and gasoline are a piece of cake by comparison. If there were a fair way to design a tax on unhealthy food that didn’t single out one type like soda, we would have done it a long time ago lobbying notwithstanding. I agree about getting rid of the subsidies for unhealthy food production but the farm lobby has always been powerful despite the significant decline in the number of farms and farmers over the last 50 or 60 years.

  26. rbaer,
    It is insane to prop up people with chronic illness. You end up with a chronically ill country. The demise of America will be due to it’s lack of future vision. Sick people are not the future. They lived their lives and now it is time to move on.

    I see a different set of problems. As far as the country is concerned the chronicaly ill are baggage. There is no profit, except politically, in funding care. They should fund their own care. People die, doc. Going broke denying it is not the mark of a great country. No one is saying push them aside. But no one should be borrowing for their care, either. They won’t borrow on their own. No one would loan them the money.

  27. “I agree that a tax on unhealthy food would be extremely difficult to design and implement.”

    Not with a bar code system. We’ve never tried it so how do we know. Of course the fast food and soft drink industry will lobby intensely to stop it – they’d rather see us fat and diabetic so they can get rich. By the way, why do we spend all that enforcement money trying to stop people using illegal drugs – seems we’re trying to change peoples’ bad habits?

    “the corn subsidies for instance have to go”

    Absolutely the first thing that should be done, then transfer them to fresh fruits and vegetables. Interesting that we don’t tax poor eating habits but we subsidize bad ones.

  28. Oh the New York TImes, ya they do engage in way to much demagoguery for a news organization.

  29. ” (guess who killed that with full scale demagoguery?).”

    Who would that be rbaer? What exactly was it they killed? Not like the bill was ever dicussed and open for debate, not like Obama ever sat down with anyone to discuss different parts of the bill and work through it with them, what was it that was killed and who did it?

  30. Hell MD,
    politics is about incentives and regulation – to equate it with slavery is asinine, unless you want a mixture of anarchy and plutocracy (and that seems to be what a lot of libertarians want). I have to assume that you believe that the invisible hand of market forces, in combination with liberty, will guarantee optimal outcomes for all our problems, which is ideologybased as naivete at its best.

    It’s funny that you work in an ER and are unable to realize that the US will face a spectacularly rapid decline – as soon as our streets will be filled with collapsing type 2 diabetics and people with various drug addictions, and as soon as the US GDP is spent entirely for angoplasties and drones, you will see that a dysfunctional society cannot keep up with the rest of the world, and capital and bright minds will mainly go to parts of Asia and Europe.

    Determined, you are right that many people in the US, maybe even a majority, have a problem accepting death, and unrealistic expectations both re. medical care and re the question who is paying for this medical care.
    Actually, Obama made some tepid but reasonable attempts to improve end of life care in his “garbage legislation” (guess who killed that with full scale demagoguery?). Does your emphasis on human mortaility suggest that you think that all medical insurance is useless, or even – gasp – all medical care? In that case, I am sorry for you that you chose the wrong profession.

  31. Here’s the link that sums it up for me re entitlement and sheer audacity of expectation by our allegedly more functioning elderly:


    Again, if everyone, irregardless of true need or not, expects a full court press for health care interventions for terminally ill conditions, where does that lead the other 75% of our culture?

    Resentment is not a healthy attitude, would you agree!? And yet, do the boomers get this? No, as a group, they dismiss the concept as someone else’s problem. Yeah, keep up that attitude once the majority reaches their mid 70’s!!!

  32. As a nation, we actively subsidize billions of dollars worth of sodas, junk foods, etc. with SNAP (food stamps). Yet, ever effort to restrict the program to healthier food choices has met a lonely death. We have decided that taxpayer subsidized twinkees are now a fundamental right. Then we wonder why our poor are becoming morbidly obese…

  33. Haldol only has the potential to work on those who are psychotic and a sizeable portion is due to a chemical imbalance of dopamine, serotonin, and most likely some other neurotransmitters. What goes on in the halls of Congress, the White House, and their rabid faithful in the 50 states that cheer this garbage legislation on is just personaity disorders and sheer clueless faith and hope focused on these alleged leaders words, not attentive to the deeds. So, drugs won’t make a difference, even though their grasp of reality is tenuous at best.

