Opinion

Forget single-payer: Let’s focus on personal responsibility

When many Americans choose not to live healthfully, the health-minded shouldn’t be on the hook for the financial consequences.

Editor’s note: This is an opinion piece; the views expressed are the author’s own and do not necessarily represent the views of The DO or the AOA. This is a response to a July opinion article that supported Medicare for All.

Amid the ballooning costs that plague the complex U.S. health care system, one idea seems to be universally acknowledged; change is required. Some seek to change current legislation, others request a full Affordable Care Act (ACA) repeal. However, debates in the political arena are mired by pre-existing conditions and who foots the bill.

Left by the wayside is how to minimize costs at the level of prevention.

Consider vaccination: many accept that a small price to prevent a disease is better than several thousand dollars to remedy it.

If a parent decides against routine childhood vaccinations and their child gets a debilitating, costly disease which decreases their quality of life and elevates the risk of many comorbidities, the community suffers a larger burden that could have been prevented for a nominal cost.

This parable parallels the nationwide obesity epidemic; lifestyle choices beget negative—yet avoidable—consequences. Preventive care is intimately tied to the concept of personal responsibility.

The system’s broken, doc

Unfortunately, data indicate that many Americans are not caring for themselves. Medical care is heavily skewed to combat existing problems. This situation has produced a system that hemorrhages money for care and a population that simultaneously becomes less healthy. Something has to give.

Obesity, a generally preventable disease with roles in Type 2 diabetes, atherosclerosis, depression, osteoarthritis, and myriad other diseases, is the poster child of comorbid conditions. Its prevalence and trajectory are harbingers of increased medical costs.

Erich Berg, OMS II

One in three American adults is obese and according to some estimates, one-half of adults in the U.S. will be obese in little more than a decade. Weighing the costs per capita in obese versus healthy patients, and the decreasing age of onset, it appears obesity and its derivatives will become unaffordable by those who bear the fiscal burden. Current efforts seem doomed to contain this chronic condition.

“I have a right to live how I want.”

As providers, it is difficult to address this topic without sensitivity and empathy. Autonomy must be respected regardless of a patient’s weight or smoking and drinking habits. Yet, autonomy is a great argument against a single-payer health care system; although some choose to live recklessly, the more health-minded should not be mandated to cover such damaging lifestyle choices.

Skin cancer from tanning beds or injuries to an unrestrained driver are other examples that certain behaviors cause poor health outcomes. It’s clear cut. Applied to health insurance, this concept would shift the approach to primary and preventive care to discourage high-risk behaviors and tackle the key issue of unfettered increases in costs. Instead of higher taxes for everyone to offset risky behaviors, Americans should be held individually accountable for their wellness. They maintain autonomy to eat, drink, and be merry. But, the health-minded shouldn’t be on the hook for the financial consequences.

The government’s role

Although universal care is derided in this opinion, government does have a key role in the vision. States could limit the sugar content in beverages, tax fast food, or dictate that the waist-to-hip ratio become a “new vital sign,” rewarding providers with better health outcomes regarding obesity.

Legislation could take years, but if the private sector deters disease through old-fashioned behavior reinforcement, savings would follow and lives could be improved. After all, an ounce of prevention is worth a pound of cure.

Further reading

It’s time for a single-payer health care system in the US. Here’s why.

Medicare for All equals quality health care for none

26 comments

  1. Interesting thought, but maybe a little over simplified. Where does one draw personal responsibility in the congenital, hereditary, or intrinsic diseases. How does this system weigh the cost of cystic fibrosis against tobacco abuse?

    1. I understand your point. Congenital is less than 1% however and that’s cool. The real cataclysm is the others who are uneducated in diet excercise and clean air. A society that promotes abject atrocities to one being needs to be confronted feeling set aside tenderly.
      I give the kid credit. The monster is in the closet

  2. Where does one draw personal responsibility in the ubiquitous structural violence we see so clearly in poverty, or the decisions/afflictions of a parent or family member? “Nobody knew healthcare could be so complicated.”

  3. I appreciate the DO publishing your opinion since it is not exactly a popular one among OMS, particularly ones in leadership groups. The thing is, providing access does not obligate any patient to utilize that access. They retain their autonomy to ignore their health. Not providing access at all by not supporting a public option actually takes away their autonomy by not allowing them the option to refuse or utilize medical care. I get your point and don’t disagree that personal responsibility must play a role, but your premise is flawed as above.

