The Affordable Care Act and the Death of Personal Responsibility

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.

126 replies »

  1. 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.

  2. 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

  3. 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 🙂

  4. 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.

  5. 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?

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

  7. 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 …

  8. 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.

  9. 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.

  10. 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?

  11. 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) “that to secure these rights, governments are instituted among men” (women added later) “deriving their just powers from the consent of the governed” . So the gov’t is set up to secure these rights – The Const. was the document the founders set up to create the gov’t whose job it is “to secure these rights”…

    As for property – it deosn’t say the government can’t “take” it at all, but only after “due process” and just compensation” and the right to tax for “the general Welfare” is clearly stated …

    I suspect you would rather return to the Articles of Confederation when the Fed. Gov’t was considerably weaker ….

    One’s “personal and intellectual property” – how does one define that?
    Is “personal property” co-terminal with “private property”? Are you entitled, for example to “own” the only oasis in a desert?

    Should my child go without an X-Box because your child needs an operation? Yeah, i think so … What about you?

  12. 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”?

  13. 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 …

  14. “the gov’t is supposed to guarantee those rights ”

    No! The reason for the Constitution is to limit the federal government’s powers so that the people had the right to life, liberty and the pursuit of happiness (property) by being protected from government. You have things backwards.

    “Liberty is not unbounded” That is correct, but the federal government’s infringement upon its citizens was limited by the Constitution.

    Healthcare: Do you believe in property rights? Do you believe your personal and intellectual property is owned by another? None of us want to see a child go without health care, but it is a matter of trade offs. Should your child goes without because my child has a need? One has to be careful about creating obligations for others.

  15. 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.

  16. Al

    As citizens, presumably we are signed on to the concepts enshrined in the Dec of Independence and the Const – the right to life, liberty and the pursuit of happiness – and the gov’t is supposed to guarantee those rights – your right to liberty may well obligate me to act in certain ways that I might not wish to, and vice versa … Liberty is not unbounded …

    As for healthcare – apparently you don’t want to “give up your money” for anything other than your own desires –

    As for a “nose job” – is that medically necessary? If your kid had no nose, might you think it “necessary” for him to have one? Or would you rather send him to school without one? And if you had no money to get him one, would you not be glad that others were willing to “chip in” for it?

  17. 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” ….

  18. Aquifer: Demonstrate how you are promoting liberty by creating obligations on others.

    Example in healthcare: Tell me why one should have an obligation to give up money intended for his child’s well being in order to provide a nose job for another.

  19. @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.

  20. Al,

    So what is it you think i think of individual liberty? Can one have liberty of one has no access to healthcare because one cannot pay for it …

    One’s right to swing one’s arms ends where another’s nose begins – or is that right boundless in your universe ….

    Perhaps “fascist’ was a poor choice of words on my part, i will grant you that, at least …

  21. 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?

    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?

  22. 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.

  23. 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.

  24. Aquifer, do you know the basic ideas behind fascism? It doesn’t seem that way, but maybe you have a unique definition so I’ll leave it up to you to define your terms. The fascists of mid century past initially impressed Roosevelt. A few large businesses worked very closely with government and in many ways that is what Roosevelt was attempting to do.

    The Supreme Court actually permitted some abominable legislation to stand. Do you really believe that Congress should be able to regulate the production of wheat intended for personal use even though the wheat would not travel across state lines? The Supreme Court said yes. So if you decided to grow wheat in your back yard for your own use you want Congress to be able to regulate it?

    Maybe you call the SC fascists because they didn’t let FDR pack the court.

    You have said enough to let us know what you think of individual liberty. By the way the case I referred to was Wickard v Filburn. If you want another case find the one where the government decided that when you went to a butcher you didn’t have a right to pick out the chicken of your choice. That too was a SC decision.

  25. 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.

  26. 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?

  27. Al

    So, you are an expert on Constitutional interpretation? A strict or loose constructionist?

    Roosevelt was saddled with a SC much like ours – a bunch of pro business conservatives who felt it their duty to protect the sanctity of wealth from the scourge of democracy … They were the fascists ….

    My is=deas on healthcare? hardly mine – just solutions that most of the other developed countries have adopted and whose citizens fiercely defend – citizens who look upon the American system with disbelief – how can any civilized country base the provision of healthcare for its citizens on the ability to pay instead of on need?

  28. 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.


  29. 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.

  30. Aquifer,

    Collectivists like to interpret any passage of the Constitution in the fashion they feel fit and then complain about their decisions later. I don’t know if you are one or not, but many of the Green statements are. They are all too willing to impose obligations on others and not only that, but they don’t even know if what they wish to do will help or hurt. Your use of the preamble to the Constitution seems to indicate that you wish the Constitution to mean whatever you want at the time. Alternatively you may be unaware that you are picking out a sentence telling what the objectives are behind the limited specified federal actions that are permissible under the Constitution. If the founders had wished the document to actually mean what you think then there would have been no need for a listing of the duties that followed. Remember Constitution is for the federal government. Each State has its own Constitution and you can move to the state that best meets your needs

    Roosevelt’s new Bill of Rights were a collection of ideas that may have helped some people, but they were ideas that could not be guaranteed and levied heavy obligations upon other people. To enforce Roosevelt’s idea in this area we would have had to become more like the fascist nations of the time. You might be horrified at my use of that term, but remember Roosevelt wanted powers he was not entitled to and when he couldn’t get those powers legally he wanted to pack the Supreme Court, illegally. Sound familiar?

