03/04/2009 01:52 pm ET | Updated May 25, 2011

Is There Personal Responsibility in Healthcare?

In both his Inauguration speech and the State of the Union, President Obama repeatedly referenced responsibility in the aggregate as well as individual. With public demands increasing for universal health care and health-care-as-a-right, one must ask does that right come with any responsibility?

This question is being dramatically played out in Washington DC, and the State of Arkansas. Governmental agencies are offering low-cost health insurance but finding their products a hard sell. The people seem...resistant.

The problem is not limited to DC and Arkansas. In 2006, approximately 44 million Americans had no health insurance. Of them, 12 million were eligible for State or Federal Aid Programs but chose not to enroll.

There are a number of reasons why low-cost insurance is a "hard sell." Some people fear they cannot afford even very small payments, such as $50/month. Many, especially illegal aliens, are afraid of exposing themselves to the system. Some people do not even know such low-cost Programs exist. Most point accurately to cumbersome, user-unfriendly, incomprehensible forms, and a demeaning as well as time-consuming process.

Each reason has some merit. Yet each individual who chooses not to enroll expects to receive medical care when sick (probably in an Emergency Room), and does not expect - certainly will not be able - to pay.

Responsibilities: Government, Hospital, Provider

The government pays more than it should because an ER is much more expensive than an office visit and the patient's illness might have been prevented or certainly be less severe had he or she sought earlier medical care. As people are national assets, the government has a responsibility to optimize the health and therefore the productivity of these assets.

Every hospital has both an ethical as well as a legal responsibility to provide care, even when - as is often true- the care will be uncompensated: "free" to the patient but not "free" for the hospital. It still has to pay its employees, suppliers and debt service.

The provider has ethical, legal and very strong cultural imperatives to provide care to sick people. Nurses and doctors are socialized to feel responsible for a patient's wellbeing. As a result of their recommendations, providers are responsible for generating costs in health care but do not generate the need for those expenses. They are cost-drivers who are micro-economically disconnected from both the consumer and the payer. Providers are (partly) responsible, (totally) accountable, having no control over either expenses or payments.

Patient Responsibilities

Do patients have personal responsibility for their own healthcare and if so, to what extent? This is obviously a sensitive subject but one that must be openly discussed.

We patients (people) are ultimately responsible for our own health and wellbeing. The providers should be held responsible for their advice and actions only. We patients should be responsible for the consequences of our decisions and actions.

I should be held responsible if:
I smoke cigarettes and get lung cancer.
I weigh 400 pounds and get diabetes.
I have a brain injury after riding a motorcycle without a helmet.
I could have prevented or ameliorated my medical condition - one that requires large expenditure of resources.

I should not be held responsible if:
I get lung cancer but never smoked a day in my life.
I eat reasonably, weigh 180 pounds and get diabetes.
I ride a motorcycle with a helmet and have a traumatic brain injury after an accident.
I could not prevent my medical condition.

Every parent, every psychologist, indeed every person beyond the teenage years knows that incentives effect behaviors. When my mother congratulated me on getting an A grade, her behavior encouraged me to get more. If you want to reduce gasoline usage and the emission of toxic gases, offer incentives for people to buy "green" (eco-friendly) automobiles. In our healthcare system, there are no incentives for patients to behave in a healthy manner. The incentives that do exist encourage illness and care of sick people rather than prevention and promotion of health.

Imagine a machine that refuses to allow preventative maintenance or a car sticking out its tongue out through closed lips to resist a fill-up. Hard to imagine.

People are different from machines: they have free will. They can create and innovate (a wonderful potential) but they can also behave not in their own best (medical) interests. People - as both the responsible persons and as national assets - must pay for the consequences of their decisions - both literally and figuratively.

Is there personal responsibility in healthcare? The unfortunate answer is no! Our present system not only discourages such responsibility, it actually prevents it.

We need a new healthcare system with personal responsibility, accountability, consequences, evidence, and feedback embedded in it.