    I sincerely believe there are those who comment here regularly who have probably one of three agendas in endlessly claiming helping others to live longer is “the right thing to do”:
    1. Absurd and ungrounded faith that people can live beyond their genetic potential, because death is unacceptable to face in these alleged times of technology defying the boundaries of life. Or,
    2. Keeping people dependent on medications, machines, and the endless visits to health care providers who will have become beholden to politicians is just the ultimate control grab by said “leaders”. Or,
    3. Unaccepting of accountability for actions and choices does not have consequences as there are always others who will figuratively, or sometimes quite literally jump in and “save the day”.
    Or, combinations of the above.

    People can’t handle the fact that “people die”. My daughter went to the funeral of one of her classmates who died of cancer recently, and it was tragic, painful, and sad. But, as unfair and unfortunate as this loss was, it happened, it will happen again tomorrow in other peoples’ lives here in America and across the world, and we can’t change those truths.

    You as a society will never contain health care cost if we can’t let people finish their lives as life intended. And I bet you will read rebuttals and attacks that in the end are not grounded in the reality I live in.

    The question I propose to readers at this site who are objective and unbiased, do you want to live in the alleged reality these people champion for? Good luck if you do!

  34. Tax and subsidize is only one mechanism. The ultimate goal is to treat preventable diseases and bad lifestyles as a public health problem, which they are. There are other ways and means. We need to invest more in our public health system and disease prevention to maximize our return. People live longer, healthier, happier, more productive lives, then die quickly when they do finally die. That is the Holy Grail of medicine. We won’t get there without public health and disease prevention.

  35. Most of you need a strong dose of Haldol. You are totally out to lunch, healthy or otherwise, if you think anything changes behavior except money. Go ahead and tax junk food. There will be junkfoodstamps for the poor people who can’t afford the twinkie tax. Wouldn’t be fair for them to be deprived of twinkies.

    Therein is the problem: Which problem is the problem? It depends on your point of view. It definitely cannot be a moral question. Congress is incapable of legislating based on morality.

    The best way to cut the cost of healthcare is to stop paying for it. It would be much more useful to start forming a list of things you will not buy with public money. My personal favorite is feeding tubes in nursing home patients. They should be illegal and well as unfunded. Dialysis for cocaine addicts on disability are another easy for me to cut line item. If you are cocaine positive you are not on dialysis anymore. Scooters and lift-chairs also come to mnd.

    Eliminate all prescription drug coverage with a monthly cost over $50. There are a lot of great drugs no longer used because of some perceived advantage of the new and improved agent.

    I frankly believe in evolution. Was Darwin a liberal or a conservative? Doesn’t matter. What matters in getting out of the way of evolution.

    You cannot change another’s behavior unless you own him. What is your next move after “incentives” fail? Slavery is right around the corner. Or is it collectiveism?

    The only thing you can do is change what government will do. Cap the budget for healthcare expenses. The unfunded mandate goes away. The “social contract” never was real. It is a political apperition. You cannot have a contract with people that ignored the original one (The Constitution) in the first place. Direct benefits subject to the winds of politics were never intended as part of the Constitution.

    Face facts. People die. To imply you can help people live longer by making choices on their behalf demeans the life of everyone, including the annointed decider,

  36. tax and subsidize is all government, I sooner see them out of it all together. How do you subsidize the farmer to grow corn but not hi frutose corn syrup? How do you stop the politicians from raiding the vegitable subsidy when the unions want a pension bump? I think its failed government subsidizing and taxing that created most of these problems in the first place. Why do so many people live in big cities with no land so they can’t grow any of their own food?

  37. @Nate

    True, true. Thus, we tax the junk food and subsidize the healthy food. We use a carrot and stick approach, with emphasis on carrot. Same thing can be said for cigarettes, exercise equipment, parks, cross-country ski trails, etc.

  38. “What we need is quick and easy access to healthy food,”

    I would like to see this put to a social test. In every government building doctors office, and school lets put out a basket of candy bars and junk food then next to it a basket of fruit and vegitables and see once and for all if it is really an access issue. I guarantee people will choose the junk food, this is America we do not have any access problems to healthy food, we have a lack of desire for healthy food.

  39. I disagree with Mr. Flower on principle. Yes, personal responsibility does exist. If you do bad things to your body, you should pay the consequences.

    As a matter of public policy, though, I am opposed to the nanny state. We could do much more going with public health than we could with penalizing people. We need to overhaul our food distribution system. We need to integrate healthy lifestyle education into our schools. For those of us in sedentary jobs (ahem), we should have treadmill desks to work at.

