With COVID-19, Americans are suddenly on the cusp of talking about personal responsibility and health care. People have been harassed and intimidated out of stores for not wearing masks. There have been many debates about whether political rallies are appropriate in the age of COVID and whether those who take more risks should pay a higher cost or be treated at all.
If only we could take this conversation out of the context of a pandemic and apply it to health care in general. Let me explain.
Jason rides a high performance motorcycle and does not wear a helmet or protective gear. Jessica smokes two packs of cigarettes a day and refuses to quit. Jeremy tends to overeat and weighs 100 pounds over his recommended weight. From a medical perspective, these are all high-risk lifestyles. To what extent is society responsible for paying for health care for these people and what is the role of personal liability?
Common sense says that people understand their life choices and would have health insurance that covers their choices. It also seems logical that risk-taking insurance companies would charge customers more for policies that cover the lifestyle choices that frequently result in illness and injury.
Unfortunately, that is not how health insurance and health care policy evolved in the United States.
The tragedy is that no one talks about personal responsibility in the ongoing health care debate. The left simply wants more government involvement. The right still believes in free markets, but sidesteps the issue of a person’s contribution to their own health and well-being.
The entire socio-economic system in the United States is based on free choice. The personal responsibility that everyone must assume is inherent in these choices. Health care should be no different.
Car insurance is purchased and people with poor driving habits pay more for their policies. Homeowners with good maintenance, smoke alarms and security systems pay less for insurance. So why is health insurance treated differently?
It all goes back to how health insurance developed in the United States. Since 1943, employers have received tax relief when they provide health benefits to employees through group insurance. There are some modifiers, but essentially employees are grouped into risk pools, regardless of the health risks of individual members of the group. Half of all Americans receive their health insurance from their employer through this type of group-based arrangement.
Medicare and Medicaid began in 1965 and Obamacare benefits in 2014. Forty percent of Americans receive their health insurance through these government programs. There is no significant health underwriting in these taxpayer funded plans and therefore high risk lifestyles are not a concern for people participating in these programs.
The remaining ten percent of Americans are either uninsured or in the private individual health insurance market, where again, no significant risk underwriting takes place.
The question is whether people would change their high-risk behavior if they were entirely responsible for their own health care costs.
Advocates on the political left claim health care is a “right.” How does personal responsibility figure into this belief? Should the rest of us, through taxation, fund health care for people who choose to engage in high-risk behavior?
Obamacare has proven that the government cannot force people to buy health insurance. Even though the law imposed an individual mandate (which has essentially been repealed), only 40% of the 50 million who were uninsured when the Affordable Care Act became law chose to purchase insurance or register with Medicaid.
If the government pays for all medical care, which it does in Medicaid and in a single-payer system, could bureaucrats ban high-risk behavior? Could cigarettes be banned? Could people be forced to be proportional in height and weight? Could patients be forced to comply with taking their medications and follow their doctors’ orders?
Rightly, such harsh government mandates would be unacceptable to Americans. On the other hand, the financial impact of any high-risk activity should not be passed on to taxpayers, most of whom lead responsible lives.
The logical solution is to remove government from our health care delivery system and allow patients, as consumers, to control their own health care spending and be responsible for their own lifestyle decisions. . Meaningful reform would require a change to the federal tax code so that individuals can receive the same tax relief that employers have enjoyed for 70 years. This would require supplier price transparency; and this would require health insurance reform and the restructuring of existing government health programs.
Unfortunately, there are currently no federal or state programs in which personal responsibility plays a key role or is incentivized to play a key role. The closest example of a more direct approach is seen in how some employers reduce employee premium costs if employees participate in an exercise program, smoking reduction plan, or of weight loss.
When the government is responsible for our health care and taxpayers are forced to pay for it, the idea of personal responsibility becomes meaningless. The rights of government are not concerned with personal responsibility. Expanding health care rights could even distance people from personal responsibility.
It sounds absurd, but tragically a reality.