On my pediatrics rotation in medical school, several residents told me they worked with children in part because they sometimes found themselves judging adults: Did they do drugs? Were they fat? Why did they drink so much?
The idea that Americans should take personal responsibility for their health is not new, but it has recently received renewed attention.
What does it actually mean to take personal responsibility for health?
The basic idea is that if we adopt healthful lifestyles, are compliant patients and save money for our own medical care, we’ll feel better, spend less and reduce our burden on others. The details of how this philosophy is applied, however, get complicated: Which programs work and which are counterproductive? Does “personal responsibility” save money or just shift costs from insurers to patients? Who should judge whether we’re living a healthy enough lifestyle: Doctors? Insurers? Government?
Vice President Mike Pence has argued for “bringing freedom and individual responsibility back to American health care.”
Many Americans think it’s OK to ask people with unhealthy lifestyles to pay higher insurance premiums and deductibles. Efforts to inject more personal responsibility into health care, however, have not consistently been shown to lower costs, improve outcomes or save lives. Effectiveness — or lack of it — is often in the eye of the beholder.
That individuals bear some responsibility for their health is undeniable. Behavior contributes to nearly half of cancer deaths in the United States, and up to 40 percent of all deaths. But viewing personal responsibility as a central driver of longer lives and lower medical costs is problematic.
American life expectancy has increased markedly in the past century, and few would argue it’s because we now lead healthier lives by dint of willpower. It’s also not clear healthful behavior saves money: People who live longer use more medical care. Smoking cessation, for example, may actually increase long-term health care costs. And ensuring that people bear greater financial risk doesn’t seem to help them make better decisions: A RAND study found that making people pay more for care does reduce how much they use, but that they cut out both highly effective and marginally effective services.
Medicaid reform is the policy context in which personal responsibility is most frequently discussed. The Trump administration recently decided to allow states to impose requirements for people to maintain Medicaid eligibility.
Kentucky became the first state to take advantage of the shift, implementing new rules that would require many of its Medicaid recipients to have a job or do volunteer work in order to keep their health coverage. People would also be locked out of their coverage for six months if they fail to notify state officials of changes in their employment and income.
Fifteen people have sued the federal government, asking a judge to block the new rules.
In 2007, West Virginia asked Medicaid-eligible individuals to sign a personal responsibility agreement to qualify for enhanced benefits. The agreement required beneficiaries to keep medical appointments, take medications, avoid unnecessary emergency department visits and participate in health screenings.
Those who didn’t sign it — or couldn’t hold up their end of the bargain — had their benefits cut, and were enrolled in a basic plan that restricted prescription drug coverage, limited access to mental health and substance-abuse services, and excluded weight management or nutrition education programs. Both children and adults were subject to the agreement, which raised a basic fairness question: Children might be at the mercy of unreliable parents or guardians to follow the rules.
Less than 15 percent of those eligible signed the agreement, and more than 90 percent of children with Medicaid had benefits restricted. A central motivation of the program was to reduce emergency department use, but overall, people were more likely to visit the emergency room. There was no clear improvement in health or healthy behavior. The experiment was scrapped in 2010.
Personal responsibility is, of course, not a binary construct. When we say unhealthy behavior — overeating, smoking, excessive alcohol use — is not your fault, we may rob people of the initiative to change it. When we say that same behavior is all your fault, we fail to recognize a more complex reality: Health is a product of genes, environment, work, education, family, medical care and many other factors.
Although it seems we should encourage personal responsibility, punishing the opposite may be heavy-handed and even counterproductive. Breaking down every factor that leads patients to develop cancer or heart disease or Alzheimer’s — and penalizing or rewarding them based on the share they could in theory control — seems a herculean and morally suspect task.