    Currently, we have quick and easy access to junk food, no activity, and acute disease management. What we need is quick and easy access to healthy food, lot of exercise and disease prevention. I try to incorporate as much of this as I can into my life and my medical practice. Professionally, I am penalized with more red tape when I try to access the good services for my patients. It’s a shame I can someone’s hospitalization, surgery, chemotherapy, labs, imaging, and palliation paid for lung cancer; but I cannot get $300 for stop-smoking pills.

    People are responsible for their own actions, but we need to make bad choices harder and good choices easier.

  40. Agree with the three points. “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.” and I would add a good system design which was alluded to in point four. People, whether regarding health or finances, are not as rational as we think.


    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
    (available in hardcover, Kindle, and iPad / iBooks)
    Website: http://www.davisliumd.com
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  41. ” I can educate them about exercise, but the neighborhood is too dangerous for a walk or run in the park.”

    Talking group demographics not every individual of course but how do they make it down to the corner store for cigerettes or beer or down to the fast food joint for their unhealthy meals society supposedly forces upon them? Running the stairs is great exercise as well. These same people don’t seem to have saftey problems when it is something they want versus something they should do but don’t. Groups of them walking the neighboorhood would probably help improve the saftey as well.

    ” I can teach them healthy food choices, but healthy foods are expensive”

    Water is free compared to what they pay for soda, this is just not true, healtnhy foods are available and they are just as cheap or cheaper then junk.

    “. I can schedule them to see the health care practitioner at the free clinic, but if they don’t have transportation they miss appointments.”

    Again when it is something they want they seem more then capable of making it, it might not be as easy as jumping in their car and driving there but again its just an excuse.

    Bigitry of low expectations, we continue to excuse 90% for the true problems of 10%

  42. Comments: In response to Barry Carol June 25 @ 6:15
    I have to agree that financial incentives for healthy behavior work for middle and upper class insured individuals. I am a middle class American who works 40 plus hours per week and is covered by a primary and secondary insurance. I have every tool available to make responsible choices. But what about the poor and uninsured?
    I am not an economist, but I do volunteer as a nurse at an urban community center. Health screening and education is a large part of what I do. I can educate them about exercise, but the neighborhood is too dangerous for a walk or run in the park. I can teach them healthy food choices, but healthy foods are expensive and the food pantry passes out macaroni & cheese, canned goods, and salt cured meat. I can schedule them to see the health care practitioner at the free clinic, but if they don’t have transportation they miss appointments. If they do show up, they can’t afford to comply with the treatment plan and medications. I can give them written education material at a low grade level with resources to access care they need, but due to low education level they lack the ability to navigate the complex public health system. A few of the people I see at the center are reaping what they have sown, but most are reaping what others have sown………….

  43. 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.





  44. Margalit and Mike –

    I think there are quite a few businesses in the modern economy that have to be big in order to be economic. I’m thinking of auto and aircraft manufacturing, electric utilities, railroads and airlines, drugs and devices just to name a few. The increasing importance of technology and scale in the financial services industry helped to drive consolidation there. The capital markets need to be big and deep to adequately serve the large, multi-national businesses of today. Smaller businesses are still served mainly by banks, including community banks, many of which are struggling under the weight of soured commercial real estate loans.

    Margalit mentioned Wal-Mart but there are 35,000 supermarkets nationwide and thousands of convenience stores all of which sell unhealthy food. People can choose not to buy it except in inner cities where healthy foods may be either scarce or unaffordable or both. The big box retailers in a variety of categories brought lower prices on a wide array of goods thanks to economies of scale, and, in Wal-Mart’s case, an unmatched distribution system. I don’t think most people would be willing to give that up even if they could despite a few bad actors here and there from time to time. The bottom line in the business world is that if you don’t satisfy enough customers enough of the time, eventually you won’t have any customers. I wish the same were true of government but it isn’t.

  45. 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…

  46. 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.

  47. 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.

  48. 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

  49. “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

  50. An important concept is the high variability in latitude that people have in making personal healthy choices according to context- mostly Socio-Economic Status (SES). The higher the SES the greater the capacity to make healthy choices in life.

  51. 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?

  52. 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!

  53. 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.

  54. …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?

  55. 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.

  56. 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.

  57. “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.


  58. 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.

  59. 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.

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

  61. 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.

  62. 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.

  63. 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.


  64. 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.

  65. 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

  66. 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?

  67. 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.

  68. 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.

  69. 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).

  70. 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…

  71. …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….

  72. 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)
    -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.

  73. 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.”