The West Virginia Medicaid program offers a two-tiered benefit package for patients qualifying for Medicaid services. The enhanced plan provides expanded prescription coverage, wellness programs, mental health services, and specialty services but is available only to patients who are compliant with medical recommendations, keep appointments, and make healthy lifestyle choices.³

However, limiting access to benefits because of patient behaviors may further increase the disparities already noted. These disincentives do not take into account religious, cultural, or socioeconomic factors.⁶ Patients may not comply with treatment recommendations because of financial or educational barriers, and limiting access to benefits without fully understanding the reasons for patients’ behaviors is not beneficent, nor does it promote justice in health care. In addition, this kind of program may jeopardize honesty in the physician-patient relationship, as patients may be reluctant to admit difficulties in adherence to a plan for fear of losing health benefits.⁶

Implementation of incentive programs must be evidence-based and work to avoid the potential for increased discrimination against vulnerable populations.

The Affordable Care Act (ACA) of 2010 attempts to assign a level of patient responsibility through the individual mandate to purchase health insurance.^7,8 It strives toward a more equal distribution of health care by providing health insurance for many Americans who lack coverage under the current system. Premised on a belief that better access to preventive care results in overall lower health care costs, it works to address, at least in part, the concerns of cost containment by requiring all individuals to carry some form of health insurance.⁸

The ACA may not be the most appropriate compromise, and it may not withstand political pressure or judicial review. But without some kind of health care reform, health care may well become a commodity that none of us can afford.

There must be an acceptance of shared responsibility both for individual health and our national health care system. We must continue to encourage positive health behaviors among our patients, with a wider appreciation for the perspective of justice, as we work together toward defining the new gold standard in compassionate and appropriate care, recognizing duties to act for the benefit of our patients and to serve as responsible stewards of the health care resources entrusted to us.

References

1. Rodwin, Marc A. Patient accountability and quality of care: Lessons from medical consumerism and the patients’ rights, women’s health and disability rights movements. Am. J. Law Med. 1994; 20(1-2):147-67.
2. Buyx AM. Personal responsibility for health as a rationing criterion: Why we don’t like it and why maybe we should. J. Med. Ethics 2008;34:871-4.
3. Steinbrook, Robert. Imposing personal responsibility for health. N. Engl. J. Med. 2006;355:753-6.
4. Morreim, Haavi E. Redefining quality by reassigning responsibility. Am. J. Law Med. 1994;20(1-2):79-104.
5. Larson N, Story MT, Nelson MC. Neighborhood environments: Disparities in access to healthy foods in the U.S. Am. J. Prev. Med. 2009;36(1):74-81.
6. American College of Physicians. Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond. Philadelphia: American College of Physicians; 2010: Position Paper (www.acponline.org/running_practice/ethics/issues/policy/personal_incentives.pdf). Accessed 10 March 2012.
7. Gostin, Lawrence. The National Individual Health Insurance Mandate: Ethics and the Constitution. Hastings Center Report 2010;40(5):8-9.
8. Blake, Valarie. American Medical Association Policy – The Individual Mandate and Individual Responsibility. Virtual Mentor: American Medical Association Journal of Ethics. November 2011;13(11):799-802.