  4. An excellent point, penned simply. I believe many doctors think this way, though we often wonder how to implement it in a beneficent way.

  5. Very simplistic opinion piece but point well taken. I’d encourage you Erich to take a look st what New York State and even NYC have done with regard to health policy – caloric content on restaurant menus, taxes, labeling, etc.

    Taxes on unhealthy foods “Twinkie tax bills” – have been brought forth now for many years. It’s not a new concept. It’s met resistance largely because of strong “food lobbies” (companies like CocaCola, FritoLay, etc have strong lobby groups) not just the notion that people resist government interference on personal behaviors. Food is big business.

    Good luck w ur second year of med school Erich

  6. Very oversimplified. Perhaps consider an MPH in addition to your medical degree if these are the topics you’d like to address. I can’t even begin to offer plugs to all the holes in this. One thing I will offer up, medical schools offer woefully inadequate education in nutrition, arguably the crux of all prevention. Doctors are part of the problem. Ask yourself, are you eating a whole food plant based diet? If not, you are also behind the curve in nutrition research regarding prevention. Consider health disparities based on socioeconomics, for example people in low income settings that simply do not have ready access to healthful food. Best of luck as you continue your education.

    1. Could not agree more! Every medical student should have an MPH because we need to understand that health behavior is affected by numerous interpersonal, social, environmental and cultural factors. Acquiring a healthy BMI is not just about personal responsibility and willpower.

    2. Thanks for your read and comments. Food deserts are nothing short of an excuse for the obesity epidemic in this country. Per the USDA, of all the households in the U.S., a mere 2.2 percent live more than a mile from a supermarket and have no transportation. Two percent. Another fact is the poorest 1/3 are not predominately affected by obesity – the middle 1/3 class bears the highest prevalence. Agree that doctors are not doing enough. But then again, even if they were the patient bears the responsibility to implement positive lifestyle changes, which is central to my theme. Thank you for the well-wishes.

  7. I agree, Erich, partnering with our patients to address preventable disease is critical. The patient has to feel empowered to work towards their own good health outcomes. However, I think your assessment misses many of the bigger issues.

    We, as a society, are already paying for the adverse outcomes of preventable disease. 64% of healthcare costs in America are already being paid for by the government through Medicare, Medicaid, the VA healthcare system and other government sponsored programs. But our current health insurance models, with high out of pocket costs, disincentivizes compliance with treatment regimens, and disincentivizes seeking out preventative care. I agree with you that prevention is vital, but less comprehensive insurance coverage will not help get us there.

    Education is critical. Health literacy among our poorest and sickest patients tends to be low. It is not as simple as demanding that people simply take more responsibility for their own health. Not everyone has access to the same information about healthy practices, or the same resources to buy healthy and nutritious foods. There are so many systemic inequities that contribute to why patients make the decisions that they do. The physician can play an important role in health education, but if people are discouraged from seeking routine care because of cost, they miss out on the important lessons about maintaining good health.

  8. Oversimplified and problematic to view health care in this siloed way. Medicine has many dark spots in history that have aided in creating the health outcomes we have today. It is imperative that doctors unpack what they are seeing in their clinical settings and strongly resist labeling and patient blaming. Understanding the roles that trauma and oppression play in health is undertaught in medicine.

  9. This opinion doesn’t acknowledge that there are a large number of people who can’t afford to be live a healthy lifestyle. Many places are food deserts; selling only food rich in fats and low in nutrients and seldom fresh/fruits. If they can find access to healthy food, they are usually unable to afford the cost. How do average Americans stand a chance against mass advertisement, poor access to healthy food and importantly, decrease access to physicians and/or nutritionist? You cannot say people are drinking and being merry, when it is their only option. As someone who comes from a disadvantage background, I know how hard it is for families to make this costly changes. I agree that Americans need education but the problem is much more complex than you realize. The healthcare system is not setup to educate on patients prevention but only to provide bandage for the bigger problem. It’s important to leave your judgement about patient’s at the door about how your patient’s have been living. I think there is a point in medicine where you have to realize that without people’s poor choices… there wouldn’t be a need for doctors.

