Obamacare Foes to Newly Insured: Put Down the Donut

A partially-eaten donut. John Brecher / NBC News

The White House may be bragging about the 3 million people who’ve got a new shot at health care, including the 2.4 million who’ll get Obamacare on the taxpayer’s dime, but critics have a few choice words for the newly insured: Put. Down. The. Donut.

Commentators like Sandy Pukel, a nutritionist from Coral Gables, Fla., have joined a chorus of scolds who say that expanded access to insurance is just another example of an eroding code of personal responsibility in America.

“If you’re going to go eat donuts and drink Coke and eat crap, you’re setting yourself up to be sick,” said Pukel, 68, who operates a line of healthy “food cruises."

“People are not going to have to take care of themselves because they don’t have to pay for it.”

Specifically, Pukel can’t see the point of offering more government-paid health insurance to people who smoke, drink, overeat, avoid exercise and otherwise fail to look after their own interests.

“I sometimes get angry that people like me are subsidizing the population at large,” Pukel wrote in a recent blog post. “If we are, indeed, in this together, it would be nice if more of us tried a bit harder to keep up their end.”

Image: Cigarette
Smoking costs the health care system more than $193 billion a year, government estimates say. John Brecher / NBC News

And he’s not alone in his criticism. More than half of U.S. adults — 56 percent — now say it’s not the federal government’s job to make sure all Americans have health coverage, according to a Gallup poll conducted late last fall. That’s up from a low in 2006, when only 28 percent of adults felt that the government should stay out of health care coverage.

Of course, expanding the ability to buy health care coverage was the goal of the 2010 Affordable Care Act, which seeks to provide insurance to the 15 percent of Americans who don’t already have it.

The Jan. 1 start of coverage under the health care marketplaces, called exchanges, has renewed questions about the estimated $1 trillion expected to be spent on federal subsidies in the next decade — and whether those who get access to care will make the best of it.

Research suggests that the newly insured do, in fact, use more care and feel better about their health. That’s according to the Oregon Health Insurance Experiment, a study by researchers at Harvard and MIT that compared 10,000 people who were newly enrolled in Medicaid and 10,000 who weren’t.

“With access to subsidized care, people do access a range of health services,” said Katherine Baicker, a professor of health economics at the Harvard School of Public Health. “They go to the hospital more, they use the doctor’s office more, they use more prescription drugs.”

The latest run of data, published last month, found that they also use the emergency room about 40 percent more often others.

The twist? All of that increased access didn’t result in measurably better health, the second study in the series showed. There was no drop in rates of high blood pressure, high cholesterol or diabetes. People didn’t get thinner. In fact, their body mass index, a measure of obesity, stayed about the same.

“Insurance alone was not sufficient to produce decreases,” Baicker said.

Some critics would lay that problem at the feet of the individual patients. Daniel Callahan, a medical ethicist at the Hastings Center, sparked a firestorm last year with a paper that suggested that a strong dose of fat-shaming might actually be the key to driving down obesity rates in a nation where two-thirds of adults are too heavy.

“Safe and slow incrementalism that strives never to stigmatize obesity has not and cannot do the necessary work,” wrote Callahan, adding later. “The individual seems to be left out of this.”

But even Callahan agrees that enforcing some code of personal responsibility is a slippery slope. Why people gain weight, struggle with smoking or contract certain diseases may be dependent on a range of factors besides individual conduct, he said.

“It is very hard to determine how responsible anyone is for his or behavior,” he said. “I say treat ‘em all — illegal, immoral — and raise taxes on the rich to pay for it.”

Focusing on the expansion of insurance under Obamacare misses the point, supporters say. People with insurance have always paid for the uninsured, whether it’s through direct subsidies, higher premiums or higher costs to cover uncompensated care. Critics have been paying for others' care all along, even if they don't know it or want to admit it, experts say.

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Sugary sodas are one of the prime contributors to America's obesity epidemic, experts say. John Brecher / NBC News

Other health and ethics experts, while not quite so brash, agree with Callahan. Certainly, there’s no shortage of health problems made worse by laziness or inattention. One third to one half of patients with chronic ailments such as diabetes and heart disease fail to take their prescribed medications as directed, noted Tom Hubbard, vice president for policy at the New England Healthcare Institute.

Sometimes it’s because of the high cost of drugs, but other times, there’s no good reason.

“They start skipping pills or they don’t take the right dose or they stop taking them all together,” he said. That kind of inattention costs the health care system about $290 billion annually, NEHI found.

That’s in addition to the nearly $150 billion annual price tag for obesity and more than $289 billion for smoking in medical expenses and lost productivity, according to the Centers for Disease Control and Prevention.

But cultivating good health habits is a challenge for everyone, not just the newly insured, added Joan Alker, executive director at the Center for Children and Families at Georgetown University.

She said she believes the conversation about personal responsibility is a “cheap shot” and a distraction from the problems caused by a growing economic gap between the rich and the poor.

“People make choices and that affects their health,” she said. “Does that mean we’re going to leave them there to die and to suffer? I don’t think that’s the kind of country we are.”