Obamacare, Broccoli, and Health Freedom

With the Supreme Court ruling the Patient Protection and Affordable Care Act also known as Obamacare is back in the public eye. The attention has focused on the individual mandate to buy healthcare insurance, or should we now say the tax on those who choose not to buy health insurance. This of course has been the most controversial, and in many ways the most important element of the act. This brings us closer to the ideal that many of us hold of universal health coverage. I for one don't particularly like the specific mechanism here which is to require individuals to bear the burden of their insurance. I believe that universal coverage is a responsibility of society as a whole. Every society has a responsibility to care, to the best of its ability, for its sick, its  poor, it's old, and it’s young.

Society's responsibility does not negate individual's responsibility for their own health. Society’s responsibility is to give individuals the tools for self-care and access to care. But as the old adage goes, you can lead a horse to water, but you can't make it drink. Individuals are responsible for drinking. All the time we make decisions with health ramifications. Do we smoke, do we wear a motorcycle helmet when riding, do we drive or walk, do we drink soda pop, eat trans fats or too much meat? Do we eat our vegetable, exercise regularly, have close friends, relax, and do things that have meaning in our lives?

Should buying broccoli be mandatory? Many of those who argue against the individual mandate, we can now call it the uninsured tax, have claimed that if this is legal it would be legal to mandate that people buy broccoli. Of course the absurdity of this claim is that of all the things a government might do, progressive or reactionary, making its citizens buy broccoli would be close to the last thing they would ever do. I am probably one of the few people who think this would be a rather good idea.

Let me explain, I am for individual health choice, I believe strongly that people should be able to decide whether to eat broccoli, or drink high fructose corn syrup out of a liter bottle. I don't believe that individuals should be required to have broccoli in the refrigerator at all times. But I do believe that when individuals are making the choice between broccoli and high fructose corn syrup, incentives matter. Incentives are among the tools society gives individuals for making our choices. We presently incentivize corn, that is to say, farmers are subsidized to grow it. Now I have nothing against a good corn tortilla, or some fresh polenta, but I would gladly pay a bit more for those treats, and a bit less for my broccoli.

Cost is one form of incentive, information is another potentially important form. Most of what we hear about food comes from the food industry itself. Even the information we get from the USDA is heavily influenced by the food industry. I wonder if perhaps there is just a little bias in that information. It's only when we can fully and fairly know and understand the potential health benefits and health risks in our choices that we can make truly free choices.

I would support agricultural subsidies shifting from corn to garden vegetables such as broccoli. This of course raises the risk that industry would find a way to extract sugar from broccoli stems, and feed broccoli to cattle. I think we’re a long way off from that. But more importantly, I believe that there is an important public health responsibility, for more, more accessible and more accurate nutritional information, and for limits to be placed on the corporate promotion of products that are health hazards. I'm not overlooking the difficult challenges in getting solid science around nutritional information. In fact the debate about what is solid scientific information should be a central part of a healthy democracy. Regrettably in the area of democracy like the area of health, we are short on the tools needed for us to take individual responsibility. 

Getting back to the Patient Protection and Affordable Care Act, it strikes me that it suffers from very little in the way of tools for health self care responsibility. Nonetheless, one way in which the act allows for insurance companies to incentivize self responsibility, is excluding tobacco use from its list of pre-existing conditions. What this means is that an insurance company can charge more to a smoker than a non-smoker. Of course if you're concerned about mandatory broccoli, and if requiring people to pay more for insurance if they smoke is legal, why not require people to pay more for insurance if they don't eat broccoli. Ironically, financial incentives are more likely to be successful among those who have money than among those who don't. Smoking is ironically more common among those who don't have more money.

Another step that Obamacare takes towards improving health care choices is its research initiative. This initiative provides funds for what is called patient centered outcome research, and is basically an attempt to look at health outcomes of various clinical interventions.  This research has the potential to be translated into tools to help patients choose among a variety of health care options. If it does this that would be phenomenal. Unfortunately it is only a potential. It could lead to mandate certain standards of care. While standards are useful, I don't believe that one standard applied to all individuals health needs, and standards that prevent experimentation and exploration have the potential to do more harm than good.

The political joke in the opposition to Obamacare is that many things in the program were borrowed from Republican policymakers, only to be later oppose those same policymakers. Individual mandates? Great idea, thanks Mittens. Well I'm going to do it again, I'm going to borrow couple ideas put forth by my good friend  Newt Gingrich. Cut straight from the cloth of his “plan to save lives and save money”:

• Reward health and wellness by giving health plans, employers, Medicare, and Medicaid more latitude to design benefits to encourage, incentivize, and reward healthy behaviors.
• Invest in research for health solutions that are urgent national priorities. Medical breakthroughs–ones that prevent or cure disease rather than treating its symptoms–are a critical part of the solution to long-term budget challenges. More brain science research, for example, could lead to Alzheimer’s Disease cures and treatments that could save the federal government over $20 trillion over the next forty years

When it comes to cost, Obamacare is at best a Band-Aid on a hemorrhage. If we could really implement these two ideas from Mr. Gingrich we might be able to make a real dent the cost of health. The other cost care challenges are to remove the profiteering of the insurance and pharmaceutical industries, and to move away from a fee for service system.