Politicians, particularly Republican candidates, among them Mitt Romney and Paul Ryan, like to emphasize the importance of individual responsibility – especially in railing against the Patient Protection and Affordable Care Act, known as Obamacare. Indeed, America was founded by individuals working hard to earn rewards rather than free-riding on the wealth of society.
At the Democratic National Convention this week, Democrats have defended and reclaimed Obamacare as one of President Obama’s signature achievements. (See Bill Clinton’s rousing endorsement last night.) But some Americans seem to be under the impression that the health-care law is a step away from personal responsibility, a step toward socialized medicine. That’s certainly the message they got from the Republican National Convention last week.
As knowledgeable columnists and health-care experts have pointed out, the opposite is the case. It is the pre-Obamacare system that involves free-riding: A patient who shows up in the emergency room is treated even if uninsured, but the hospital has to pass the cost on to the rest of us.
The abdication of personal responsibility is especially great to the extent that the medical community can attribute health afflictions to such risk factors as being overweight. (According to recent studies, every obese American adds 42 percent to medical costs, relative to those of normal weight.)
Obesity can sometimes be attributed to poor diet, lack of exercise, or other personal behavior. But researchers find it can also be genetic. Individuals with such risk factors or pre-existing conditions may not be able to get private insurance under the pre-Obamacare system – even if they don’t want to be free riders. The private health insurance plans often exclude them. In such a system, personal responsibility is sorely absent.
The Affordable Care Act (ACA) of 2010 was designed to solve this problem, with its “individual mandate” and its prohibition on excluding customers based on pre-existing conditions. Establishing personal responsibility is the reason why conservative think tanks proposed the idea of the individual mandate in the first place, and why Mitt Romney approved it as part of the health-care law enacted in Massachusetts.
All this has been said many times, of course. But new analysis exposes another disconnect between rhetoric and reality when it comes to personal responsibility in health care:
The states opposing Obamacare are the states where people are least likely to take personal responsibility for their health in their daily behavior.
Members of Congress from states with high incidences of obesity, poor eating habits, and poor exercise habits are much more likely to have voted against the health-care reform; those from states that rank high on physical fitness voted for it. The relationship is highly significant statistically.
Similarly, states that show signs of risky sexual behavior – high incidences of pregnancy among girls age 15-17 and the sexually transmitted disease chlamydia – tended to vote against the ACA. The same is true of states with high rates of smoking, drunk driving, and shootings.
Look at the graph above. The vertical axis shows how many of each state’s members of Congress supported the 2010 reform. The horizontal axis is a composite index of measures of personal responsibility. It is an average of a physical fitness index, which includes obesity and physical exercise, and a risky behavior index, which includes teenage pregnancy, drunk driving, and firearms assaults. These are patterns of irresponsible behavior that impose costs on others in two ways: directly (victims of a drunk driver) and indirectly (passing on hospital costs of treating the uninsured).
The vote was strongly against health reform among the congressional delegations from Mississippi, Alabama, South Carolina, Kentucky, Oklahoma, Kansas, Georgia, Tennessee, Texas, and Missouri. These tend to be some of the states with the highest rates of obesity, teenage pregnancy, drunk-driving fatalities, and firearms assaults in the country.
The reverse is true among many of the state delegations that voted for Obamacare: Colorado, Massachusetts, Connecticut, Hawaii, New York, New Hampshire, Minnesota, Rhode Island, New Jersey, and California.
There are outliers, of course, especially Utah. Perhaps this is because much of its population abide by Mormon teachings that promote healthy personal behaviors and prohibit risky ones.
Overall, however, states that voted against Obamacare, often in the name of personal responsibility, are those where populations exhibit the least individual responsibility when it comes to their own personal health behaviors, as identified by medical researchers.
In spite of the predominant GOP rhetoric, Obamacare is actually the right answer for those who believe in personal responsibility – not just in word but in deed as well. The pre-Obamacare system is not.
Jeffrey Frankel is the Harpel professor of capital formation and growth at the Harvard Kennedy School of Government.