The campaign to expand Medicaid health insurance eligibility in Idaho brought some broad health policy questions to the forefront. I am thankful we are having these discussions now; we have put this off for a long time. One of the recurring counter arguments I heard when talking to voters was how “giving people a free handout” (Medicaid health insurance) made the recipients less likely to be responsible. This is the “moral hazard” argument that is well-studied and documented in economics. I’m not sure why this argument doesn’t apply to employment-based insurance also, but I get the rub. We all want people to be responsible and any program that might discourage responsible behavior should be scrutinized.
So, let’s scrutinize. I’m sorry if this gets uncomfortable. I’ll put on the gloves and you’ll need to bend over. You see, I am a doctor.
When I first meet a patient (before the gloves and bending over) I ask them questions about their symptoms, their medical history. One of the many questions I ask is phrased carefully: “What medicines do you take?”
Approximately 2/3rds of the time the patient response is phrased: “They’ve got me on a pill for my blood pressure, and they have me take a cholesterol medicine.”
I believe the words we use can often reflect how we think about things. In this case, “They have me on” suggests, I believe, the patient feels little involvement in the commitment to take a medication. In fact, the phrase suggests they are forced to take it, like “They have me in solitary confinement.”
When I can have the time, I encourage patients to say “I take a medicine for my blood pressure. I take XYZ for my cholesterol.” I believe in promoting ownership in our health. The passive, unengaged patient is not healthy.
I have no sense that people on Medicaid, Medicare, VA (that is, government-funded) benefits are more likely to use such phrasing. In fact, I have no evidence that such language is in fact related to a sense of disengagement with one’s health. Maybe you can ask yourself how you feel about the medications you take and the language you use to describe them.
If we can promote engagement in responsible behavior, engagement in our health, we may in fact promote better health. Private insurance companies spend a good deal of money with programs like this. In some plans, premiums are lower for people who participate in exercise, weight loss, healthy diet, smoking cessation. The hard part about all these programs is that the return on investment is probably 10-20 years out, and people change health insurance companies every 3 years, so the company rewarding the behavior doesn’t receive their return on investment.
I’m all for promoting healthy behaviors. But the best way I have found to do this is with direct interaction with a person, be that doctor-patient, or friend to friend. Governor Otter started building this plan 6 years ago with the Patient Centered Medical Home model for primary care in this state. It is an ongoing and successful model for healthy primary care relationships that could have leverage to change behavior.
I can’t believe someone writing a law in Boise will suddenly make people change their attitude toward their own health. But I can sure see them trying. Without gloves on.