Sunday, July 15, 2012

It's Time to Take Resposibility for Our Health

If you smoke or drink, that’s no longer your fault, it’s your genetics. You just inherited a predisposition for addiction. If you are obese, that’s no longer your fault, it’s a glandular problem, a metabolic disorder, or due to your genetically-caused diabetes. We have been pathologizing all of these problems that our society faces. The bottom line is that people need to take more responsibility for their health.

By pathologizing all these problems, people feel like these issues are not their fault. This can lead to a sense of helplessness, and people feel like they cannot do anything about these problems, and so they do not do anything about these problems. This functions as a positive feedback loop and only makes the problem worse. Also, they think that their only solution is medicine or surgery, which can have a lot of deleterious side effects and complications.

At the same time, I don’t want to generalize; there are situations where this doesn’t apply. Some people with diabetes are extremely overweight or underweight, and there is not much they can do to remedy this. Charles Fried, in Right and Wrong, goes so far as to say that “when the disadvantage is medical or educational it is a disadvantage to the person rather than to something which the person has done or chosen” (126). Essentially Fried argues here that a person’s medical problems are not that person’s fault. This seems to imply that most medical problems are genetic rather than environmental (i.e. caused by diet, lifestyle, etc.). He says that medical misfortune is misfortune to a person just like a fire can be misfortune to a house. In some cases this argument might be valid, but most of the time this is not the case. If this were how society viewed medical problems, then this would be a moral hazard. If people were not held responsible for their medical problems, then there would be less incentive for them to take care of their bodies because they feel that their medical problems are not their fault and that there is nothing they can do about them. From a scientific perspective, there are certainly some diseases that are genetic and are not the person’s fault; that’s just the card they were dealt. However, most diseases have at least some environmental component, so a person should take responsibility for their illness. Failure to do so will only worsen the obesity epidemic in the United States, which leads to heart disease and other cardiovascular problems, diabetes, and cancer. This, in turn, puts a strain on the health care system and causes us to spend even more money on health care. Therefore, by taking responsibility for our health, our citizens will not only be happier and healthier, but we will also partially remedy our health care spending crisis.

Affordable Care Act

I initially thought the Patient Protection and Affordable Care Act (PPACA, or just ACA; watch this video from the Kaiser Foundation for a great overview of the law) was going to be ruled unconstitutional by the Supreme Court. It doesn’t seem constitutional to force everyone to get health care, and this is exactly what Chief Justice John Roberts said. We don’t force everyone to eat healthy. We don’t force everyone to exercise. However, Roberts argued that the mandate is actually a tax levied by Congress on a citizen’s decision to forgo insurance. This logic seems to follow, as we tax other decisions that people make, such as smoking. Also, our government taxes people to pay for health care for people over 65 (Medicare), so why would it not be allowed to do the same for those under 65? Regardless, I am thrilled that the ACA will be carried out. Everyone should have access to health care. Health care should be treated as a basic right; this is the way it is viewed in most other Western countries. Indeed, one of the reasons I have chosen to become a doctor is to provide health care for as many people as I can.

As an aside, I have a newfound respect for Chief Justice Roberts. He was not afraid to rule against his fellow conservative colleagues. I’ve always had a lot of respect for Justice Anthony Kennedy, typically known as the “swing vote” because he sometimes sides with the conservative justices and other times with his liberal colleagues. He doesn’t let politics get in the way of his decision-making, and this time I am glad that Roberts did the same. I commend him for the courage it took to make this decision.

So what does this mean for us as medical students and future health care providers? My first thought is that we are going to be busier and have more patients to see. On the plus side, we won’t be dealing with the issue of having to provide care for the uninsured, and I would imagine it is currently very hard for doctors to prevent giving care to patients that lack insurance. Therefore, the ACA will decrease the burden of uncompensated care on doctors and hospitals. In addition, there should be less insurance company bureaucracy to deal with, so we will have more time to care for our patients. Lastly, the ACA will give states and local governments more resources for preventative care, which will help our population become healthier. After all, this will be our goal as doctors.

My only real concern is the cost. The Congressional Budget Office estimates that the ACA measures will cost us $938 billion over 10 years. However, the ACA also includes provisions for cost reduction (mostly from health care providers and insurers, which will be paid less, mostly in the Medicare department), and the country will actually be saving money. This seems amazing, and I am curious to see if this will actually happen.

Lastly, what does this Supreme Court ruling mean for our country’s imminent presidential election? I personally don’t think it will have too much of an effect because the bigger issue for the election will be the economy. However, according to a June Ipsos poll, 73% of independent voters oppose the ACA, which favors Romney, who has said he would work to repeal the ACA on his first day as President. This is rather interesting when you consider the Massachusetts health care law enacted during Romney's tenure as governor, which mandated that nearly every Massachusetts resident obtain health insurance. The smart move might have been to accept the ruling on the ACA and focus on other issues, like the economy. It will definitely be an interesting presidential election, but for now, it looks like many more millions of Americans will gain health insurance. This is definitely a reason to be happy.