    1. I am happy to see this opinion piece. As a country, out focus has been on health care as a right. Too few have embraced the view that this right should be balanced by personal responsibility for one’s health. I am completely against bariatric surgery, which is fraught by failure and complications. One of my mentors from may years ago was a general surgeon who also happened to be a preacher. He would look at his obese patients and say “Mr or Mrs So and so, how did you ever let yourself get like this?” Patients need to ask themselves this same question, then do something about it. If you don’t take personal responsibility for your health, then don’t make society responsible for your health care bills.

    2. Appreciate your comments, but the facts disagree with you; food deserts are an excuse for the obesity proliferation in this nation. Per the USDA, of all the households in the U.S., a mere 2.2 percent live more than a mile from a supermarket and have no transportation. Two percent. Second, eating healthy can be inexpensive. The higher cost to eat fresh myth has been debunked many times over. ‘Without people’s poor choices there wouldn’t be a need for doctors’ – this is very shortsighted and ignores every genetic disease to ever burden man.

    3. There is some truth to the “food desert” issue, but that is only one part of the problem. It’s not just what you eat and drink, but how much you eat and drink. So lack of self discipline is a much larger part of the problem, and is also responsible for sedentary lifestyles and lack of exercise as well. And then there are parental models. I can’t tell you how often I see obese parents with their obese kids, whether in a restaurant or coming out of a store, eating and drinking high-caloric empty nutrition foods. For many thousands of years parents have been responsible for raising their children, and now you want the healthcare system to be the educator? These people need to educate themselves, motivate themselves, and change their own behaviors. Very simply, people need to take responsibility for their own health.

  10. I have to agree with the other comments. Yes, personal responsibility is an important part of one’s overall health, but you haven’t taken into consideration the complexity of what it takes to actually make healthy decisions for many of our patients, including access to healthy, affordable foods and safe spaces in which to exercise.

    As an example- in NYC, I could buy a banana for $0.25 from the fruit cart on the corner of the streeet. In the bodega next to my clinic in the Bronx, a banana cost $1, while you could buy 2 bags of chips for that same dollar.

    I also urge you to look at the research around Adverse Childhood Experiences (ACEs) and the impact they can have on chronic disease and life expectancy. Perhaps, as another commentator suggested, an MPH is a good degree for you to consider!

  11. Why participate in health insurance plans at all? If you’re talking about patient responsibility why not simply bill your patients and let them worry about filing and paying you? Many dentists, most lawyers, and a lot of collision shops have opted out of the insurance participation game. Participating means relinquishing professional control for payment of your services. Aah, but these days if you’re are a hireling with a hospital or group then you have to do as they say, don’t you? I wonder what physicians from 100 years ago would think.

  12. Keep those thoughts going. We here never seem to learn from bad behavior. Once read that 85 % of Health problems are from bad decisions. US Health has always been,“Crisis Management “.

  13. I’d like to share a quote from Robert Sapolsky’s book “Why Zebras Don’t Get Ulcers”:

    If you want to improve health and quality of life, and decrease stress, for the average person in society, you do so by spending money on public goods- better public transit, safer streets, cleaner water, better public schools, universal health care. The bigger the income inequality is in a society, the greater the financial distance between the wealthy and the average. The bigger the difference between the wealthy and the average, the less benefit the wealthy will feel from expenditures on the public good. Instead, they would derive much more benefit by spending the same (taxed) money on their private good- a better chauffeur, a gated community, bottled water, private schools, private health insurance. As Evans writes, “The more unequal are incomes in a society, the more pronounced will be the disadvantages to its better-off members from public expenditure, and the more resources those members have [available to them] to mount effective political opposition.” He notes how this “secession of the wealthy” pushes toward “private affluence and public squalor.” And more public squalor means more of the daily stressors and allostatic load that drives down health for everyone. For the wealthy, this is because the costs of walling themselves off from the rest of society, and for the rest of society, this is because they have to live in it.

    We live in a country where too many of our patients work 40 hours a week, are financially responsible, yet still are forced to live in their cars because they can’t afford to rent even a cheap apartment. Walmart is owned by the wealthiest family in America, yet they put out food donation boxes for their employees in their stores so they can help each other eat. Is this really the country we want to live in? Arkansas is about to drop Medicaid coverage for over 4300 of its citizens because they failed to meet new “work requirements.” Maybe since they don’t work, we should also deny them access to fire departments, the police, and public schools because they are so undeserving.

