Some years ago, surgeons in Australia were refusing to provide heart and lung surgeries to smokers, even those who needed the operations to stay alive. “Why should taxpayers pay for it?” one surgeon argued in the policy’s defense. “It is consuming resources for someone who is contributing to their own demise.”
Though some were outraged — the Australian Medical Association called it “unconscionable” to ration services based on personal habits — many agreed with this stance. They saw nothing wrong with patients paying for the consequences of their actions.
Seema Verma, President Trump’s pick to lead the Centers for Medicare and Medicaid Service, sees things the same way. Verma, a health policy consultant, helped to reform Indiana’s Medicaid program, working with then-Gov. Mike Pence. With an eye toward competition and personal responsibility, her program, known as Healthy Indiana Plan, mandated monthly contributions from beneficiaries, even individuals at the federal poverty line. There were stiff penalties for missed payments: termination of coverage or transfer to a pared-down plan that offered limited services.
Verma has written that personal contributions are a way for Medicaid recipients to have “skin in the game.” She has said that traditional Medicaid regulations “disempower individuals from taking responsibility for their health, allow utilization of services without regard for the public cost, and foster dependency.”
Verma’s views are in line with those of many Americans. A majority say it is fair to ask people with unhealthy habits, like smoking and overeating, to pay more for health insurance. Even President Obama has said that Americans should be “doing something about their own care.”
At some level, this makes sense. People should be agents of their own wellbeing. I myself am sometimes put off by patients who don’t seem to care about their health and then demand a quick fix.
But personal responsibility is a complex notion when it comes to health. Individual choices always take place within a broader, untidy context. Demanding personal accountability often ignores that context and can lead to discrimination against the people least equipped to defend themselves.
I once took care of a young man with severe congestive heart failure who had a toddler at home but no reliable child care. We were supposed to start him on a blood thinner early in his hospitalization, but it got overlooked. Then, rushing to get his blood thinned, we overshot and had to stop the drug completely, leading to frustrating delays in getting him home. In the end he signed out of the hospital against medical advice. He told me he had to care of his baby.
He came to the clinic a week later looking embarrassed. He had left without prescriptions, so he had been taking no medications since discharge, leaving him short of breath. But the attending physician I was working with refused to give him prescriptions. She said he had to go to a walk-in clinic. She said he had to learn “personal responsibility.”
Patients should be encouraged to make healthy choices, but punitive measures to force those choices can backfire. They also presuppose more control over health and sickness than really exists.
Representative Roger Marshall, a Kansas Republican, said in a recent interview: “Just like Jesus said, ‘The poor will always be with us.’ There is a group of people that just don’t want health care and aren’t going to take care of themselves.” When the interviewer asked him to elaborate, he said, “ I think just morally, spiritually, socially, [some people] just don’t want health care. The Medicaid population, which is [on] a free credit card, as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising.”
Consistent with Marshall’s views, under Verma’s program in Indiana, missing two payments can get you kicked out of Medicaid for six months. We don’t know why some patients in Indiana are delinquent on their payments, in part because little data has been made publicly available. (The Center on Budget and Policy Priorities, a left-leaning organization, says Indiana has not cooperated with attempts to assess the program independently.) But a Medicaid experiment in West Virginia in the late 2000s suggests people often fail to comply with such requirements because of mundane, if no less demanding, life pressures.
In the West Virginia program, Medicaid patients who signed pledges to enroll in a wellness plan and follow their doctors’ orders were rewarded with special benefits, including unlimited prescription-drug coverage, diabetes care, and nutritional counseling. Even so, many patients still did not sign up. Those with limited transportation options or childcare responsibilities could not commit to regular office visits. Sadly, patients who could benefit most from the additional services were often least able to comply with the requirements, rendering them ineligible.
Irresponsibility can lead to unhealthy habits and thus poor health. But so can social status, income, family dynamics, education, access to healthy foods and genetics. It is reasonable to demand personal responsibility, but patient noncompliance is as much a function of poor communication, medication costs, cultural barriers, psychiatric illness and inadequate resources as it is of willful disregard of medical advice.
Americans are right to worry about rising health insurance premiums, and there is no denying that the relatively healthy majority will continue to pick up the tab for the sick minority, even those whose misfortune appears to derive from lifestyle choices. That is the nature of insurance: The fortunate among us subsidize care for those less fortunate.
But punitive measures like the kind Verma espouses will not improve the health of the vulnerable populations she is supposed to help. They will also probably lead to higher costs in the long run. Championing personal responsibility is fine, but punishing patients who make poor choices will only worsen this country’s health.
Doctored: The Disillusionment of an American Physician Intern: A Doctor’s Initiation