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23 Journal of Health Care Law & Policy 227 (2021)


How far should we go in assigning individuals causal responsibility for their own health status and what should the implications of any such assignment be?

Few would deny that most adults have a major role in achieving and maintaining their own health. However, it is not at all clear where one should draw the line between what is freely chosen and what is determined by forces outside a person’s control. Medical care plays only a small role in most people’s overall health, and often social, environmental, and personal factors are far more important. Incentivizing an individual to take better care of her health by adding incentives or penalties to her health coverage, even if done as reasonably as possible, may be far less effective than altering key social and environmental factors that are strongly linked to health status.

Altering health coverage to include wellness incentives in an effort to manipulate individual behavior is a problematic trend. On the one hand, including such incentives ostensibly furthers the principle of distributive justice by encouraging individuals to take more responsibility for their health. But, on the other hand, such incentives not only misconstrue the purpose of coverage, but also arguably create an injustice by inappropriately elevating individual responsibility for health while ignoring the larger, systemic contributors to chronic diseases and conditions. Consequently, this injustice is harmful to all of us. Making access to health coverage contingent on health improvement efforts decreases access to health care services by making it more difficult or costly for individuals to obtain, retain, and use coverage, and inappropriately and disproportionately burdens the more vulnerable, without outweighing benefits. This practice focuses attention away from the larger causes of the problems, while blaming individuals for matters that are not completely within their control.

This article will examine these issues as they manifest in private and public coverage in the form of employer-sponsored wellness programs and Medicaid personal responsibility requirements. Part I will examine the history and increasing devolution of responsibility for health onto individuals through changes in employer-sponsored wellness programs and personal responsibility requirements in Medicaid programs. Part II will examine ethical considerations regarding these changes. The article will conclude by showing that the degree to which we currently allocate responsibility for health onto individual behavior versus the government is ethically problematic and likely to lead to poor societal and financial outcomes. Individual choice has a role to play, but only in concert with collective legal action on larger policy issues.