You’re Sick. Whose Fault Is That?

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 has recently received renewed attention. Vice President Mike Pence has argued for “bringing freedom and individual responsibility back to American health care.”

Mick Mulvaney, director of the Office of Management and Budget, expressed a more punitive view, saying, “That doesn’t mean we should take care of the person who sits at home, eats poorly, and gets diabetes.”

The call for personal responsibility is not new, nor just conservative. Barack Obama said, “We’ve got to have the American people doing something about their own care.”

Many Americans think it’s O.K. 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 partisan beholder.

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?

Medicaid reform is the policy context in which personal responsibility is most frequently discussed. The Trump administration has signaled a willingness to allow states to impose requirements for people to maintain Medicaid eligibility.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, previously helped shape Indiana’s Medicaid expansion. To get full benefits in Indiana, patients must contribute monthly to a “personal wellness and responsibility account.” If they fail to pay, they may have benefits cut or lose coverage entirely for six months. They must also make co-payments for certain services, and pay a fee if they use the emergency department unnecessarily. A preliminary report suggests the program has had mixed results. A final evaluation is expected later this year.

Other states are considering similar proposals, but a recent redesign of West Virginia’s Medicaid program offers reason for caution. 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 over all, 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.

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.

Personal responsibility is not always demanded equally of people at every income level. Many lawmakers want more “skin in the game” for Medicaid recipients, but not as many clamor for higher deductibles for wealthy Americans — even though they’re more likely to have enough “skin” to meaningfully play “the game.”

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.

Personal responsibility is an attractive goal with deep roots in American culture. But if it’s too aggressively pursued, it may conflict with another worthy ideal: In a nation as wealthy as the United States, sick humans deserve health care — even if they can’t pay, and even if they’ve made some bad choices.

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Dhruv Khullar, M.D., M.P.P., is a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research. Follow him on Twitter at @DhruvKhullar.

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