August 24, 2006 06:45 PM
by Robert Steinbrook, M.D.
The concept of personal responsibility in health care is that if we follow healthy lifestyles (exercising, maintaining a healthy weight, and not smoking) and are good patients (keeping our appointments, heeding our physicians' advice, and using a hospital emergency department only for emergencies), we will be rewarded by feeling better and spending less money. The details of programs that emphasize personal responsibility, however, are often sketchy, and many difficult questions related to individual freedom and patients' autonomy remain unanswered. For instance, which well-meaning measures to promote responsible behavior actually make a difference, and which are primarily coercive and potentially counterproductive? Which measures may actually improve health or save money, and which may merely shift costs from government, private insurers, or employers to patients?
There are many examples of initiatives that are meant to promote personal responsibility. The World Health Organization will no longer hire persons who smoke, suck, chew, or snuff any tobacco product, although it will still recruit people "who do not have a healthy lifestyle." In the United States, some employers target smokers, some even going so far as to fire workers who smoke when they are not at work. At some companies, health insurance may cost less for nonsmokers or for people who complete weight-loss programs, and employees may receive financial incentives to participate in health screenings, fitness programs, or tobacco-cessation programs. Wal-Mart has considered discouraging unhealthy people from applying for work by including some physical activity in all jobs. A national survey conducted in July 2006 estimated that 53 percent of Americans think it is "fair" to ask people with unhealthy lifestyles to pay higher insurance premiums and higher deductibles or copayments for their medical care than people with healthy lifestyles.1 In November 2003, the comparable figure was about 37 percent. A healthy lifestyle was defined as not smoking, frequent exercising, and weight control.
Promoting personal responsibility for health and for obtaining health care is also part of the federal government's "Roadmap to Medicaid Reform." Under the Deficit Reduction Act of 2005, states have increased flexibility in designing and implementing their Medicaid programs, which are jointly financed with the federal government. For example, they can require cost sharing for certain medical services, such as the use of nonpreferred drugs and nonemergency care furnished in a hospital emergency department, and can participate in a demonstration program to evaluate the potential effectiveness of Medicaid-funded personal health accounts, which are similar to health savings accounts.2
The redesign of the West Virginia Medicaid program has recently become a leading but controversial example of efforts to reward personal responsibility. West Virginia has a population of 1.8 million; as compared with the United States, it has a higher percentage of residents with Medicaid coverage and near-poor or poor incomes (see graphs). In May 2006, the federal government approved the state's plan to provide reduced basic benefits to most healthy children and adults who are eligible for Medicaid because of low income while allowing them to qualify for enhanced benefits by signing and adhering to a "Medicaid Member Agreement" (see box).3 The enhanced benefits include all mandatory services as well as additional age-appropriate services that focus on wellness. Examples include diabetes care beyond basic inpatient and outpatient services, cardiac rehabilitation, tobacco-cessation programs, education in nutrition, and chemical-dependency and mental health services. Under the basic plan, prescriptions are limited to four per month; under the enhanced plan, there is no monthly limit. According to Nancy Atkins, the commissioner of the Bureau for Medical Services in the West Virginia Department of Health and Human Resources, the goals of the redesign are to streamline administration; tailor benefits to specific groups; coordinate care, especially for members with chronic conditions; and "provide members with the opportunity and incentive to maintain and improve their health."
