03/14/2009 06:45 pm ET | Updated May 25, 2011

Should Fat People Pay More?

Suppose you and I go to McDonald's. I order a cheeseburger and a coke. You order a triple-cheeseburger, super-sized fries, a coke, and an ice cream sundae. We each made choices and those decisions produced different demands on and costs for McDonald's. Should we pay the same?

In his early speeches, President Obama included the idea of personal responsibility and thereby brought it out of the basement to which it had been relegated. Whether in politics, finance, education, or health care, we need to be personally responsible.

Responsibility does not go away when we ignore it, it simply falls on someone else. Someone must decide - to act or not to act. Both are choices and choices always have consequences. Someone usually gets the blame and someone always takes the credit.

Remember that to be held responsible, one must be in control. You cannot be held responsible for things over which you have no control. Is there personal responsibility in healthcare? For the insurance company and for the provider, there IS, but not for the patient.

Insurance companies are behaving responsibly. Wait! Do not start ranting about how crazy or wrong I am. When an insurance company tries to deny care and thereby avoid payment, they are behaving responsibly - to their shareholders, the people to whom they have a responsibility to make money. The company has no responsibility for our health and wellbeing. If you do not like this arrangement (and I certainly don't), then change the system but do not say insurance companies are irresponsible.

What are the providers' responsibilities, remembering they can only be responsible for what they control? Providers are responsible for giving good advice and being technically proficient in procedures. That is the extent to which they are responsible for our health. In other words, they are not!

Questions: what are we the Patients responsible for and are we behaving responsibly? Answers: our decisions and No. When we super-size our fries (eat to excess) and smoke cigarettes (poison our lungs and block our arteries) we choose spend more healthcare dollars but not out of our pockets. When we get rheumatoid arthritis or breast cancer, we were not in control and we are not responsible. Our genes gave us the diseases, not our actions.
Back to McDonald's. You made more demands than I, and appropriately, you paid more. When you smoke cigarettes or weigh 400 pounds, you choose to make more demands (on healthcare) but do not pay more. Is this behaving responsibly?

People as patients should be responsible for personally controllable health risk factors, such as smoking, obesity and alcoholism. That responsibility should start with paying more than those who make lesser demands for healthcare dollars.

Those who cry for universal health care often give no thought to personal responsibility. They should. The British NHS offers so-called universal health care and has for years been trying to inject some level of personal responsibility into their system, with little success. The concept of patient-provider contracts flew like a lead balloon. Incentives toward healthier lifestyles are gaining some traction. WHEN (not if) we design a new healthcare system for the USA, it must include at its inception the concept of personal responsibility.

Fat people and smokers should pay more (for health care).