    Your ”I” and “we” is a little convoluted. What you really want is for party A to tell party B what to spend on party C. You also want to tell party C how to spend that resource. You don’t even have proof that your ideas in healthcare work. In fact the proof points in the other direction. I want you to feel good about yourself, but I want you to do it on your own dime, not on mine, or anyone else’s.

  31. Al,

    My response “Vote Green” was a simple reply to a “what do we do?” post. As i believe in single payer or Medicare for all, the only way to get that is by supporting pols who do – that’s the Greens …

    I would have said no more at that point, had you not responded with “laughter” …

    “Collectivist” – not sure what you mean by that, but if you mean the idea that we do have certain obligations re our fellows, is that what you object to? Does individual freedom obviate any mutual responsibility?

    Our entire culture, not just our technology, is moving in an “i” direction – and the irony is, the private, unaccountable, moneyed interests are gaining more and more control over our lives, all in the name of increasing our “individual freedom” –

    That is the tension – the Constitution was written to set up a stronger central component than the failed Articles of Confederation – the Bill of Rights to prevent a “tyranny of the majority” – but we seem to have forgotten the Preamble – “We the people, in order to form a more perfect Union, ….promote the general welfare ….”

    ISTM that the provision of healthcare is ground zero, in many ways, for the direction we go as a country – are we “a country” or just an aggregation of individuals whose sole concern is defending our “freedom” ? “Freedom “to do” or freedom “from”, as in Roosevelt’s 4 freedoms? Was Thatcher right that there is no such thing as “society”? If so, then there is no need to “organize” it, and if that is so, there is no need for a Constitution at all …

    You are right, this isn’t the place, perhaps, to discuss political theory – but i can think of no other area than healthcare where the tensions between “I” and “we”, between the “rights” and “responsibilities” of an individual in a Constitutional representative democracy are so sharply brought into focus …

    It is because, in some areas, I thought the responsibility of me as a part of “we” outweighed the rights of me as an “I” that i got into healthcare in the first place – I think we have gone too far in the “i” direction for too long … Where do other “healthcare providers” stand? What does the Hippocratic Oath really mean? what obligations does it impose?

    So do i want a totally collectivist society? No, the private sphere has its place, but IMO, that place is not everyplace – THAT is a discussion i think should be had everywhere, always. Private enterprise, “the market” is not coterminal with the “general welfare” …. There is a time and a place for “collectivist” action – anyone who insists on solely one or the other is not only missing the boat, but sinking it ….

    So, if I were solely promoting “collectivism”, i would be touting a purely socialist party – i promote Greens as a political choice because i don’t believe they are purely “collectivist”. Stein, a physician, described herself a “pragmatist” – you go with what works – though it may indeed work well in other areas, “the market” is not only a poor, but in many ways a counterproductive, model for the provision of healthcare, the “incentives” are all, IMO, in the wrong direction – THAT is a discussion I DO think we need to have on blogs such as this … That is a voice i bring here – if it is considered inappropriate, well what can i say – to me that is all the more reason to press on, in the belief that until it IS considered not only appropriate, but necessary, we will continue to flush ourselves down the drain …

    End of soapbox ….

  32. 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..


  33. I’m not on the list to discuss politics in general. Though I find many of the Green Party’s desires to be admirable, the words used and the underlying politics strike me as collectivist even though that type of society might be the furthest thing in the minds of many that support the Green Party. The idea of federalism and the Constitution as a limiting factor to government seems to have been lost. We saw what such promises led to in the 20th century.

    I think you should ask yourself the question whether or not you truly value individual freedom. When you impose obligations on free people that means you don’t. Also remember democracy is not a great form of government for democracy permits 51% of the population to enslave the other 40%. That is why we are a Constitutional Republic and that is why it is so dangerous to tamper with the Constitution.

  34. Al,

    Fair enough …

    I suppose you are aware there is considerably more to the GP than fuzzy tree hugging ….

    What do you find naive or unconstitutional?

  35. I wouldn’t go that far. Their platform is naive and lacks an understanding of the Constitution. As far as the environment goes everyone wants a clean environment and most love plants, animals and open spaces. But, people have a right to live and enjoy their lives something those that call themselves green frequently seem to abuse.

    So yes we have some agreement, but how far depends upon how collectivist you might be and how much you are willing to infringe upon my being

  36. Can’t say I have been happy with the selection of candidates from either side, but I don’t see a green light from the green party either. One has a choice to laugh or cry. I choose laughter.

  37. Al

    While voting Green may promote humor in your circle- voting D/R only sorrow for the vast majority ….

  38. Vik,

    I agree is AMA firmly owns the pedestal in DC and has the ear of people in Washington cesspool that is our political system feeding the pockets of the same old constituencies. I don’t know how to break that cycle either, but am interested to hear how one way that the people could affect “change”.

  39. Oh my, Mark, your comment about taking a ‘nutritional-epidemiologist’ trip thru your local supermarkets, chain restaurants, and fast-food emporiums – along the way notice the lack of outdoor physical activity gave me the chills.


  40. 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

  41. 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

  42. 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

  43. Jon,
    I appreciate your points about the language that we use in the clinical setting – what word or words do you feel would be appropriate in lieu of obese? I am at a loss for what to say except stating a person’s weight aloud without indicating over or under in pounds or kg’s.-LJ

  44. Vik,

    Who controls biometrics at large? And it seems focusing their efforts on culture change first is daunting because we are such a multi-faceted society. What are yours, or others’ thoughts on this?


