Writing for the New York Times' "The Upshot," Dhruv Khullar, a physician and researcher, reflects on the role of "personal responsibility" in health care in the United States, contending that "[e]fforts to inject more personal responsibility into health care ... have not consistently been shown to lower costs, improve outcomes, or save lives."
Khullar explains, "The basic idea," when it comes to personal responsibility in health care, "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." However, "the details of how this philosophy is applied ... get complicated," he writes.
Personal responsibility and Medicaid reform
According to Khullar, "Medicaid reform is the policy context in which personal responsibility is most frequently discussed"—even more so since the Trump administration signaled a "willingness to allow states to impose requirements for people to maintain Medicaid eligibility."
Indiana's Medicaid expansion, for instance, requires beneficiaries to pay into a "'personal wellness and responsibility'" account to receive full benefits—and failure to pay may result in a benefits cut or a coverage lockout. In addition, certain services are subject to copayments, and beneficiaries are fined for unnecessary ED use. According to Khullar, a preliminary report "suggests the program has had mixed results."
But while other states are weighing similar changes to their programs, "a recent redesign of West Virginia's Medicaid program offers reason for caution," Khullar writes. The state in 2007 asked individuals eligible for Medicaid to enter a "personal responsibility agreement to qualify for enhanced benefits," Khullar explained. Individuals who opted not to sign the agreement or couldn't meet the requirements "had their benefits cut, and were enrolled in a basic plan" with more limited benefits.
Overall, according to Khullar, fewer than 15% of eligible individuals signed the agreement, and since the program redesign also applied to children, more than 90% of kids under Medicaid had their benefits restricted. While lowering ED use was a key goal of the program, an assessment of the program found that overall, individuals were more likely to use the ED, and "[t]here was no clear improvement in health or healthy behavior," Khullar writes. The program stopped in 2010.
And outside of Medicaid, Khullar points out, a study from RAND Corporation found higher deductibles can lead individuals to skimp on "highly effective and marginally effective services."
Moreover, according to Khullar, "personal responsibility is not always demanded equally of people at every income level." He notes that while many lawmakers have called for Medicaid beneficiaries to have "more 'skin in the game,'" it's less common to hear calls for high-income Americans to pay higher deductibles, Khullar writes—"even though [high-income residents are] more likely to have enough 'skin' to meaningfully play 'the game.'"
A more balanced approach
It's "undeniable" that people "bear some responsibility for their health," Khullar writes, "but viewing personal responsibility as a central driver of longer lives and lower medical costs is problematic."
He writes, "Personal responsibility is … not a binary construct." He explains that "when we say unhealthy behavior—overeating, smoking, excessive alcohol use—is not your fault, we may rob people of the initiative to change it," but to suggest "that same behavior is all your fault, we fail to recognize" that "[h]ealth is a product of genes, environment, work, education, family, medical care, and many other factors."
Khullar concludes that while "[p]ersonal responsibility is an attractive goal with deep roots in American culture, ... 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" (Khullar, "The Upshot," New York Times, 1/10).
Understand the wellness spectrum—and promote healthy habits at work
Programs aimed at promoting healthy habits among employees are likely to lead to improved employee engagement and productivity—but they're unlikely to reduce the total cost of care. To do that, you'll need to take a population health approach.
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