Individual Responsibility and Health Care

QUESTION:  Why should we take care of people who have never been interested in taking care of themselves?  People with poor health habits and lifestyles should not be protected from the consequences of their choices.

Project EINO would agree that people should have incentives for healthy and socially responsible lifestyles.  To that end we believe that much improved funding and program strengthening for public health, especially public health education, should be a part of a new universal health care system.  The reinvigorated public health system would make the consequences of smoking, excessive drinking, lack of regular excercise and other health hazardous living much more clear and appreciated in the public's mind (and to our young people especially). See also what public health experts say.

It is not true, however, that most chronic conditions and serious acute health crises in this country are avoidable by a change in lifestyle.  There are many cases in which the most health conscientious person in the neighborhood was stricken with a tragic illness, or the most cautious person in the workplace was injured in an accident.  So clearly, admitting personal responsibility as a positive value does not excuse disregard for the social responsibility of caring for the less fortunate. And we must realize that any of us or our families might suddenly find ourselves in the "less fortunate" category.

A second problem in the simple-minded approach that people only need to take responsibility for for their own health misfortunes is attaining agreement on what the features of healthful lifestyles are.  Some features would probably be widely accepted like not smoking or abusing alcohol, but how much excercise should be required, or how much overweight allowed, or how frequent the consumption of high nitrate sausage, or how much time spent on extreme sports/ or motor sports before "we judge" the participants to forfeit their right to be covered by a universal health care umbrella? And how many of us are not disqualified by one occassional vice or another? How much latitude should we give young adults?  

QUESTION:  So does Project EINO advocate increasing personal responsibility or diminishing the role of personal responsibility for one's own health status?

Project EINO believes in increasing personal responsibility by increasing the public education and awareness of lifestyle in maintaining good health and putting one's health at risk.  The strengthening of our weakened public health system is one of the six principles for a new UHC system.  We believe that there needs to be a great deal more education and discussion on most choices before our society should endorse any incentive for good health practice.  Moreover, it is not appropriate to have public health education outspent 10 or 20 to 1 by corporate advertising for unhealthy lifestyle practices, targeted to specific populations and then glibly state that it is a matter of personal responsibility. Certainly corporate influence on our children (on tv, in schools) must be carefully considered and regulated so that later as young adults they have the chance to make informed and responsible lifestyle decisions.

How dishonest is it to talk about personal responsibility when so much opportunity is decided at the moment of birth, by social status, ethnic background, gender and pre-natal and early childhood health services? Read through the FAQ section on Injustice in Health Care or just look at how skewed the offering of some critical services are CLICK HERE. Isn't it clear that anyone who truly appreciates self-reliance and personal responsibility as core American values, should also be committed to the principle of all Americans having a decent shot at success and provision of a good life for themselves and their family, at least having such an opportunity given hard-work, sacrifice and strenuous effort?

QUESTION:  But if people took personal responsibility for their health wouldn't that enormously reduce health care costs for everyone and make it easy for everyone to be insured?

Yes sort of, but the question is phrased incorrectly. It seems true and borne out by studies that much of the expense for health care in the USA could be saved if we had a population with better health habits and healthier choices.*1 But development of better health habits doesn't occur in a vacuum in any country - its part of an entire public health system by design and prioritization.

In Canada 2000-2002 there was an enormous amount of advertising against smoking, for example -especially directed towards young adults. And there were programs in place to fund and encourage (reward) smokers for quitting. This together with encouragement of outdoor recreation (plentiful state-supported facilities) will all lead the population, especially during formative years, towards healthier tobacco-free lifestyles. But in Canada everyone clearly benefits by these programs as it is public money that is explicitly saved and the same funds can be spent on illnesses that cannot so easily be avoided.

In the US system public money is not as clearly expended and public programs not so clearly put at risk by excess spending on poorly chosen lifestyles - so there is much less political will to bear the costs of shaping and encouraging the better lifestyle. A single risk pool sort of system would certainly give all state legislatures and politicians in Washington a direct reason to save these public funds for needed medical care. Thus this question is true but gets cause and effect mixed up. People will be making better choices and saving us money by limiting poor lifestyle when everyone is linked together explicitly with a single pool of risk.