  45. Christopher and LJ,
    If you truly understood the complexities of this person’s life, I would suggest you would not be using the term “obesity” and certainly not the term “morbid obesity” to describe your patients/clients. The first is a remarkably inaccurate/unscientific term describing a measurement that was never meant to be used for what it is being used for. The second is an incredibly pejorative term which makes no sense – if obesity is a disease then why would you call it morbid? Do you use that word in front of cancer or heart disease or multiple sclerosis? No, of course you don’t because it makes no sense to use a word that means diseased (morbid) in front of another that is indeed a disease – (diseased, disease?). So, why use it in front of obesity – because the second dictionary definition of morbid is “gruesome” – and that is what many, if not most health professionals bring to the table when they work with people who are fat – plenty of research on this BTW. The language that we use, even to ourselves, is so important in the clinical setting – I am guessing that, it is unlikely that your “confronting” of this women 1) taught her something she was not already aware of or 2) had much of a positive effect on her health – just some things to think about – Jon

  46. Christopher,

    Great points! What is the harm of having Dawn sign a form that says she understands the risks of her lifestyle and then deny treatment (and costs) later on? It appeared she was unwilling to change behaviors at that time, so giving her a “written notice” including one or two short term goals seems fair- give her something to be accountable for, and someone to be accountable to..

    You might have been the only person who professionally confronted her about her weight/health status but at least it was a start. Another point, physicians and nurses are afraid to use the “obese” word in front of their patients/clients.
    I am an RN and understand the complexity of rendering care to Dawn and her family.


  47. Hi Vik,
    This was an interesting read and I wholeheartedly agree with many of the points you present. However, I’m curious about the supposed obligation of the ACA to address personal health responsibility. Whose duty is it? The government? The “healthcare institution”? Or is it your parents and your environment?

    You mention that you learned to keep yourself healthy because of your upbringing, not because of the government’s health care policies. Like your son, I also learned to maintain a healthy diet and lifestyle from my parents. It was our families that did this; it was not the posters saying “eat vegetables!” in our middle school cafeterias, the medical health pamphlets, or the language on governmental bills. Personal responsibility should be stressed, but I don’t agree that this was the ACA’s duty specifically. The issue, in my opinion, is the fact that our government is fundamentally structured to support personal freedoms above all, and in that school of thought, people are technically allowed to eat, behave, and live however they want.

    As a first year medical student, I saw a 55-year-old morbidly obese patient I’ll call “Dawn” (not her real name). Dawn’s diet consisted of McDonalds 3 times a day, each time her husband driving out to pick it up and return it for her, at which point Dawn ate it alone in the living room. While we ended up prescribing her additional pharmacological treatment, the best I could do in terms of personal responsibility was persuading her to agree to walk to the car and eat at McDonalds at the restaurant rather than eating it at home without leaving.

    With this story in mind, which is becoming increasingly common for me as I progress as a student, I seriously doubt any change in classification of “obesity” by the ACA would affect Dawn’s lifestyle. In my opinion, Dawn’s road to a healthier routine involves seeing her physician regularly and having the physician on her team, encouraging her to change her behavior. Gyms are completely out of the question for a patient who is arguing against walking 30 seconds to a car to eat fast food three times a day. If she completely refused to change anything, what are the options? Should physicians be brash and rude? I don’t think that’s the most effective way to get somebody to change their behavior. Should we have the power to institutionalize her into a “rehab” for healthy lifestyle? Should we have Dawn sign a form that says she understands the risks of her lifestyle and then deny treatment (and costs) later on? Absolutely not.

    Unless you think the ACA should have had a component for compulsory institutionalization or prospectively denied healthcare to patients who refuse to change their lifestyles, I feel your frustration (which I share) should be placed elsewhere. If anything, classifying obesity as a disease may be the least-worst alternative, so some public funding can be shunted towards the problem.

    If the “cure” to obesity lies in changing the environment which facilitates this lifestyle, I’m much more appalled with the typical school lunch than the marginal societal loss in medicalizing obesity. From a big picture I agree it sounds like classifying obesity as a disease is validating the behavior, but on a one-on-one level with most of the patients I see who truly suffer from obesity, at no point do they feel the government is encouraging them.

    Dawn certainly didn’t, and neither did her 11-year-old daughter we saw that afternoon who was showing early signs of type 2 diabetes.

  48. What did you find the most interesting in that posting please? I am an EdD student in a course that requires me to blog.. Any comment would be appreciated THCB!

  49. The ACA doesn’t prevent people from pursuing health promoting lifestyles, people do that to themselves – with a huge push from a corporate system committed to profits and disease promotion through marketing dominance.
    The margins of the ACA make a feable attempt to patch the wounds by mandating some of preventive care bandaids, but that isn’t what undermines self-engagement in healthy living and eating in this country. If you want to find that study the machinations of the Department of Agriculture and then take a ‘nutritional-epidemiologist’ trip thru your local supermarkets, chain restaurants, and fast-food emporiums – along the way notice the lack of outdoor physical activity.

  50. Nyp: after reading the author’s reply to you, I am pretty sure his reference to educability was aimed at you, not employees.

