Personal Responsibility- Opportunities and
Challenges for a Healthier America
by: Greg Vigdor, Washington Health Foundation President & CEO
The 2012 presidential election is only a few weeks away and it seems like Barack Obama and Mitt Romney can’t agree on much of anything. Lots of arguing, lots of finger pointing…..but not much common ground. Funny thing is – one of the only things they do agree on, they’re wrong about!
Both candidates have revealed by action that, despite the rhetoric, they are in pretty much the same space with regard to how to deliver and finance medical care. That is, through the current American health care delivery system, rather than some major change to it. Haven’t we tried that long enough? Isn’t it time we look for new ways to fix our broken system?
For example – one of the health issues that has popped up in the Campaign is the reference by Governor Romney to the now infamous "47%”. Specifically, the suggestion, spoken by the candidate but usually unspoken yet believed by many leaders on both the right and left, that nearly half of all Americans are unwilling to take "personal responsibility" for themselves. Right or wrong, that idea is worth taking a look at – particularly if we want to move toward real change in the health system.
As explained many times in our Healthiest State blogs, emails, letters to the editor, and other communications over the past decade, this 47 percent thing is a pretty big deal if it’s true. This is because the "social determinants of health"- which detail how it is that we can produce health for ourselves, our families and our communities- largely depend on people taking action to improve their health. More than half of these social determinants relate to our individuality, outpacing such significant community based determinants such as education, housing, and the like. Even more striking is that individual action dwarfs the potential of medical care to produce health. The numbers clearly bear that out; while consuming over 97% of our health resources, medical care contributes no more than eight-to-ten percent to the creation of health.
So, it is a fundamental starting point for our Healthiest State Campaign that we must engage people to take responsibility and action to improve health. Much of our multi-million dollar financial investment in the Healthiest State Campaign related to helping people do this over the past 8 years. Even with limited organizational resources, we were incredibly successful in doing so.
From this extensive work, I would observe that it is relatively easy to get people to take action to improve their health, if presented with the right frame and opportunities. It is critical to speak to peoples’ aspirations and hopes more than their fears. Through practical and meaningful ways to get engaged, and even better if imbued with fun, competition or other natural motivators. And even more powerful when we can reach out and listen to them as individuals and develop customized solutions for them, rather than canned answers from insensitive bureaucratic systems. For example, what our Personal Health Advocates do to help people figure out how to pick and use their health coverage - including how to help clients accept personal responsibility for some facets of their health.
Yet, doing this work on a grander scale remains a challenge, largely because of the way the call for "personal responsibility" plays out practically in our society. First, health care organizations, political parties, government bureaucrats, and others who benefit from the status quo make it hard for organizations like ours, or untold millions of people, to pursue their dreams for health and their willingness to take greater responsibility for health. It just isn't in their interests to help people do this, so they point their huge resources at other things- the things that benefit their bottom line. Shame on them.
To counter this ‘resistance to change’, we need to find some change juice in the public, or a more transcendent national belief in the better angels of our nature. Yet, the opportunity to do so also gets caught up in the loud philosophical divide of thought leaders on the left and right over social issues in our Nation. They may share a belief in the end result of better health behaviors by people, but filter it through their ideological purity.
On the left, the usual refrain is that we must create health by collective action. On the right, by greater personal action. Our belief - supported we think by the vast majority of regular people who consider this question- is that you can only achieve this by building not just action but responsibility for doing both. We must both promote personal responsiblity AND build greater collective responsiblity. It is NOT one or the other.
On the left, there is usually lip service to the role of the individual and need for personal action and responsibility but an overwhelming focus on how the collective will create better health FOR people. One basis for this is their sympathy for the plight of many of those in need of better health behaviors- the poor and needy- who don't have the resources, time or circumstances to take greater responsibility. So, they say, we must find ways to help them. And, it would seem to us, we should.
But for many on the left, it seems like it is far more about a philosophy that relies on state paternalism. That is, a belief that it is the government's job to force better behavior on behalf of the whole. For example, the Affordable Care Act provides major new resources to pursue health through a Prevention Fund (something that we argued strongly for during the health reform debate). But, the bureaucracy of the federal government's use of these funds largely misses the connection to apply this to the opportunity of personal action. The vast majority of the millions of dollars in new money is being directed at government efforts to take collective action through "policy change" toward healthier habits, rather than more directly trying to change behavior at the individual level. Their argument is that the policy environment will set the tone for healthier living and better personal behaviors, deploying health improvement by making the healthy choice the easier choice for people.
It is not an argument without merit- and a major part of our Healthiest State Campaign over the past 8 years has aimed to implement this ideal in Washington state. For example, by requiring the inclusion of tobacco cessation drugs in the state medicaid program. That allowed addicted smokers access to the necessary tools to help them stop. Or making healthy options available in vending machines. Another example would be requiring informed consent by parents before they choose to not immunize their children. These types of strategies are supported by evidence that suggests they can succeed as part of a broader effort to build greater personal health action on the part of people. But they will not work alone- witness a recent study that points out how people who live next to a new park actually use it for physical activity less than others. Or, think of whether you reach for the chocolate cake or the fruit bowl at parties.
