Monday, June 12, 2006
Responsibility for Health
Sorry to be away for so long! Events overtook me. So I'll be doing my "May stint" here for a bit of June. I'm also doing some blogging on IP topics at Madisonian.net; I'll save this space for my other interests.
There's been a lot of talk on the news lately of a celebrated Pittsburgh Steelers quarterback (Ben Roethlisberger) who crashed his motorcycle and was badly injured while not wearing a helmet. TV news stories focused on several NFL players who've defied contracts requiring them not to ride helmetless, and on the American Motorcyclist Association's opposition to helmet laws. Proponents of helmet laws then noted that a high percentage of motorcyclists don't have insurance, and claimed that, at least for those riders, their "personal choice" had dire consequences for the public purse. Apparently the AMA is having the better of the argument in several states, including Pennsylvania, which appears to have recently repealed its helmet law for riders over 21.
But at least some people are being held responsible for their health. Under the Deficit Reduction Act of 2005 (which passed in 2006, and actually increases the deficit), states are permitted to impose all manner of paternalistic restrictions on Medicaid recipients:
Starting July 1, West Virginia will phase in a redesigned form of Medicaid that requires patients to sign a "member agreement," promising that they will keep doctors' appointments, take prescribed medicine and not overuse hospital emergency rooms. Patients who refuse to sign or to follow the rules will be eligible for less care.
I was recently at the Health Law Teachers Conference, where participants marveled at the conflicts of interest lurking here. Are doctors supposed to turn in patients? How about ERs? The biggest problem is, of course, that medical spending is driven less by profligate patients than by chronic illness (a point my colleague John Jacobi makes in his Michigan J. L. Reform article, Consumer-Driven Health Care and the Chronically Ill).
For me, the bizarre contrast here highlights a few problems in our political culture. The common impulse to let the insured rider "off the hook," while scrutinizing Medicaid expenditures, betrays a troubling indifference to the nature of "spillovers" in health care. Perhaps the insured cyclist's care will be "paid for;" but if you're the one who's triaged behind him in the ER waiting room, you're bearing some cost for that action. And perhaps the Medicaid recipient will be scared away from overuse of the system by the new paternalism; but perhaps he'll also miss out on necessary health care (and preventive interventions) once he's been "cut off" for insubordination.
So perhaps the bottom line is: it's not just the uninsured, or "wards of the state," who need to take responsibility for their health. Given limited health care resources, just about anyone who demands care for a preventable condition may be viewed as unfairly diverting that from another who could not avoid her fate (and who happens to have ended up, by virtue of bad timing or lack of purchasing power, at the wrong end of the triage line). This is not to say that I'm behind the whole "take responsibilty" mantra in health reform--I'd take it a lot more seriously if it were backed by significant funding for preventive care. I just want to say that it should not be focused only on the poor.
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