England Journal of Medicine has two
freely-accessible articles this week. As is usually the case,
their free articles are about important topics at the intersection of
medicine and social policy, and are worth reading. However,
this time, both articles rub me the wrong way. (Hat tip: href="http://psychmatters.blogspot.com/2006/08/colossal-collection-of-wandering-eye.html">Psych
The first, href="http://content.nejm.org/cgi/content/full/355/8/753">Imposing
Personal Responsibility for Health, by Robert
Steinbrook, M.D., is an opinion piece about the the concept of what the
author calls personal responsibility in health care.
The second, href="http://content.nejm.org/cgi/content/full/355/8/756">Personal
Responsibility and Physician Responsibility — West Virginia's
Medicaid Plan, is by
Gene Bishop, M.D., and Amy C. Brodkey, M.D. It is about a
specific implementation of the idea in the first article.
Here's the first paragraph:
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.
Now, I have plenty to say about the West Virginia plan, but that is not
what this post is about. Maybe I'll get to that later.
What bothers me about the two articles is that they are mislabeled.
You see, society has no reason to be concerned about personal
responsibility. If someone is overweight and has all kinds of
medical complications and dies early, that is not a matter of concern
for medical or social policy. The personal
responsibility aspect of it is the business of the patient.
That is what personal means.
The reason this got my attention is that the phrase personal
responsibility is a catchphrase of the current
Administration. It is a shortcut that represent an excuse for
cutting social programs, so that money can be diverted to enrich the
military-industrial complex. I'd hate to see the medical
establishment buying into that agenda.
The key to understanding this issue, and to understanding the bee in my
bonnet, is to realize that the phrase personal responsibility
is the wrong phrase to use in this context. As I said before,
matters of personal responsibility are of no concern to policymakers,
whether in the Federal Government, or in medicine.
What matters to us is not personal responsibility,
but social responsibility. If someone is
overweight and has all kinds of complications and dies early, it is not
the personal ramifications that concern us; rather, it is the effects
of those problems on the rest of society. It makes one of the
members of our society less productive and less participatory, it had
negative effects on the person's immediate family, friends, and
coworkers, and it costs us all money. Those things are not
matters of personal responsibility. No. It is
social responsibility that we are talking about here.
The thing is, social responsibility has become a catchphrase of the
political left. It is commonly used to denote topics such as
pollution, social programs, and energy conservation.
If we are not careful about our use of these phrases, there is a
terrible risk. The risk is that the phrase personal
responsibility will become associated with a right-wing
agenda, and social responsibility will become
associated with a left-wing agenda. This sloppy phraseology
could lead to sloppy thinking. It could lead to these issues
being perceived as partisan issues.
There is no reason for that to be the case. We ought to
consider each issue on its own merits. We do not need to
decide what we think about the issues based upon which party has most
effectively labeled it with a catchy phrase.
For example, health care saving accounts were touted as being
consistent with the concept of personal responsibility. That
sounds nice, and it is a good selling point. But is obscures
the fact that HSAs are mainly a tax shelter for the well-to-do.
The people who need them the most, cannot afford to use them,
and if they do use them, the tax benefit is quite small. But
it is possible that some people could get misled into supporting them,
even though the scheme is not in their best interest. They
might think "Oh, personal responsibility, that sounds nice.
I'll vote for that," even though they would reach the
opposite conclusion, if they actually considered the merits of the
Likewise, Some people might use the phrase "social responsibility" to
advocate for something like energy conservation. Some people
might get turned off by the phrase, since it sounds a lot like
"socialism" which has a certain reputation.
Getting back to the articles, I must say, I realize that the people who
write the titles of the articles have to use shorthand expressions, to
some extent. Perhaps I shouldn't find fault with them, for
choosing phrases that have subtle political connotations. But
these are important issues. We need to consider them
thoughtfully, not make snap decisions based upon catchphrases.
Would it help to note that there is no inherent conflict between personal and social responsibility? It is my personal responsibility to see to it that I discharge my social responsibilities.
I think that the when authors of the NEJM pieces refer to personal responsibility they are focusing on the locus of agency. They are noting that actions for which patients must assume responsibility are significant factors in the success or failure of healthcare interventions.
Actually, both "personal responsibility" and "social responsibility" are irrelevant here (no offense intended). While they may frame the political issues that cause a given politician, pundit, or administrator to choose one policy or another, they are not, in and of themselves, the major policy issue at stake.
The reason why our federal government and state governments cover healthcare under Medicaid is not (solely) out of a feeling of social responsibility. The real reason is because it actually saves us money in the long run, as counterintuitive as it is. These are people who will not be able to receive medical coverage on the free market, either due to inability to afford it or disability status, or both. As you stated, when they fail to receive adequate care, it costs us all money.
So what bothers me the most about these changes isn't an issue of responsibility, whether personal or social, but that CMS erroneously believes that this is a cost-saving policy. They are trying to behave as a private insurance company would, because apparently they slept through the policy class on market failures and collective action. In the short run, they will lower expenditures by covering healthier people who are more compliant and thus more efficient to insure, but expenditures are not the true measure of cost and savings, and McClellan knows that.
Besides, according to CMS's most recent Mid-Session Report, Medicaid expenditures are dropping along with Part D expenditures, while Parts A&B are apparently going up, so I don't see why they need to try to cut costs like this. Granted, they seem to believe that the threat of loss of coverage will incentivize beneficiaries to act healthier, but these are people who have already faced many barriers to healthcare, clearly the problem is not a lack of disincentives.