Health Care Reform: What Will It Take to Change Americans’ Lifestyles?

Darrell M. West
Darrell West
Darrell M. West Senior Fellow - Center for Technology Innovation, Douglas Dillon Chair in Governmental Studies

July 27, 2009

Proponents have high hopes for health care reform. Through requirements for employer and individual coverage, more competition among insurers and the expansion of health information technology, they expect Congress to improve the quality of medicine, reduce costs and expand coverage to those currently without health insurance.

The problem with legislative action, though, is that it is not likely to alter the personal behavior that is one reason life expectancy in the United States — 77.9 years — ranks 42nd in the world, well below that of Andorra, the Cayman Islands and most European countries. Americans eat too much, get too little exercise and have diets that are too fatty. According to the American Obesity Association, more than 30 percent of children today are overweight. This ticking time bomb threatens to explode and have dramatic consequences for national health care spending, regardless of what Congress does in the next few months.

What is needed today is not just legislation, but serious thinking about how to get Americans to lead healthier lifestyles. If we want health care reform to reduce costs and improve good health, we need a public education campaign emphasizing exercise, balanced diets and healthier living. But is changing lifestyles something government is any good at doing?

In 1961, President John F. Kennedy launched a national physical fitness campaign that involved public service announcements, presidential events and schools running fitness competitions. As a student in the 1960s, I recall participating in a series of 100-yard dashes, 600-yard races, sit-ups, pull-ups and other assorted activities. I was terrible in timed events, but they had their desired effect. Schools kept track of individual performance, and those meeting minimum standards earned a jacket patch. Eventually, I got my patch and wore it, as did many of my classmates. The country for the first time became conscious of the virtues of fitness.

But changing personal behavior isn’t easy. The most glaring example of failure is Prohibition. A constitutional amendment outlawed the sale of alcohol across the United States in an attempt to limit the detrimental aspects of liquor consumption. However, its major effect was the creation of thousands of clandestine speakeasies across the nation. The abysmal failure of Prohibition to alter the behavior it was seeking to restrict led to its repeal in 1933, 14 years after it was ratified.

In more recent times, legislators have tried to make driving safer, first by mandating seat belt usage and then by discouraging cell phone calls while driving.

The effort to encourage seat belts has been reasonably successful. According to statistics compiled by the National Highway Traffic Safety Administration, the use of seat belts has risen from 60 percent in 1994 to 83 percent in 2008. Efforts to outlaw cell phone calls while driving, though, have been completely ineffective.

A Nationwide Insurance survey found that 81 percent of Americans say they have made a call while driving. Cell phones represent a serious distraction to those on the road, but we have done little to address the role this behavior plays in highway safety.

The biggest success in behavior reduction has been antismoking efforts. Public campaigns to reduce cigarette smoking have been remarkably successful. Through a combination of legislation outlawing smoking in public places, public service announcements in major media and health warnings placed on cigarettes, smoking has fallen in the United States from 42 percent in 1965 to 21 percent today, a 50 percent reduction.

But the history of antismoking efforts demonstrates the extraordinary actions needed to alter personal behavior — in this case, an overwhelming amount of scientific evidence on the medical effects of cigarettes and a sustained campaign against tobacco companies.

This suggests that aggressive government action is required to get people’s attention. Will politicians have the will to go after fast-food companies, vending machine proprietors and soda manufacturers? Not likely. It will be hard to turn McDonald’s, Burger King and Wendy’s into the equivalent of Big Tobacco. And it is even less likely we will place health warnings on the Whopper!

That leaves us with the need for personal responsibility. Dealing with health care costs is going to take a sustained effort on the part of each individual. We should not expect the government to cut health care costs and improve well-being through legislation. Unless all Americans take responsibility for improving their own lifestyles, the United States will continue to lag other nations on major health care outcomes.