Rights and responsibilities in health care: striking a balance

IN MANY STATES, TEENAGERS CAN APPLY FOR A DRIVER’S license when they are 16 years old. To obtain the license, they need to pass a written examination, perform adequately on a driving test, and demonstrate that they have insurance. But all drivers can do things to lose their license. For example, the law requires that drivers stop at red lights, even in the middle of the night when the street is empty. If drivers choose to ignore this law, they risk being ticketed; enough tickets will probably cost them the right to drive. These requirements are not arbitrary; they were developed to preserve life and reduce the cost of everyone’s insurance. When young adults are 26 years old, they can no longer be covered under their parents’ health insurance plan. However, they have other coverage options. If they work, and their employer offers insurance, they need only check a box. If they apply for an individual policy, they may need to prove that they do not have preexisting conditions and will need to provide extensive background information. But in either case, they do not need to know about the health care system or how to use it efficiently and appropriately. Misuse of the system may cost them a monetary penalty, but for these young adults, those penalties will seem far less important compared with the loss of their license to drive. What if this approach to health insurance changed? What if to obtain and keep health insurance, individuals had to pass something like a driver’s license test? What should they study to prepare for the test? What should be taught? What skills should be demonstrated? Should insurance be more costly, or even withdrawn, not because individuals become sick but because they do not use preventive services or evidence-based care in a manner that both protects their health and reduces health care costs for others? If society both provides health insurance and helps those who do not have the ability to use services effectively, what kind of penalty for misuse would be ethically and morally acceptable? Should penalties and rewards be applied first to the middle class, as opposed to disadvantaged individuals who are enrolled in Medicaid? Over the last 40 years, tests and drugs have been developed that can predict or change the course of illness—even a potentially silent condition such as hypertension. The medical profession has responded to these changes by teaching physicians skills for motivating patients to obtain necessary diagnostic tests, take necessary medications, be vaccinated, and receive routine preventive services. However, physicians have not had remarkable success in improving adherence to necessary interventions, such as those for hypertension, or in containing the costs of providing care. Is it time to admit that unless patients assume greater responsibility, these problems will not be solved? For instance, consider a health system in which individuals who have health insurance and are competent to care for themselves would be required to take medications and have procedures known to be necessary and would do so; and a severe penalty would be imposed if they do not. What if individuals were required to receive vaccines for which they were eligible, as soon as the vaccines became available— and were penalized if they contracted an illness the vaccination could have prevented? What if individuals with hypertension or hyperlipidemia who did not take their medications became responsible for some of the costs of future cardiac care? If the nation’s future health system is expected to contain costs and improve value, shouldn’t the recipients be expected to be true partners in achieving those goals? This kind of sea change would take time to implement, would need to be preceded by education, and should be first implemented among individuals for whom language or competence would not be a barrier to getting required care. This policy would also need to focus on medications and procedures for which effectiveness has been well established. Blue ribbons and awards are given to health plans for having high mammogram rates, high colonoscopy rates, and appropriate levels of hemoglobin A1c and low-density lipoprotein cholesterol among their members. Perhaps the awards should be given to patients instead of physicians and health organizations. Perhaps it is time to say to the American public: “Certain procedures, medications, and preventive care will make a difference in your health, and it is your responsibility, not your physician’s, to take or to do them.” If individuals want to use their car warranty to get repairs, they have to show that they have provided at