Personal Responsibility, Public Policy, and the Economic Stimulus Plan

Abstract

There is a tension between acknowledging the role of personal responsibility in health care and the role of social factors that influence individual decisions. Although often unspoken, this tension occasionally arises in ethical arguments about patient care (should Mr. Jones, a heroin addict, be discharged from the clinic if he misses another appointment?). It also surfaces in policy discussions (should health insurance cover surgery for morbid obesity?). Recently, it's been an underlying theme in partisan conflicts about health reform. But the economic stimulus package provides an opportunity to put the current debate about personal responsibility and social factors to good use: it can help target federal spending to achieve greater immediate and long-term benefits. The Marketplace of Individual Health Choices Free-market conservatives tend to believe in personal responsibility and to hold that incentives can influence personal decisions, including decisions that affect health. Each individual faces a different set of personal incentives, which is why each of us can and should make different choices. But conservatives tend to focus on price as the only manipulable incentive and sometimes overlook the fact that the physical and social environment one lives in, which can make it much easier or harder for individuals to act responsibly, is part of this incentive structure, too. Political liberals, on the other hand, understand that social policies can incentivize personal decisions, but they tend to focus on public policies that explicitly encourage socially desirable behaviors. Like conservatives, they often focus on price as an incentive, such as tax code changes or direct price supports to encourage certain behaviors. But these efforts can backfire, and they always draw the ire of conservatives, who see such policies as socialistic forays into a designed economy and examples of an inefficient, disrespectful, big brother ideology. But at least there is this one bit of common ground for the two sides--that incentives matter in personal choices. The ideological arguments don't break out until one considers the role of government in establishing incentive structures. This area of agreement leaves an opening for a compromise role for government spending, at least with regard to health care: government spending that makes it easier for individuals to make healthy choices might--through personal responsibility and market principles alone, no coercion or socialism needed--lead to benefits for individuals and society. Individual Responsibility and Health There is no doubt that individual health habits--personal choices--affect health outcomes and costs, both individually and for society at large. At the societal level, Americans spend more than $100 billion on obesity- and smoking-related illness alone; caring for preventable illness accounts for much of the difference in per capita spending on health care between the United States and European countries. (1) If we could recapture that money, it would be enough to provide health insurance to all Americans. By one prominent estimate, just reaching reasonable and achievable levels of prevention for seven common illnesses could save billions in health care expenses per year and would increase national productivity by $1.1 trillion per year by 2023 (the t is not a typo). (2) At the individual level, basic lifestyle changes can prevent non-insulin-dependent diabetes and are more effective than drug treatment for those who already have the disease. (3) Regular exercise extends life, improves cognition and memory, is as effective as medication in treating depression, and even improves one's sex life. (4) Granted, it's been in vogue recently to argue that not all prevention programs save money; and it's true, not all do. (5) But those who argue that prevention does not save money because you have to die from something eventually are generally talking not about lifestyle changes, but about the costs of screening tests, drug treatment for hypertension or hypercholesterolemia, and other secondary and tertiary preventive care measures. …