  51. Whether or not you agree with the author’s perspective, the writing itself is just brilliant. Thanks, THCB.

  52. I agree that the Affordable Care Act (ACA) is problematic in terms of raising consumer consciousness. The social consequences of convincing people that in order to become well they must first become sick seems bizarre. As does telling someone every ailment they suffer from can be “fixed.” The U.S. certainly is not the only Western society dealing with profit-maximizing commercial organizations and government intrusion on self-inquiry and healing. Each of us will suffer at one point or another with sickness, old age, poverty, death, and the inevitability of facing problems and dealing with them. I don’t need or want the ACA concepts
    of personal responsibility and mastery of lifelong wellness skills from the pursuit of actual health. In fact, I don’t want the Fed. Involved in any aspect of my life that presumes I may have missed opportunity to understand about what’s first in the line of responsibility for good health..

  53. Vik,

    Deeply cynical? I might argue not quite cynical enough. That you still believe most Americans are able, given the state of the public education system and the overwhelming influence of marketing and advertising in this country, to make educated choices and navigate the Byzantine healthcare system suggests surprising naivete.

    No, we are not going back. And maybe you are making the argument above because you see individual empowerment as the absolute last best opportunity to right the ship of state and launder the filthy social fabric. But the fact that you expend nary a word of criticism on the corporations for which Americans are nothing but a market says something … to me, anyway.

    At least have the good sense to expand your analysis to include all those who’ve behaved badly in this situation. This isn’t simply a case of lazy citizens and the nanny state–that’s not how we got here.

  54. Peter,

    You are right about where the impetus for all the lousy entrees on our sickcare menu come from, corporate America, but i suggest you are wrong about never being able to go back – can an obese person never lose weight? We are where we are because of policy choices we have made; we can make others ….

  55. Marie,

    It is true – the transition to organic is difficult and farmers really need to know they can survive the transition and prosper from it – that is why and where the subsidies that padded Big Ags bottom line need to be redirected –

    One doesn’t have to be politically active to educate on the advantages to the community of going local and from there to switching to organic …

    I know what you are saying about politics – I started out about 25 years ago, going from hermit to NIMBY to groundwater champion (hence my name ..) to actually running for office because i learned that, although there was a great deal i could do as an individual, it could easily be undone with a stroke of a legislative pen – individual effort is necessary, there is no doubt – but I have discovered and really do believe it must be paired with political action …. hence my support of Dr. Stein, check her out …

    One doesn’t have to run for office – shucks, i wasn’t really suited for it (I lost, by the way) but just be aware and supportive of those who would champion the things we need to have done – e.g. if we had more Medicare for All instead of ACA proponents in office, methinks we would be having an entirely different conversation …

  56. Jon,

    There are “a number of studies” that debunk global warming, too – the fact is one can find studies that “justify” the assertion of just about anything (the moon as green cheese may be an exception …) That is why methinks the application of the Precautionary Principle is a good rule of thumb … The idea that where significant harm is possible, erring on the side of caution is a good idea …

  57. “if we are going to be driven by science”

    If we were driven by science we’d not have processed (salt,fat,sugar) the food supply system we do. We are driven by low cost and food industry marketing.

    “actually the idea of food deserts and obesity has been greatly overstated”

    Overstated how? It’s PART of the problem in certain neighborhoods, you know, the poor ones where ACCESS to choice is limited.

  58. Points taken Aquifer. One farmer’s market group here in my area is matching food stamps to help folks buy fresh produce. And perhaps starting with locally sourced food would be a good start. Several local farms here are not pursuing organic certification because of the red tape involved. However, there are logistics and costs to be considered when requiring a whole school system to purchase local food. It’s not just a matter of changing legislation. And finally, my goal is to make my little corner of the world a better place hopefully causing a ripple effect. I am better suited to such work than political activism.

  59. This is for all who were discussing the popular concept of food deserts – Pollen and other food activists not withstanding, if we are going to be driven by science (a tall wish perhaps) actually the idea of food deserts and obesity has been greatly overstated – if you google “Studies Question the Pairing of Food Deserts and Obesity” you will see a number of new studies that debunk both the existence of these deserts and their relationship with weight – Jon

  60. Naive? No. Deeply cynical? Yes.

    Agree completely that the ACA is the result of the death of responsibility, but it is not just the death of corporate and legislative responsibility…it is also the result of the death of personal responsibility. See title. Double entendre.

    Agree completely with your laceration of federal food subsidies, which have gravely distorted food markets.

    Agree also that we are not going back. Thanks for your comment.

  61. Vik Khanna has missed the mark completely, even naively.

    Since when did the ACA initiate the death of personal responsibility – in the 4 years of not yet being fully enacted? America’s long road to cultural obesity has nothing to do with the ACA – rather the ACA is just another result of the death of corporate and legislative responsibility.

    Fast food, junk food, food deserts, processed food, salt/fat/sugar, subsidized corn, cheap meat, computer games, TV, the death of school recess and gym, and on and on have been driven by corporate America eager to make money with no accounting for the result.

    We can never go back. Only those few who can buck the marketing hype of the industrialized food production industry will carve out a healthy niche for themselves – but yet pay for the failure of the rest.

  62. I am not going to get into the politics of the ACA nor the AMA statement that Obesity is a disease. I just would like to point out, as someone who has read the thousands and thousands of pages that comprise the ACA, that with all of it’s faults, the ACA, does indeed promote preventive care and wellness program.They also expect every hospital to do a community outreach every three years to determine how to best serve the needs of the community. The trend towards accountability and responsibility is, in my opinion, promoted by the ACA instead of the opposite.

