As information and misinformation surrounding health care legislation continues to be front and center in American politics, many of my patients have begun to tell me what they think. Lately, I have had a string of patients tell me things like, "It is all about individual responsibility. If people weren't so fat, health care would be cheaper," but then they go on "those people always eat at McDonald's, never exercise, and use their food stamps to buy junk food and not fruits and vegetables. The government has enabled them to behave this way through continued subsidies and now we have to bail them out again."
It is an attractive argument. After all, we all know that not enough Americans exercise regularly and there certainly is a higher rate of obesity and major diseases (and therefore health costs) in poorer populations. But I have an uneasiness about accepting the rest of the argument because I have never been there. Through luck of birth, I grew up in a stable family which valued education. I was always safe and never had to worry about whether I would be shot while walking in my neighborhood. I always had food on the table (even though my mother admitted some months were harder than others). I have never had to work more than one job, and I never had to worry about losing that job if the city bus was late or never showed up. Compared to many, my life has been easy. So how can I possibly know what "they" are going through or understand why "they" make different decisions than I would.
The attractiveness of the "us" vs. "them" argument is that "we" are always in the right. The problem is that it quickly falls apart when challenged. Who are "we?" Or alternatively who are "they?" Are they just the poor, the sick, or the elderly? Are they just the ones who have made bad decisions? Perhaps they are just people who think and act differently than we do. Not surprisingly, we are all a "we" or a "they" depending on the perspective of the individual rendering the opinion.
Encouraging healthy behavior is great and it would likely save money, but moving the argument to an emotional one hinged on the deeper issues of society is a slippery slope. Such arguments cease to see individual people struggling to do their best in the midst of huge challenges and instead focus on bad outcomes--essentially throwing the baby out with the bathwater. I realize much of this emanates from the difficult balancing act any society faces between helping its most vulnerable citizens and maintaining the status quo. But I also know if I ever become one of "them," I hope there is some safety net in place to help me out in my time of need.