  14. The only main problem I see with this article is the idea to incentive the doc instead of the patient (“rewarding providers with better health outcomes regarding obesity.”) Instead, charge a premium to individuals with risky behavior. As for those “poking holes” and recommending the MPH (which, btw, is insulting and paternalistic to tell the author to better educate himself in regards to his OPINION), most of you are throwing the baby out with the bath water. Start with low-hanging fruit: Anyone who smokes automatically pays a premium. While not everyone can choose the food available to them, everyone can choose whether or not to smoke. Start there and add as appropriate.

  15. Please consider volunteering in a community that exists far below poverty level. Better yet, try living there for while, using only the services, stores, etc. in that community. Hopefully you will learn that not everyone has the same opportunities and access to healthy food, places to exercise, libraries, education, etc.

    I wish you the best of luck in medical school and I hope that your compassion grows along with your medical knowledge.

  16. Right on man
    Diet,excersice and clean air. Drugs are poisons and the body will heal itself. How Osteopathic is that, kudos to you!
    Granted sometimes you get hit by the bus and need a Jedi force to get you right. Been there as a trama surgeon ,KCOM 1980, third generation proud Osteopath from Flint. I’ve taken a look around and see which way the wind blows and feel Still.
    We are the minority brother. Even our Osteopathic fellows are getting bogged down in political social dribble. As a certified osteopath disease is my enemy not some bureaucracy or political agenda.
    As a moral doctor of osteopathy our trusted realitionship with a patient must be meet with the truth. Education in diet and excercise is our calling as an Osteopath. Shamefully we not only are ignorant but now somehow politically motivated into agenda biased lemmings.
    If you’re An Osteopath and you think you know what you’re doing I challenge you to read the China study by colin campbell. Also pick up a copy of the autobiography of a A.T Still after reading it I think you’ll agree with young man who wrote this post.

    1. I agree that good food, exercise, and clean air are extremely important to one’s health. Unfortunately, those things aren’t readily available to everyone/every community/every neighborhood. By ignoring that fact, the author is showing a lack of awareness about the world he lives in. Third year, if his SOM does it right, is going to tear the scales from his eyes.

      I absolutely buy into the idea of treating the whole person…and that includes treating the ills of the community (lack of access to good food, lack of access to parks and green space, lack of access to healthcare, etc., etc., etc.) in which one lives.

  17. I understand the prospective of the article but think that patient responsibility is only a small aspect of health care. As an medical oncologist, the behavior of most of my patients has little to do with them developing cancer.

    A simple way to think about health care is to return to the basic principles of prevention. Physicians all know that primary prevention is better than secondary prevention, which is better than tertiary prevention. When we discuss patient responsibility and lifestyle we are typically dealing with primary prevention. Diet and exercise are excellent primary prevention for cardiovascular and pulmonary disease. However, there are very few true evidence based primary preventions for cancer, besides smoking prevention and HPV vaccines. Cancer screening tests such as mammography are secondary prevention and do not stop cancer from occuring. Thus, a majority of cancers are not preventable and not influenced by lifestyle.

    I feel that your limited experience as a second year student, who has yet to really see and interact with patients, contributes to your prospective. I am hopeful that once you become a more experienced provider you’ll develop more empathy for your patients and realize that we are all at risk for illness and disease, even with an “ideal” lifestyle.

  18. I think you have hit on the crux of the issue for either single payor or private / employer offered insurance: personal choice.

    Although I believe that universal coverage is a better option, I agree that the flaw will still be individual freedom. How do we incentivize people to make healthy choices / de-incentivize unhealthy choices?

    As it is, we can ruin our health, and expect the government to cover the cost once we hit 65.

    If we indeed want universal coverage, we need (near) universal responsibility.

    This also affects my private / employer provided insurance. I make healthy choices, but yet contribute via my premiums to pay for the results of others’ unhealthy choices.

    Any system will be flawed, because human nature is flawed.

    None the less, I became a physician to care for ALL people in need, even if they made poor choices and suffer the resulting consequences.

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