  63. Marie,

    Au contraire – methinks that underscoring the dangers of the “food” currently on offer is a very good argument for dealing with the issue of the food deserts you speak of – when it is not “simply” an issue of feeding folk but of promoting healthcare. For example the school food programs – the food would be specified to be bought from local farmers with preference given to organics – use the vaunted “market”, literally, to incentivize the production and distribution of such food – that is why I mentioned further up that if we really wanted to deal with “healthcare” a couple of the first places we would start with are the Dept of Ag and the FDA … Also promotion of urban gardens …. The value of food stamps could be doubled when used for the purchase of such food to compensate for the higher price. The reason there is crappy food in a lot of places is because it’s cheaper – make good food cheaper and that is what will be provided. Wouldn’t it be nice if folks started complaining because there were too many fresh veggies and no place to buy Twinkies? Those are decisions we can promote through the political process …

    You are correct – we need to improve access to this stuff, and the health connection provides an additional incentive, so talking about GMOs is anything but a waste of time, IMO …

    And i would think that healthcare professionals need to get on board with this effort – as i also said above, this is what drove Dr. Stein to enter the political arena – the understanding that healthcare needed to be considered as part of a much wider context than just the time one can spend in one’s traditional “practice”. Her concerns echo my own …

  64. I believe it was then Senator Kerry who said during one of the ACA senate debates on C-SPAN, ” I want to provide for the American people the very best healthcare I can.” This quote focused my understanding more than anything on the naive philosophy and limitations of the ACA. Moving more money around, the politician’s social engineering tool of opportunity, may improve access for a few but at the expense of institutionalizing more dependent thinking. I too believe that self-responsibility and healthy lifestyle should be the foundation of American health reducing the need for formal healthcare.

  65. Interesting post. I would love to be able to incorporate more health coaching into my practice to encourage people to take ownership of their health, but time is limited. Aquifer and Kay, are you familiar with food deserts? There are plenty of urban neighborhoods that have no access to fresh food much less organic non-GMO food. There are convenience stores but no real grocery stores. Also, have you tried shopping for food on food stamps? It’s about maximizing that money not how healthy the food is. I think until access to affordable food is improved, fussing about GMOs and the like is a waste of time.

  66. Ha, ha – that happens to me a lot – but I think it is kind of funny, don’t you, that we can’t get our comments all lined up but we think we can organize medical records on-line 🙂

    BUT, i hope this site doesn’t decide to use Disqus for comments – I have had nothing but trouble with that and can’t even get into it ….

  67. Jon

    I think the issue of GMOs is fundamentally different from the issue of food groups as in fats, carbs, proteins – and in spite of the FDA, the idea that they are “substantially equivalent” is a joke – they have not been adequately tested and we are being used as guinea pigs … Indications of their affects on gut permeability, e.g., with the implications thereof, are enough, IMO, to keep them off the market until there are considerably more rigorous trials – considering that these are self replicating organisms, and letting them loose could be disastrous, and i don’t think you can really argue that the jury is out on the deleterious effects of pesticides, or wide use of antibiotics, or hormones on our “food” animals.

    I am a fan of the “Precautionary Principle” – there is no need to unleash these organisms before they have proven they are safe …

    As i said, in modern time we have tampered with more and more of our food – for the same reasons we have messed with healthcare – to increase the bottom line of big corps, in this case Monsanto, Cargill, ConAgra, etc. –

    As for “not practical” for everyone to eat them – why is that? As i said, not all that long ago it was “not practical” not to – our farm bills that subsidize Big Ag instead of small organic farmers have flipped the “practicality” of what food we eat. We could change that – tax Big Ag for adding all that stuff that Michael Pollan might describe as something your grandmother wouldn’t recognize as food, and subsidize the small family farmer who grows food the way Mother Nature has for eons … It is our policies that decide what is “practical” to eat ….

    As for much of your reply, methinks it is more of a rejoinder to Kay than to me …

  68. @Aquifer, for some reason I can’t reply to your last message but I think what happened is that I thought I wrote the reply to E Tai in the right place but then I got distracted (I am very easily distracted) and by the time I hit “send” another message — yours — had appeared in between

  69. Jon,

    I would guess from the content that your reply is not directed at my comment but it appeared under it …

    Might i make a general suggestion to folks? That we preface our remarks with the name of the person to whom they are directed? Methinks that might be useful …

  70. Aquifer,
    At the risk of being accused of killing people and being the problem because of my extensive nutrition training and experience, let me just say that nutrition science is much less exact than you may believe – and what we thought was healthy over the years has changed dramatically – don’t know how long or deeply you have been involved in this field but we have gone back and forth so many times on what is and is not healthy it is really laughable – salt, sugar, carbs, fats, different kinds of fats, antioxidants and on and on and on – of course the latest is that the Saturated Fatty acids that everyone has been scared to death of for the last, oh at least 40 years now turn out to be relatively benign according to the latest research and low salt diets can actually cause high blood pressure – when we jump to conclusions about and vilify certain foods we are almost certain to end up eating our hats (no pun intended) – plus it and the constant changing drives people crazy and often pushes them to give up completely on even thinking about food – I have taught college nutrition classes for 20 years have counseled individuals and groups, have written a nutrition-based textbook and have given keynotes and workshops at most of the major ED and nutrition Conferences in this country – I am certainly not part of the health establishment but I have been intimately involved with nutrition on all these levels for a long time – and I have a chronic, progressive autoimmune disease which I manage partially through the way I eat. I have nothing against organic foods but the literature on whether they are nutritionally superior is questionable – though I am willing to go with the fact that all of the chemicals used may add up to problems for some people – of course eating them for everybody is just not practical at this time but that is another story for another post. Finally, I can tell you from years of experience that scaring people into being healthier simply does not work – and as for shaming people into it – “nobody in their right mind would eat that” – well I hope the efficacy of that approach speaks for itself – its the same one we have been using for decades – Jon

  71. Wow – quite an attack that one – on my credentials as well as all dietitians – just out of curiosity, your nutrition training and background was what did you say? So, I am part of the establishment that is killing us all – and “nobody in their right minds eats… and nutrition professionals are one of the problems – any other non-prejudicial, evidence-based accusations you would like to make? – Jon

  72. Jon,

    ” ….there is no reason why that or any other food cannot fit into a healthy dietary regimen ..”

