Rights and Responsibilities in Health Care: Title and subTitle BreakStriking a Balance

In many states, teenagers can apply for a driver's license when they are 16 years old. To obtain the license, they need to pass a written examination, perform adequately on a driving test, and demonstrate that they have insurance. But all drivers can do things to lose their license. For example, the law requires that drivers stop at red lights, even in the middle of the night when the street is empty. If drivers choose to ignore this law, they risk being ticketed; enough tickets will probably cost them the right to drive. These requirements are not arbitrary; they were developed to preserve life and reduce the cost of everyone's insurance.

When young adults are 26 years old, they can no longer be covered under their parents' health insurance plan. However, they have other coverage options. If they work, and their employer offers insurance, they need only check a box. If they apply for an individual policy, they may need to prove that they do not have preexisting conditions and will need to provide extensive background information. But in either case, they do not need to know about the health care system or how to use it efficiently and appropriately. Misuse of the system may cost them a monetary penalty, but for these young adults, those penalties will seem far less important compared with the loss of their license to drive.

What if this approach to health insurance changed? What if to obtain and keep health insurance, individuals had to pass something like a driver's license test? What should they study to prepare for the test? What should be taught? What skills should be demonstrated? Should insurance be more costly, or even withdrawn, not because individuals become sick but because they do not use preventive services or evidence-based care in a manner that both protects their health and reduces health care costs for others? If society both provides health insurance and helps those who do not have the ability to use services effectively, what kind of penalty for misuse would be ethically and morally acceptable? Should penalties and rewards be applied first to the middle class, as opposed to disadvantaged individuals who are enrolled in Medicaid?¹

Over the last 40 years, tests and drugs have been developed that can predict or change the course of illness—even a potentially silent condition such as hypertension. The medical profession has responded to these changes by teaching physicians skills for motivating patients to obtain necessary diagnostic tests, take necessary medications, be vaccinated, and receive routine preventive services. However, physicians have not had remarkable success in improving adherence to necessary interventions, such as those for hypertension,² or in containing the costs of providing care. Is it time to admit that unless patients assume greater responsibility, these problems will not be solved?

For instance, consider a health system in which individuals who have health insurance and are competent to care for themselves would be required to take medications and have procedures known to be necessary and would do so; and a severe penalty would be imposed if they do not. What if individuals were required to receive vaccines for which they were eligible, as soon as the vaccines became available—and were penalized if they contracted an illness the vaccination could have prevented?

What if individuals with hypertension or hyperlipidemia who did not take their medications became responsible for some of the costs of future cardiac care? If the nation's future health system is expected to contain costs and improve value, shouldn't the recipients be expected to be true partners in achieving those goals?

This kind of sea change would take time to implement, would need to be preceded by education, and should be first implemented among individuals for whom language or competence would not be a barrier to getting required care. This policy would also need to focus on medications and procedures for which effectiveness has been well established.

Blue ribbons and awards are given to health plans for having high mammogram rates, high colonoscopy rates, and appropriate levels of hemoglobin A_1c and low-density lipoprotein cholesterol among their members.³ Perhaps the awards should be given to patients instead of physicians and health organizations. Perhaps it is time to say to the American public: “Certain procedures, medications, and preventive care will make a difference in your health, and it is your responsibility, not your physician’s, to take or to do them.”

If individuals want to use their car warranty to get repairs, they have to show that they have provided at least minimal maintenance. In general, individuals agree that minimal maintenance is a fair trade-off for using a warranty. What is the fair trade-off in medical care? If patients do not take prescribed medications, are not appropriately vaccinated, or do not obtain preventive screening tests, they may incur costs that others will need to subsidize. Is that fair?

Moreover, behaviors like smoking, use of illicit drugs, alcoholism, and dietary patterns leading to obesity greatly contribute to both poor health and increased medical expenditures.⁴ Although individuals are responsible for these behaviors, their prevalence is determined by many factors, most of them not under an individual's control.^{5 - 6} Nevertheless, there are ways to begin increasing patient responsibility for these problems. Should parents be expected to maintain their young children's weight-to-height index at the 50th percentile or less? Should sedentary workers be expected to participate in an exercise program provided at the workplace?

Classes using sophisticated adult learning materials could be held in the workplace. Employees could choose which health plan to join—one that required them to use the health care system responsibly, or one that did not—with the understanding that the former would be less expensive. Premium savings from using health services responsibly could be returned to the worker as a bonus. Such initiatives are already being implemented by progressive employers.⁷ To have an even greater effect, these initiatives would need to be widely adopted, and governmental support would be needed to pursue penalties and awards more aggressively.

Health reform is not only about health insurance companies, physicians, and pharmaceutical and device companies. It is not only mandating health insurance for everyone. It is not only about subsidies and penalties for not buying insurance.^{8 - 9} Health reform is about people. And people must become full participants and assume much greater responsibility for their actions if health benefits are to be maintained at an affordable cost.

The health reform bill signed by President Obama includes funding for numerous demonstration projects. Perhaps a demonstration project that contains some of the elements discussed herein will be tried, evaluated, and result in a new approach to the delivery of health care. Responsible patients and responsible communities might make it easier for physicians to act responsibly and to increase their effectiveness and cost-effectiveness. Maybe then, everyone would be able to purchase a health plan that provides necessary, high-quality, humane, and affordable care; by doing so, the health of individuals and the health of the nation would improve.