Behavior, Health, and the Reduction of Costs:

Promotion of Personal Accountability

Meghan S. McGowan, BSN


            Healthcare reform, health policy, and countless other topics on the subject have been debated over, and deliberated upon for decades.  It has become almost a cliché in the healthcare industry to hear, “44 million people in this country are without any health insurance”, or that the cost of healthcare in the United States is spiraling upwards at a rate to be alarmed at.  Despite this, almost every citizen 65 and older (99.3%) has health insurance[1].  And, while millions in this country may go without health insurance, they do not go without health care if they need it.  That is the major concern of many with the size of these numbers; treating uninsured people in the emergency department is much more expensive than treating problems before they become critical. In addition, for all citizens personal behaviors have a huge impact on the health care needed by that individual, especially in regards to smoking, diet, exercise, obesity, hypertension, etc. In sum, cutting health care costs is a major public health concern in the United States and many suggestions have been made, but data has shown that if individuals take responsibility for their health, and do their best to prevent acute exacerbations, we may in fact begin to reduce costs.






Statistics Supporting Change:

            Comparisons of Health Systems Indicators[2]:








Per Cap.















Life Exp.

74 yr






Infant Mort.








            Looking at this chart one could conclude that the United States is not getting the most for its money. We spend the greatest percentage of our  national income and spend the most per person, yet compared to other developed countries, have higher infant mortality rates and a lower life expectancy. Certainly some of this may be attributed to the nature of healthcare in the US. We treat people and infants often at all costs in an effort to save or prolong a life, thus increasing health care costs for many futile cases.  We focus on and practice acute care, rather than chronic prevention[3] and mechanisms for promoting health before they become critical exacerbations. All of this increases costs.

Could we go the way of the UK?

            Previous chapters have examined the way health care in the United States is delivered through Medicaid, Medicare, and private insurance.  Many health care reform ideas have proposed that the United States trend towards a socialized system such as in the United Kingdom or Canada for cost reduction. It has been suggested that the Canadian example may be the easiest and most natural for our country to adopt.  Yet, like the United States, these two health systems are not without fault.  In Canada, all provinces have universal hospital and physician insurance.  Federal government contribution varies between provinces and much of the funding comes from income and sales taxes.  Their system is of social insurance where all physician fees are fixed.  Because of this there are fewer doctors per patient, and were it not for the influx of foreign physicians, that ratio would be even lower.  In addition, failing facilities, shortages of new equipment and long waiting lists are the norm in this type of socialized health care system.  In Vancouver it is not uncommon to wait nine months for cataract surgery and up to four years for a corneal transplant. 

            The British National Health Service operates a bit differently, though it is financed also from general tax revenues.  Citizens have access to general practitioners, though not necessarily one of their choosing, for no cost. Prescription drugs are also available at greatly reduced prices. There is no cost for hospitalizations, doctor visits, or diagnostic tests.  The potential problem with a system like this is patients make little or no contribution to the cost of their care and so have no incentives to stay healthy and may demand more of the system.  Income control had led to emigration of physicians and to strikes and, like in Canada, to cut costs there are long waiting lists for non-emergency treatment. Even urgent cases may have to wait[4].  So while “free” doctor visits and health care for all seems appealing to many,  more in depth study of these systems reveals downfalls that not too many Americans would be willing to tolerate.  Restructuring the United States health system may, in the long run be inevitable. But keep in mind that the US has some of the best and most innovative technology in the world.  Adopting a system like in the UK or Canada would most likely slow these technological advancements and that is an effect not considered by many. 

Other suggestions

            Another suggestion for solving the health care problem is rationing health care.  Rationing can be done in two ways. First, in the traditional capitalist or market economy, goods are denied to people who cannot afford them.  While millions fall through the cracks, Medicaid is the United States’ attempt not to let this happen.  Rationing can also mean limiting goods even for people who can afford to have it - as sugar or meat was during World War II.  This type of rationing is often supported because of the following economic argument:  “Standard economic theory suggests that spending on health care is excessive.  According to this doctrine, when people pay less than the full cost of what they buy, they will consume more than is socially optimal unless their consumption benefits not only themselves but others.  This line of argument suggests that insurance induces excessive health expenditures because people pay for only part of the cost of care.”5  Though it may be true that a health system like this gives little incentive for personal health accountability, dilemmas arise from this type of rationing proposal.  Physicians may be forced to act as gatekeepers and deny patients needed surgeries, diagnostic tests, or other care.  Physicians and others would be put in a position to make quality of life judgments, futility judgments, and economic justification arguments³

What does Personal Accountability Mean?

             Encouraging people to take responsibility for their health may not be a strategy legally enforceable. What may happen instead, is an appeal to common principles of medical ethics. Public and individual health has been grounded in the importance of ethical principles like prevention of harm, justice, and beneficence. Individuals hope and expect these principles will be upheld when they make a visit to a physician or hospital.  Patients have expectations that  confidentiality will be protected, that they will be offered the  most effective treatment options, and that their physicians are knowledgeable, capable professionals. These principles, important enough to become institutionalized in many ways among our health system, might also be extended to those receiving the care.  To do this most effectively not only requires giving people active or acute care, but to give them knowledge to maintain their health. A diabetic who does not know the signs and symptoms of hypoglycemia or needs help managing his care is at risk for an expensive and potentially life-threatening crisis, as is the obese person unsure about how to begin a weight loss program, or the hypertension patient unaware of screening options.  Promoting health and encouraging accountability has the potential to protect people from harm should they continue with unhealthy behaviors and to benefit them with early detection and prevention measures for whatever illness they might be experiencing.