We also need to be exceptionally careful when trying to create personal health through the arm of government. How far can this go? Should the state compel healthy choices by outright bans on certain products (tobacco, ingredients in food, etc.), requirements to take certain acts (use seat belts, bicycle helmets, etc.), or tax penalites (e.g., cigarette taxes)? More accurately, since many of these already exist, where is the line that justifies the government to do so in some cases or ways versus others?
We have taken the view that individual health decisions through government action should be an approach of last resort. It should only be pursued in those instances where there is a compelling need, and when the case has been made strong enough that a clear consensus of people exists to support the proposed government action. Not just majority rule, but 70% or more of people in agreement. It just doesn't seem like the unfettered growth of the public health police fits with who we are as a Nation, outside of intervening in true public health emergencies like a pandemic flu.
The debate on this now has a new twist with the primacy of health insurance and coverage as the means to manage the financial insecurities of our health needs. That is, if we all share in the cost of bad individual behaviors through how we finance our health care, then doesn't this now justify even greater intrusion into behaviors that push costs on to the whole? That the Supreme Court has upheld the ability to require all to buy insurance fuels the fear among some that this Act is opening the door to a far more intrusive role by the state into our personal behaviors than ever before. Perhaps it is an unfounded fear; perhaps not.
Those in public health tend to support the world view that it is their collective actions that should be supported into the future, rather than direct people strategies. Some of this certainly means putting financial resources into their agencies and work, but it also seems that it is the result of the odd view that service to the individual is already being managed by the health care system. I kid you not- I have heard this stated as an agreed upon truth at public health conferences. Odd, because while the medical care system surely deals regularly with personal health issues, it is notoriously bad at helping people manage their heatlh behaviors. Its strength is intervening in times of illness or injury, but it has shown little ability to manage people's health over time. In particular, how to help people adapt to the life changing circumstances that negatively affect their health. You know, the things that really challenge our ability to be healthy. If the medical care system does intervene in such circumstances, it usually does so with a short attention span focused on clinical issues and not the person's larger life transition. It also gravitates toward canned products forced on people, rather than customized personal level solutions that can activate personal responsibility and action. If you have been following our work, this is why we believe the bigger transformation needed in the health care delivery system is our notion of a Health HoME. A Health HoME is designed to empower people so that the system responds to them, not the other way around.
Now, this all might sound like a diatribe against the left and its formulations about how to improve health. But the commentary really stems from the reality that throughout most of our Campaign, "democrats" and therefore the left have largely been in charge of health policy. That gives us a lot more real examples to comment on and be critical of - certainly in our state and at the national level through the passage of the Affordable Care Act.
But don't misinterpret me to believe that the "right" has some stronger position with respect to this issue of personal responsibility and engaging individuals. While they are more likely to invoke the words "personal responsibility", as we heard from Governor Romney, there is little in the way of meaningful policy suggestions as to how to create this for people. It seems a talking point more to criticize the left than a policy principle for hammering out a plan to really help people build on their personal responsibility for health in modern America. Or worse, as was suggested in the video, a reason to just ignore their needs because they can't be helped.
When pressed on the policy translation of personal responsibility, the right usually goes to other talking points, such as the need for "choice", as if this magically creates responsibility. Missing the fact that limitless choice frequently overwhelms people who are trying to take responsibility- and what can be more confusing than the health and health care system already? There is also the common theme of money in the conservative toolkit. The idea is that finances can somehow drive personal responsibility through financial incentives or penalties. But this is almost always framed around how they might pay for health coverage or medical care, not how they might pursue actual health improvement.
Well, we do think there are some things that can be done to stimulate personal responsibility, despite the lack of inclination of those on the left and the right to actually do so. Financial incentives can be part of the overall toolkit. So can setting the context for individual action in ways that make it easier for people to activate this concept of personal responsibility. But what we need is broader and multiple levels of practical supportive approaches that allow personal responsibility to activate, thrive and carry the day for health improvement. Joined by a broader belief that building health through people is the heart and soul of the agenda for action. It is the very approach that our Healthiest State in the Nation vision was built around.
We were told that these notions were crazy when we began our Campaign- by ideologues on the left and the right and many within the health care system vested in protecting the status quo. But our work in the Campaign has shown us that it isn't crazy. Rather, that it can work! Just one piece of evidence is the Governor's Health Bowl. Through the unwavering engagement and support of the people of Washington – the Health Bowl has generated more that 25 million miles of health during the past eight years. It is truly a staggering number! In addition - it is living proof that one can use the aspiration of health, along with fun opportunities to do this with others, as a way to build personal responsibility.
Has it made us the Healthiest State in the Nation? No. Will it get us there by itself as a strategy? No. But it is clear that it is an example of how one can engage many people in healthier behaviors that they are responsible for initiating. Even while we also search for practical ways to support collective actions to improve health. And then blending these and other practical approaches into an effective overall strategy for making a difference in health- rather than fighting over ideology or using divisions to advance political, financial or other self interests.
More thinking like this might indeed be the way forward to address what stands as the largest stumbling block in building a wave of health improvement in this country through individuals and their actions. That should be something we can all agree on no matter who gets elected.