Two compelling articles in this week’s New England Journal of Medicine on personal responsibility and health care. The topic is West Virginia’s new Medicaid requirement that low income Medicaid clients sign “member responsibility and rights” agreements. Clients who don’t uphold their end — taking medications, keeping medical appointments, and avoiding unnecessary ER visits — will have some of their benefits reduced or eliminated.
In the first article, Drs. Gene Bishop and Amy Brodkey explore the WV plan and the ethical dilemmas it creates for physicians:
“The plan asks physicians to violate all three fundamental principles enumerated in the Physician Charter on Medical Professionalism: the primacy of patient welfare, the principle of patient autonomy, and the principle of social justice. It raises potential conflicts by placing physicians in a reporting situation in which the public health is not at issue, possibly asking them to harm their patients or their relationships with patients. As physicians become agents of the state, poor patients’ distrust of the medical system can only increase. Although the plan’s member agreement mentions the patient’s right “to decide things about my health care and the health care of my children,” it does not recognize that noncompliance can be an expression of disagreement with the physician. The plan promotes discrimination not only on the basis of socioeconomic status, but also on the basis of diagnosis: surely, people with mental illnesses who have trouble managing activities of daily living such as keeping appointments will be discriminated against under a plan that rescinds their mental health benefits because of such lapses.”
The second article by Robert Steinbrook takes a broader look at the issue of personal responsibility for health:
“Although personal responsibility for health and for obtaining health care may seem intuitively attractive, the design and implementation of specific insurance initiatives may be complicated. Before such plans are implemented, it would be best to evaluate them rigorously in a controlled trial conducted by an independent group. If they do not improve health or save money, or have unanticipated negative effects, they can be discarded or revised.”
Not discussed in the piece is the new Massachusetts spin on personal responsibility — the individual insurance mandate included in the new MA health reform law. It’s all part of a “personal” or “individual” responsibility fabric and we ought to recognize it as such. Whether it’s for better or worse is too early to say. On the tenth anniversary of “welfare reform,” it brings to mind that the outcome of that process was neither as bad as the critics on the left feared and not nearly as good as the cheerleaders on the right pretend.
This may be the best signal for how this round of “personal responsibility” will play out. We all need to pay close attention as it unfolds.