QUESTION:  What has always worked great for our nation, though, is offering individuals great opportunities achievable through ambition and dedication to their employers. Isn't that the basis of the American Dream?

With our growing crisis in health coverage, the "American Dream" has been chipped away to a crumb of it's former self. Even those formerly very attractive benefits for high achieving, long-term dedication to employers are quickly disappearing. Partial, limited high-deductible insurance has come at the price of forfeiting other needed benefits, like a secure retirement or financial assistance with our children's advanced education.

QUESTION:  Now that consumers can choose between competing plans doesn't the free market ensure that given enough time only the plans which have superior service will come to dominate? 

In fact most working people have little choice of health plan.  Fully 42% of those who are offered some health plan at work (and many are not offered any) are offered only a single plan. 

More importantly, what the insurers understand very well is that a few cheap whistles and bells can be added for tremendous mileage in impressing the healthy majority (say 90% of policyholders) with the "great care" they receive.  Meanwhile the insurers can cut back in the areas of great cost that affect only the relatively few who face real medical hardships.  Few consumers will realize about these cutbacks and even then only too late - at the point when the insurer would love for them to quit or switch.

Read more about what Americans think of high deductible and cosumer-driven health care CLICK HERE

QUESTION:  What's wrong with the consumers' rights approach, just making information on health plans public and letting workers choose what kind of coverage they prefer?

The consumerist version of the "free market" approach to health coverage is a thinly veiled fraud.  It is impossible for workers to evaluate the critical details of competing health plans for the great variety of possible illnesses and their many possible treatments.  Furthermore, the vast majority of consumers are basically healthy and have little direct knowledge with the critical health care services until they or a family member become critically ill.  Even among the elderly 10% of these Americans use more than 65% of the health care resources.¹ For more on preventive medicine (see prior question).

Most workers shift health plans because they are forced to do so, not because they even think they have found a plan that might better serve them.  The forced changes usually disrupt their continuity of care with a physician who knows them more thoroughly and who can continue treating them with greater efficiency.  They are also less likely to find a strong advocate in a temporary physician who will fight to get them needed care (example). Read more details about schemes for "consumer-driven" health care savings.

QUESTION:  Even if it is difficult for the layperson to evaluate details without expert advice, still what could be wrong with offering a financial incentive for consumers to make judicial use of expensive health resources once they are in a given plan?

Indeed a great number of professional "health policy analysts" do advocate such incentives.  However this seems to make no sense whatsoever to us.  As argued directly from data in the preceding question, since so few of our fellow citizens (the least fortunate) expend the overwhelming preponderance of health care resources (and always will) talk of saving our health care dollars by "patient responsibility" seems base and callous.  Lifestyle may play a role (of often unknown significance) in some minor portion of critical illnesses.  It is callous and cruel though to speak of patients being responsible for their illnesses and health care costs generally.   Such ignorance is especially onerous when it flows from the mouths of physicians.  It may be an easy and assuring fallacy to the well-majority that they are responsible for their good health, but its false, cruel and divides the nation.

QUESTION: Isn't the perfect way out of America's health care crisis is to substitute health savings accountrs (HSA's) and high-deductible plans, simply buying less insurance and that's do-able immediately?

As Karen Davis, President of the Commonwealth Fund, said in March 2005:
Health savings accounts coupled with high deductible health plans have potential pitfalls, especially for families with low incomes or individuals with chronic health conditions, who are at greater risk of accruing burdensome medical debts and facing barriers to needed health care. The evidence is that increased patient cost-sharing leads to underuse of appropriate care.

What she understood is that about half of insured adults with a high-deductible health plan have medical bill problems or debts, compared with 31% of those with lower-deductible plans. Individuals with high-deductible plans are also more likely than those with lower-deductible plans to experience access problems such as not filling a prescription, or skipping a medical test, treatment, or follow-up when needed, due to cost.*1 All of these examples of "underutilizaton of care" lead to even higher premiums, deductibles and taxes because conditions go untreated until the conditions are maximally expensive and difficult to treat -also with much greater human suffering. This is a major problem with all the "consumer-driven" marketing schemes.