It's long been the American way to charge for healthcare — and medical coverage — without regard for personal behavior. Employers haven't billed their workers by the pound, offered discounts for hard bodies or trimmed premiums for people who sip Pinot Noir. Nor have public officials (with rare exceptions) pressed for Medicare or Medicaid to adopt such policies, or for Congress or state legislatures to encourage the private sector to do so.
Such rewards and penalties have been considered wrong, either because they require intrusive monitoring or because they target behavior that people can't fairly be said to control. People who take pride in their healthy behaviors have had to content themselves with their better prospects for longevity or their fit in clingy jeans.
A few weeks ago, Gov. Arnold Schwarzenegger declared his intention to remake healthcare in California. His plan to cover nearly all state residents relies on an elaborate scheme of subsidies from employers, doctors, hospitals and the federal government.
But the plan's signature is its emphasis on people's responsibility for their own health.
The governor's initiative, his website proclaims, "is built on 'shared responsibility, shared benefit.' " If the Legislature enacts it, never before would the force of law be wielded so vigorously to get Americans to take care of themselves.
The plan's requirement that all Californians buy health insurance — or face legal sanctions, including tax penalties — tracks Massachusetts' approach, adopted in April. But Schwarzenegger's proposal to link premiums and other payoffs to people's personal behavior is pioneering.
The details of this linkage are fuzzy in the documents that the governor's health policy team has released so far. These indicate, though, that the plan's "Healthy Actions" program would tie insurance premiums and "vouchers and credits" for goods and services to behavioral benchmarks.
Proposed benchmarks include compliance with recommended approaches to prevention and management of heart disease, cancer, diabetes and other serious illness. Private insurers and Medi-Cal would be required to offer such "rewards and incentives."
In his speech outlining his proposal, Schwarzenegger hinted at more far-reaching incentives. The trim and the fit, he said, "should be treated differently" from the obese and the inactive. California should "reward healthy lifestyles," not just compliance with recommended care.
Schwarzenegger's aides are nervous about portraying his proposal as potentially punitive, and they've been reluctant to specify the behavioral triggers — or the rewards and sanctions — that they have in mind.
Possibilities include weight-loss targets, fitness benchmarks and, more controversially, blood sugar levels and other measures of compliance with disease management. The governor needs to give Californians more details so that they (and the rest of the country) can debate how far the state should go to persuade people to care for themselves.
Reconfiguring healthcare along these lines may offend many liberals who believe that our eating, smoking and exercise habits are less a matter of choice than of the consequences of genetic "luck" or cultural cues.
Would penalties for "bad" behavior punish "victims" of Taco Bell's "fourth meal" ad campaign, Coors' sexually inviting NFL playoff spots or sedentary exurban living? Perhaps. Yet recasting health as a shared responsibility — the mutual obligation of citizens and their government — may be the moral and political breakthrough we need to make the leap to universal access to medical care.
Americans don't think much of handouts, and opponents of government-guaranteed medical coverage for all have made good use of this fact to defeat every national attempt to achieve it since President Franklin D. Roosevelt first tried. Though the number of uninsured Americans is approaching 50 million, the assumption in Washington remains that universal coverage and care is impractical.
The radical promise of the Schwarzenegger plan lies in its potential to move beyond the metaphor of medical care as a handout toward the bracing idea that health is both an individual and a common duty.
This idea has a bipartisan pedigree — and almost certainly a future in national politics. During the battles that led to the collapse of President Clinton's health plan in 1994, many Republicans embraced Sen. John Chafee's (R-R.I.) counterproposal to require individuals to buy coverage. Congressional Republicans eventually abandoned Chafee's scheme because they believed they had more to gain politically if healthcare reform were totally defeated. Their strategy paid off when they took control of the House in 1994, but Chafee's "individual mandate" enjoyed an afterlife among Washington policy wonks.
Laurie Rubiner, an architect of the plan, fleshed it out and promoted it broadly on behalf of the New America Foundation, an influential think tank.
Then, two years ago, Rubiner returned to Capitol Hill as legislative director for Sen. Hillary Rodham Clinton (D-N.Y.). It's hardly certain that Clinton will make the individual mandate a cause in her presumed presidential bid, but it's a sure thing that former Massachusetts Gov. Mitt Romney will. Romney's case for the Republican presidential nomination will build on his state's move toward universal coverage, based in part on Chafee's (and Rubiner's) individual mandate.
Whether Schwarzenegger will succeed in pushing personal responsibility one step further, to encompass healthy behavior, is unclear. Whatever the behavioral benchmarks he eventually endorses, critics will point to causal factors over which, they'll claim, people being called to account have no control.
People's lapsed compliance with exercise regimens, diabetes management, smoking cessation and weight-loss programs all have their explanations. Genes, culture, family pressures and financial worries surely play roles. But all behavior can be understood in causal terms, as the product of brain chemistry, psychology and social cues. Whether an action is "chosen" or driven by causal forces is a political, not a scientific, question.
For actions that promote or endanger health, we should answer this question in ways that encourage self-reliance without humiliating those who fall short — or denying them care that we widely see as essential.
Enforcement of behavioral benchmarks poses even harder problems. Should we insist that obese Americans periodically weigh in, or that doctors report blood pressure, LDLs and HDLs to public authorities before health insurance premiums are set?
Advances in medical technology present ever more intrusive possibilities. New York, for example, requires doctors to pass on their diabetic patients' glycosylated hemoglobin results (a measure of blood sugar control over time) to public authorities, though this reporting is anonymous.
Such monitoring raises questions of medical ethics, civil liberty and common decency. These matters must be broadly discussed, and limits must be clearly set, before behavioral benchmarks and incentive schemes become public policy. But within constraints of decency, rewards for healthier living hold promise. They're more than bribes for better behavior. They have the potential to reshape our social norms and the demands we make upon ourselves.
Reimagining healthcare as both personal duty and civic obligation will move us in this direction. It also might break the political paralysis that has allowed the number of uninsured Americans to approach 50 million. This is the Schwarzenegger plan's larger import.
There will surely be fierce debate over its provisions for personal responsibility. Out of this debate could come a changed understanding of our duties to ourselves and each other in the health realm.