Saturday, October 30, 2010

Nanny State and Nanny Employer

This election season has been saturated with backlash against "government takeover" of health care. Critique of the Patient Protection and Affordable Care Act ranges from thoughtful, fact-based responses to know-nothing paranoia.

The law is imperfect, but it's the best our body politic was capable of in 2010. It represents a substantial step forward. But it has touched a very raw nerve in our political psyche - the depth of our reluctance to acknowledge that health isn't just a matter of individual rights - our community has responsibilities to us as individuals, and we as individuals have responsibilities to our community.

The "Government, keep off my back!" issue is being fought out in federal court over the awkward, but necessary, legal, and ethically entirely justifiable individual mandate (see here, here, and here, for previous posts on the mandate). But the same dynamic is starting to emerge towards the growing tendency for employer-based insurance to include wellness incentives, as set forth especially clearly in this recent letter in the New York Times:
It’s About Time to Check the Fine Print on Your Health Plan” (Patient Money, Oct. 16) says that “your company may be offering cash rewards ... if you complete a health risk assessment or get screened for blood sugar, high cholesterol or high blood pressure,” as if this were an unproblematic perk. But it undermines your privacy when your employer monitors your health and offers incentives for good behavior.

We are familiar with criticism of the nanny state, but isn’t it about time to extend such criticism to the nanny employer, whose power over employees threatens their freedom to make their own health choices about their own lives?
Some workers hate their employers with the same passion the Tea Party expresses towards the government. But even for them, it's potentially easier to understand the social compact that underlies employer-based health insurance than in our highly fragmented national system.

The employer takes money the company earns and puts it towards health insurance, money that otherwise could go into wages or improving the company's competitive position. If I'm hit by a car, my fellow employees and employer are, in effect, subsidizing my care. If that happens, I hope I'll be appropriately grateful. But my fellow employees and employer are entitled to expect me to approach my own health in a responsible manner, because (a) they care about me and (b) they will be paying for the health care I need.

I have a right to smoke, become a couch potato, and toss my medications into the toilet. But I don't have a right to tell my fellow employees and employer - "I have no responsibility for the consequences - it's your role to pay for me...and don't you dare ask any questions or ask me to take any responsibility!"

Incentives (carrots and sticks) can be done well or poorly, fairly or unfairly. Behavioral economics research on how incentives work and ethical reflection on what kinds of incentives are justifiable, is well underway. As an example, here's the mission of the Center for Health Incentives at the University of Pennsylvania, a leading site for behavioral economics research:

Our mission is to facilitate research that makes significant contributions to reducing the disease burden from major public health problems such as tobacco use, obesity, and medication non-adherence for cardiovascular and other diseases through better understanding of how to design and apply incentives and other behavioral economic approaches to improving health. The center has 3 primary missions:

  1. To advance knowledge about incentive design
  2. To develop and test scalable and cost-effective applications
  3. To work with private and public sector entities such as large employers, insurers and health systems to improve health care delivery and the health of the population
I hope we see lots of debate about "Nanny Employers" in the months ahead. It will be hard for us to take glib libertarian positions when those who will be affected by our actions are our comrades at work. It's easy to rail against "government takeover," "socialism" and "Obamacare." It's harder to look into the eyes of our fellow workers and spout the same nonsense!


Christopher McCabe said...

Excellent blog! The issue of identifiability gets everywhere. Our fellow employees are identifiable to us in a way that our fellow citizens are not. Thus we feel comfortable 'spouting nonsense' about social health care that we it wouldn't occur to us in the context of employer funded health care.

Thanks for shining a light on this particular example. I'll use it in teaching if you don't mind.


Jim Sabin said...

Hi Christopher -

Thank you for your comment and kind words. I especially appreciate your perspective, because from following the link to your note I see that you work on health economics at the University of Sheffield. I think of the UK and the NHS as a setting in which the concept of "social health care" is more understandable and meaningful than in the US, since unlike us, you have a budget for the population the NHS cares for, and you don't believe in leaving people out, as we appear to do.

If "spouting nonsense" is a factor in UK political dialogue, I'd be very interested in learning more about it.

I'd be delighted and honored if you used the topic of this post in your teaching!