Of course the major question that arises from these statistics is: will health behavior and health accountability really make a difference?  The Center for Disease Controls website at lists excellent information about all kinds of lifestyle and health related information. We do know that huge promotion and education campaigns have made a difference in some aspects public health. Vaccinations and promotion of hand washing have prevented countless incidences of disease and saved many lives. Anti- smoking and drug add campaigns and lawsuits have decreased the use of those substances.  But we still do not do enough and we don’t know much about the amount of preventative care Americans receive.  The CDC indicates that despite some success, two thirds to three quarters of one year old children have not completed their immunization series. Another study indicated that physicians may over estimate how much prevention and promotion education they really are doing[5]

Statistics Supporting Personal Accountability:

            Data from the Office of Disease Prevention and Health Promotion present eye-opening statistics on the financial reasons for encouraging personal responsibility.  This country spends millions of dollars due to the unhealthy or risky behaviors of individuals.  Though a bit dated, we can only assume that in the last ten years costs have risen with advanced technology, thus making accountability even more critical in reducing healthcare expenditure in the United States.


Costs of Treatment for Selected Preventable Conditions in 1989[6]



Avoidable Intervention*

Cost per patient**

Heart Disease

7 million

Coronary Bypass Surgery



I million new cases/yr

Lung and cervical cancer treatment



600,000 per year

Treatment and rehab



2.3 million

Quadriplegia treatment and rehab

Hip fracture treatment and rehab




HIV infection

1.5 million infected

Lifetime AIDS treatment



18.5 million abuse alcohol

Liver transplant


Low Birth Weight Baby

260,000 born each year

Neonatal ICU


Inadequate Immunization

20-30% aged 2 and younger

Congenital rubella syndrome treatment

$354,000 (lifetime)


            * Example - other interventions may apply

            **  Represents first year of costs. Lost productivity to society and other losses not included.             

Real Life Case Study

            Fortunately some agencies in the health care industry are recognizing the importance not only of promoting health, but enabling individuals to be healthy and be accountable for their health. In on example, a woman was diagnosed with breast cancer at the age of 51.  She had a mastectomy but was diagnosed three years later with pancreatic cancer. Surgery caused her to be diabetic.  Today she is back to work and controlling her diabetes. She thanks the efforts of Future Health Corp, a small population risk management company who’s philosophy is, “identifying the small percentage of patients in an insurance pool who are most likely to land in the hospital and then devoting resources to keeping them healthy..”. Doing this can, “significantly reduce the cost of caring for the entire group. This means an insurer can reduce restrictions on other covered members and still save money[7]”.  And, it works. When this patient got sick, a nurse called her every week (in addition to home care arrangements already set up for her) to answer questions, trouble-shoot, and offer solutions for unexpected bumps in the recovery road and the bureaucracy of the health care system. Future Health provided this service to her for free and saved her health insurance company a lot of money at the same time. Future Health’s small population focus differs from managed care organizations of today who try to monitor whole groups, leading to restrictions and rules and retrospective rather than prospective care.  It boasts reducing hospitalizations of its patients by 30 to 50 percent and savings of as much as 35 percent on health care costs4


            There are countless behaviors people can adopt to improve their health, maintain their health, and promote their health.  These behaviors are generally categorized as healthy living, or lifestyle choices.  Health promotion and screening in and of themselves will not necessarily improve the health of an individual. So, while it is important for the government, public and private agencies, insurance companies, and other health related groups to  give people the opportunity to learn about health and take steps towards healthy living, it is ultimately up to the person to make the choice or change.  This would not be so important if studies haven’t proved over and over again that people who engage in healthy lifestyles live longer and get sick less, and most Americans agree with this.  In 1987 a Gallup poll showed that over 80 percent of Americans agreed that if they ate right, didn’t smoke, and got regular checkups they could avoid cancer.  And over 80 percent believed they could control their weight and cholesterol enough to ward off a heart attack[8].  Americans know what they need to do to stay healthy and it’s important for public health professionals to be aware of and encourage this.


For More Information try these websites:

1. For information on Health People 2010, health indicators, insurance statistics and much more:

2.  For information on smoking cessation:

3. American Cancer Society at

4.  American Diabetes Association:

5. American Heart Association:


[1]  U.S. Census Bureau, “Health Insurance Coverage 2000,” U.S. Department of Commerce (2001).

[2]  Barbara Daly, University Hospital, class notes.

[3]  Charles Marwick, “US Healthcare System too Geared to Acute Medicine,” British Medical Journal, 322 (2001): 572.

[4]  Linda Brubaker Ropes. Contemporary World Issues- Health Care Crisis in America. Santa Barbara, CA: ABC-CLIO Inc. 1991.

[5]  David Kindig and Robert Sullivan. Understanding Universal Health Programs. Ann Arbor: Health Administration Press:1992.

[6]  Charity Anne Dorgan. Statistical Records of Older Americans.  Detroit, MI: Gale Research; 1996.

[7]  Shannon Brownlee, The Washington Post. “Let’s Do The Math” March 6, 2001, page HE10.

[8]  Michael S. Goldstein. The Health Movement: Promoting Fitness in America. New York: Twayne Publishers; 1992.