    A bit too broad for my palate … There is mounting evidence that GMOs are bad news in a number of areas and that processed food processes out nutrients.

    I find it amusing that not too long ago, ALL food was “organic” as were the critters that fed on it; now we have to go out of our way and pay more to find ANY food that is. For the vast majority of our evolutionary history, our physiology was founded on it. It seems to me that the farther we stray from organic, non processed and pesticide, antibiotic/hormone free food, the sicker we get ….

    And it is not enough to “supplement” our nutritionally challenged food with pills – there is growing (pardon the pun) evidence that the certain vitamins, e.g. when isolated from their food stocks don’t seem to work quite as well – they seem to lack that “je ne sais quoi” that makes them work …

    So yeah there are food vigilantes, but it seems to me there are a few fundamental principles, and the primary worth of organic – non GMO, pesticide, antibiotic/hormone free – food is one of them ….

  73. Where did I say all should eat alike? If you read, as I suggested, you learn that all do not require the same food…….If you are indeed “a nutrition professional,” you are considered one of the problems, in my opinion. If you were trained in a medicine-based curriculum, you hawk the same junk science that physicians and nurses learn. You’ve proved my point in saying “.there is no reason why..that or any other food cannot fit into a healthy dietary regimen.” It seems you may well be a part of the cliche-thing medical establishment that’s killing us all.

  74. Dear Kay,
    A bit oversimplified that explanation I would suggest – the idea that there is one “healthy” way for everybody to be eating is problematic – so, if you do the research on you as an n of one that is very different from the suggesting that everybody should eat the same as you because what you have researched/implemented works for you (and don’t forget the power of the placebo effect) – As you know few of the “experts” agree on what is really a healthy diet and it flip flops back and forth all the time anyway (most recent research suggests we have been wrong all along about Sat Fatty Acids) As a nutrition professional I am uncomfortable with the comment that “nobody with a brain eats that” for just about any food for 2 reasons – 1) there is no reason why that or any other food cannot fit into a healthy dietary regimen and 2) 25 years of good solid research shows us that the good food bad food thing sets people up for all kinds of problems – Jon

  75. Al – maybe i do need reading comprehension upgrades – these threads always get me confused as to who is speaking to whom. So I am thinking that putting the person’s name at the beginning of the reply helps ..

  76. Dear Vik: The problem with wellness programs is that one must assume the information provided is valid, not tainted by self-serving research by physicians and/or Big Pharma. That doesn’t happen. …Medicine is not a hard science; it is closer to an art. Therefore, “experts” do not exist, although they assert themselves as such. ……..If one eats from a Heart Association Cookbook, one is in trouble immediately. Trash. Worse are A. Diabetic Association publications about control; they tell you how many chicken mcnuggets a diabetic can eat. Nobody with a brain eats those in the first place……..You are responsible. But your salvation is not in listening to one doctor or expert but reading widely and deciding for yourself. Then you have to help those not capable of doing that research.

  77. Rajiv: thanks for the note. Well, not to disappoint you, but there is clearly some evidence that when individuals take greater responsibility for their health (aiming, for example, for the American Heart Association’s ideal cardiovascular health), they experience a compression of morbidity and, along side that, they use fewer resources. Indeed the Heart Association’s data, well accepted and widely published, show that people who have all the cardinal health habits (normal weight, don’t smoke, exercise often, eat a calorie-managed diet (mostly plant-based) diet, have 80% lower morbidity and mortality than people who have none of these characteristics.

    People with lower morbidity and mortality use fewer resources.

  78. Vik — loved the post, though I was cringing at the headline “… the Death of Personal Responsibility” before I read the content. To me the headline seemed to promise that you were going to be railing against people for not taking personal responsibility, that you were going to be like the many who like to claim that our healthcare expenses are so high because people aren’t taking care of themselves, and that therefore we should be implementing more coercive incentives to get people to comply. I was relieved to see that you’re advocating the opposite.

  79. AH: thanks for reading, understanding, and commenting on what I actually wrote. As you can no doubt tell, that’s apparently harder to do than one might expect. I have many more great things in the pipeline, and Al and I are working up a couple together. Stay tuned for lots more hashing out.

  80. Vik you are absolutely on point. And I wish more of our nation’s parents were like yours, in encouraging exercise as a therapeutic measure and not just recreation. I do think this debate is pointing us in the right direction however. Lets keep hashing it out.

  81. Thanks for your note, Jon. I love your concluding sentence…that Jenny Craig and bariatric surgeons are out partying after this series of policy foibles. Indeed, if I actually ran corporate wellness programs, as some of the less engaged commentators noted, I would be out partying with them, because the ACA gives me the push to go wild. Hey, that’s a great name for it: Wellness Gone Wild. Thanks for the inspiration, Jon.

