Beyond health care 'rights'

If society is to guarantee care, patients must take greater responsibility for maintaining their health

February 25, 2010|By Stephen C. Schimpff

During the presidential debates, Tom Brokaw asked, "is health care a right, a privilege or a responsibility?" It was the right question, but the candidates' ducked it. When it comes to health care reform, we correctly hear a lot about "rights." As the debate goes forward, however, Congress and the president need to also confront the issue of responsibilities.

Americans have been clear that they are concerned about the costs of medical care -- both directly and through insurance. They are concerned about being left without insurance because of a preexisting condition. They are frustrated that the wait time to see their doctor is long and the time allotted is short. And they are concerned for their fellow citizens who can afford neither insurance nor adequate care.

Americans have many adverse lifestyle behaviors, such as obesity, smoking and lack of exercise. As a result of these behaviors, and because the population is aging, many have or will develop a complex, chronic illness such as diabetes or heart failure. These chronic illnesses consume more than 60 percent of all medical care costs. They require lifelong, expensive, well-coordinated care -- not by a single physician but by a multi-disciplinary team. Primary care physicians do not have time to offer good preventive care to ward off these illnesses or to provide "care coordination" to those with them. Insurance does not pay for these essential activities. The result is that as more of us develop chronic illnesses, with the resulting (avoidable) visits to specialists and unnecessary expensive prescriptions, procedures, tests and hospitalizations. We end up with lower quality, yet higher total costs of care. These are the fundamentals that need to be addressed in a comprehensive manner.

A key to success is to balance health care rights with corresponding responsibilities. As a local example, Howard County has instituted the "Healthy Howard" plan, which offers the uninsured access to primary care for a minimal fee along with specialist care given pro-bono and hospital care for no charge. But in return, each patient must work with a health coach to develop a set of goals for the year such as weight control, smoking cessation, exercise enhancement and/or stress reduction. Patients also are expected to receive appropriate vaccines and obtain basic screening such as checks for high blood pressure. It is a balance of rights and responsibilities.

Congress is appropriately seeking insurance for all, regardless of preexisting conditions and regardless of ability to pay. It is not inappropriate for the taxpayer to expect the individual receiving such benefits to accept the responsibility to lead a reasonably healthy lifestyle, to not only maintain and improve health but to also lessen the cost of care. Another reasonable expectation -- or responsibility -- in return for eliminating the preexisting-condition issue is that everyone participates in insurance so as to keep the risk pool large and the costs down.

In another pairing of rights with responsibilities, commercial insurers and Medicare should offer patients incentives to hold down costs by reducing premiums for those who maintain an appropriate weight, exercise, do not smoke, get their vaccinations and have screenings done.

Balancing rights and responsibilities applies to doctors as well. Primary care physicians should be able to have a reasonable income without a huge patient load or the necessity of short visit times. In return, the patient/insurer/payer should expect excellent preventive services for all and good coordination of the care of patients with chronic illnesses. Doctors who want malpractice reform (a right) need to do their part to markedly improve patient safety (a responsibility). In this model, both doctor and payer/patient have their rights and their responsibilities -- resulting in better care, healthier patients, less-stressed physicians and reduced total costs to the system.

This combination of rights and responsibilities can assure that everyone has access to insurance and incentives to better health. It will reduce expenditures through improved quality and reduced frustrations with the "system." It satisfies the legitimate argument that medical care is something everyone deserves to have with the equally important argument that we all need to accept a meaningful level of responsibility for our health and its costs.

Dr. Stephen C. Schimpff is a retired CEO of the University of Maryland Medical Center in Baltimore, a professor at the schools of medicine and public policy, and author of "The Future of Medicine -- Megatrends in Healthcare." His e-mail is and his Web site is

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