I visited my parents this past week. The are both in their 80s and in relatively good health although my mother received a diagnosis of diabetes while having a medical exam for an unrelated problem. I spent some time educating her about Type 2 Diabetes, the causes (genetics and weight gain) and the options (medication and/or weight loss and exercise). I stayed with my brother-in-law and sister and the conversation turned to the health care law and the implication of the upcoming election.
My brother-in-law is thoughtful Republican (his description) and while he would like to see everyone have access to some form of healthcare he questioned whether we weren’t already providing it (through EMTALA ) as well as why couldn’t somehow penalize folks with poor health habits. I already had a pretty good answer for the first part of his question but have always been troubled by the second. The nagging feeling that it is somehow wrong was offset by an e-mail I received offering a $25 per month discount to our health insurance if I certify that we (my spouse and I) are non-smokers.
The public debate leading up to the law (and following the passage of the law, the continuing “conversation”) has been unenlightened. The discussion leading up to the Clinton health plan offers a lot more insight into these issues.
Reinhard Priester wrote an article in Health Affairs detailing what our current collective values were and what societal values should be emphasized in an American health care system. He points out that access, while considered important, is a confusing concept to most Americans. When we discuss who should have access to care, do we mean everyone gets it or do we mean if you get really sick you get everything you need to get better (or until you are too sick to use it)? The writer feels that we as a society should be working to get everyone access because,
access should be the driving value because of health care’s importance in promoting personal well-being, avoiding irreversible harm, and preventing premature death. Everyone should have access to health care to cure or prevent illnesses, mitigate symptoms, and ease pain and suffering.
He identifies a reason we are still having such trouble accepting the concept of unfettered access.
Although the value that care should be provided to poor and disadvantaged people is long-standing, its ethical obligation is limited to providing charity for the so-called worthy poor. Unlike the value of access, the charity ethic complements other values of American medicine. Individual and institutional providers are free to select which of the patients unable to pay are worthy of receiving free care. The concept of the worthy poor derives from the peculiarly American notion that for many poor people, poverty is somehow deserved. From this perspective, access to necessities such as health care, and clearly to all of life’s luxuries, depends on personal effort, achievement, or merit.
The ensuing 20 years has not led to Americans becoming more accepting of universal access. The concept of the deserving poor has morphed into that of the deserving sick person. Our current surgeon general, for example, has been called to task for her “unhealthy” weight. Along these lines West Virginia tried to impose a “personal responsibility” standard onto their Medicaid program in 2006 but was unsuccessful on several levels. The state was unable to get the “responsibility” paperwork signed by the responsible party due to poor planning on the part of the agency and the “experiment” failed. Many expressed concerns that such a program would lead to a worsening of the health of those the program was intended to help:
There are many reasons why patients might not comply with medical recommendations. These include poor physician–patient communication; side effects of medication; advice that is impractical to follow for reasons that include job responsibilities and difficulties with transportation or child care, psychiatric illness, cost, the complexity of the recommendations, or the language in which they are communicated; and cultural barriers. Patients who may benefit from additional services, such as diabetes care, education in nutrition, or chemical-dependency and mental health services, include many who might have difficulty with compliance, thus increasing the likelihood that they will not be eligible for these services under the West Virginia program.
In an accompanying article, the problems with “personal responsibility” are nicely outlined but best illustrated in a case
Mary Jones is your 53-year-old patient with diabetes and obesity. These conditions developed after she began to take an atypical antipsychotic drug for schizophrenia. Jones signed a treatment contract stating that she will keep all her medical appointments, attend diabetes education classes, and lose weight. She attended one class but became paranoid and left halfway through it, and she has gained 5 lb. You gave her educational materials to read, but you have discovered that she doesn’t understand them. She has just missed her second consecutive appointment with you; last time, she didn’t have bus fare. Neither her glycated hemoglobin nor her blood lipids are at target levels. You are now legally obligated to report this information to your state Medicaid agency, and Jones may lose her mental health benefits and some of her prescription coverage as a result.
In short, before shouting about overweight welfare recipients, perhaps physicians should endorse a more nuanced position (such as has been outlined by the ACP). Even better, perhaps we should support changes in the societal structure that will reduce obesity.
When I left, my mother committed to making better meal choices and exercising more (or even at all). For her, to not do so does not mean that she will lose access to health care. I hope that continues to be true for everyone. On the other hand, perhaps adding the cost of an extra 5 packs of cigarettes a month to the insurance might change some behaviors.
Allen Perkins is Professor and Chair, Department of Family Medicine, University of South Alabama. He blogs at Training Family Doctors.
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