  82. It is time that we ALL (patients and providers ) “come clean” about the mutual lie that we have been living and hawking.

    The $2.2 trillion dollar plus US organized medical enterprise has little to do with human health outcomes. This has been known for several decades!

    see http://www.unnaturalcauses.org

    Dr. Rick Lippin

  83. m13, thanks for your comment. We need more of your wisdom in the trenches and in forums, such as this one. Please keep reading and writing.

  84. My bad,Aquifer–I was agreeing with you. I didn’t see what E Tai saw at all! I think I just posted this reply in the wrong place.

  85. Great Ceasar’s ghost! Sacrebleu!

    How could the executive editor of THCB let this happen?!!

    They published something that was meant to provoke and, egads, promote, too.


    P.S.: I don’t run corporate wellness programs. I critique them, and I develop organizational strategic wellness plans, which I then hand off to employers to do with as they please. Consistent with my writings, however, I warn employers not to be seduced by facile claims of wellness vendors and benefits consultants bearing good news about HRAs and biometrics and to focus their efforts on culture change first.

  86. Al: thanks for your note and for continuing to read my work. I enjoy jousting with you. BTW, I share (and sympathize with) your concern that the AMA does not necessarily represent the views of many practicing physicians. The problem, of course, is that they have the pedestal and the ear of people in Washington where the cesspool that is our political system, just seems to churn ideas that benefit and embolden the same old constituencies. I don’t know how to break that cycle (actually, I do have some ideas), but I do know the community docs need to find alternative ways to have their views heard. People like you, commenting on what you read at THCB and elsewhere is a good start.

  87. Let me play referee here for a moment. I think Al Lewis’s note is in reply to E Tal, not Aquifer.

    Now, having clarified that, Aquifer, thanks for your initial note. You understood exactly what I was trying to communicate. Thanks for your nice summation.

  88. Actually, you just insert my or Al Lewis’s name into the THCB search box or go to the Wall Street Journal or Health Affairs or The Doctor Weighs In, or my blog, and by the time you’re done you will have gotten quite an education on what’s wrong with ACA-fomented corporate wellness.

    You could also just wait until later today or tomorrow and read the essay that Al and I wrote for AOL.com, in which we tell employees to proactively ignore this stuff. Of course, all this presumes a certain level of educability.

  89. I think that many of the respondents here are missing the main points of this post at least as I see them. The wellness provisions of the ACA are a non-evidence-based, unscientific disaster. They are largely based on the successes claimed by the Safeway CEO – which, of course never actually happened. There is no available evidence to suggest that the kinds of coercive, incentive-laced solutions promoted by the so-called Safeway Amendment will improve health or save money, and,as the initial post suggests growing evidence of potential significant iatrogenesis both physiological and psychological – including (as the Prevention Institute and others have pointed out) cost shifting to those who can least afford it and pissing off people who don’t care to be coerced into turning the workplace into a doctor’s office, inevitably leading to decreased engagement at the workplace and all the negative consequences that occurrence portends – I am all for promoting health for individuals and organizations – but this medicalized coercion is not the way to go – As far as the AMA is concerned the transparency is glaring – They went against their own scientific advisory council to make their decision – because the decision has nothing to do with science – Really? In the short time doctors have with their patients, the limited training most of them have in nutrition, exercise or behavior change, they are going to waste a few minutes of their time doing more hounding of fat people to lose weight? – (after all, most fat people don’t know they are fat because it doesn’t come up that often in this culture – and when they do get hounded it works so well) – that’s why the AMA went against the recommendations of science? Maybe, but could it maybe have something to do with getting all these very effective weight loss approaches covered by insurance -weight watchers. Jenny Craig and bariatric surgeons are out partying after this decision – Jon

  90. That’s what you learned? Did we read the same article? If so, one of us would not score high on the reading comprehension section of the SATs

  91. It also benefits the wellness industry. By far the largest single contributor to medicalization relative to the size of the field is the wellness industry

  92. Hey Quack (great nickname, BTW): your point is an excellent one. The only suggestion I would make is to substitute the “responsibilities and resources” for
    “incentives”. It is unrealistic to expect that people should anticipate an endless stream of external rewards for pursuing what is really enlightened self-interest (i.e., the more I do to take care of myself, no matter how modest my circumstances, the more resources I have [financial, emotional, psychological] to do other things). And, indeed, people should expect that there is a safety net to catch them when necessary. Thanks for chiming in.

  93. What a spectrum of isolated points of view! I am with Dr Vicstrom, there is no reason we cannot have personal responsibility, public health, and a strong safety net.

    First we need an improved MEDICARE for EVERYONE. That can cut total spending by about 30% (activities that serve only to enrich the insurance carriers) and thus allow coverage of EVERYONE for a little less than total now spent caring for about 3/4 of population. Financing care via the tax system will also remove a huge burden from businesses, which may allow them to hire the people they need.

    I agree we tend to over-medicalize life in USA, but if folks are freed to seek care (see above) then good, comprehensive care will include advice about what each person can do (exercise, diet, etc), and that can be supplemented by public health and school programs to promote good habits. As a retired endocrinologist, I have seen medicine from both sides.

  94. I disagree with many of the responses. We can have personal responsibility, public health and a strong safety net. These things are not mutually exclusive. It’s all about how we structure the incentives, like everything else.

  95. So somebody tell me how corporate wellness programs, as encouraged by the Affordable Care Act, leads to “the death of personal responsibility” and the loss of our precious bodily fluids.

    Isn’t this guy’s post really just a bunch of hot air?

  96. E Tal, he makes his living running corporate wellness programs because he’s seen the limitations of a nanny state, not the other way around.

    As a surgeon, I concur with him. There certainly needs to be ways to help people to help themselves and a system that incentivizes personal change. But it is far too often that I see people who want the ‘system’ to (a) take care of their issues without effort on their part and (b) believe that anything short of perfect is an illness.

    Hearing about his son reminds me of the story about how Jack La Lanne got started. He had asthma and was told by the establishment to take inhalers and stay at home, accepting his frailty. He heard a lecture one day about the benefits of exercise and started to practice himself. He continued this till his death in his mid-90s and recommended it for everyone to help improve their functional abilities and quality of life.

    And the topic of medicalizing all ailment is one that psychologist Martin Seligman has researched and discussed for years. As society becomes more fractured, with fewer positive drivers, and more disjointed economy, church, government and family, we see a host of issues involving both physical and mental health issues. To treat all of that with prozac, lipitor, lopressor, lisinopril, and glipizide is counterproductive and something seen every day in doctor’s offices. Getting their blood pressure checked and diabetes screened on a regular basis is great to establish data points, but then what’s needed is a walking regimen, improved nutrition, some sunlight and positive upward spiral in their lives that comes in part of from personal effort.

  97. E Tal

    You know, I didn’t get that impression at all from the article – In fact I got rather the opposite … We need to emphasize, foster and promote the “alternatives” to pills and procedures that comprise the bulk (excuse the pun) of modern medicine …..

    It may be the author is pushing his business, but that doesn’t change what are, in my opinion, are rather trenchant observations about the state of modern “healthcare” …

  98. nyp

    Considering that that a recent study suggested that “overweight” folks may score better in certain categories than “normal weight” folks, and that every time one turns around the levels of various parameters that “need” to be treated with Rx seem to get lower and lower, methinks a healthy skepticism is indeed a good thing to cultivate. Not to mention which even the concept of “prevention” seems to consist of more drugs …

    I don’t know where the author is coming from politically, but it seems to me that any physician who doesn’t emphasize to the patient that his/her health depends to a great extent on how well )s )he takes care of his/her body – eating, drinking, smoking habits – i.e. areas of “personal responsibility”, needs to refresh their ideas on what it means to be, become, and/or stay, healthy …

    As for “personal responsibility” to get health insurance – that is an entirely different subject – I am of the opinion that is a societal responsibility to provide, and not a personal responsibility to get ….

  99. The author’s point of view may be summed up as follows:
    If you’re obese it’s your fault, and you shouldn’t get any help solving the health problems that stem from this condition, otherwise you’ll never learn your lesson in personal responsibility.

    May you die a slow and painful death for belonging to a large group of fellow Americans who have:

    – Little or no education on healthy nutritional habits (can’t let the nanny state and Michelle Obama “indoctrinate” our kids now, can we? Only corporations are allowed to educate us via advertising)

    – Little or no access to healthy food (can’t let the nanny state “pick winners and losers” in the food industry)

    – Few or no means to pay for health insurance (because we’re better off spending twice as much of our GDP on healthcare as any other OECD country and getting worse results, in the name of the holy free market and insurance company profits).

    The author makes his living running corporate wellness programs. Any government “takeover” of healthcare is bad for his business.

  100. Bravo!

    ” ….even though what they suffer from most are things that more medical care cannot fix: economic dislocation, fractured families, and jobs they hate.”

    Reminds me of the description that Dr. Jill Stein gave for entering politics – she was frustrated with treating folks in her office and having to, as she said, send them back into the environment that was making them sick … So she is now into “political medicine” – putting healthcare in the wider context of social ills …

    The author is correct – this medicalization of every aspect of the human condition serves only the pharmaceutical and medical procedure “industries”. If it’s healthcare we want to provide, two of the first places to start is the Dep.t of Agriculture and the FDA ….. And then we could make sure folks have decent jobs at decent wages so they can afford the food, shelter and education they need to stay healthy …

  101. 1. So permitting employers to require their employees to have their blood pressure and cholesterol levels checked equals “the death of personal responsibility”?? Sure.

    2. What does the AMA’s decision to categorize some forms of obesity as a disease have to do with the Affordable Care Act?

    3. I assume you applaud the individual responsiblity requirement, originally formulated by the conservative Heritage Foundation and adopted by Mitt Romney, that penalizes individuals who seek to shirk their responsibility to obtain health insurance for themselves and their families. You do agree with last year’s Republican nominee that “it doesn’t make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way,”

  102. “Egotism at its worst” is having the guts to actually state one’s belief that he/she has the “responsibility” to manipulate and coerce an entire society to behave in a proscribed way. That is the hauteur. Patient’s can leave their physician should he/she appear to dictate. One cannot escape the hauteur of the “policy maker.” That is a very real and very frightening difference.

  103. It’s my hope that you are targeting the hauteur of those in the medical profession, those who act as a dictatorial principal toward a student. I also hope you don’t have the naive “given” that all have the brain power, the family support, the funds, etc., ad infinitum, to develop responsibility for health management and health choices. That attitude is egotism at its worst.

  104. I think this post is on target and I think better than the one on Obesity and the AMA. We agree patients should take control over their own lives, but I hope you realize that organized medicine known as the AMA does not represent the practicing physician that is at the bedside.