It makes me sick

Although,as I said yesterday, the social environment is a very powerful determinant of health, in the U.S. we tend to think more about the physical environment. I suspect that's because it doesn't force us to ask questions that are quite as difficult. Nevertheless, the physical environment is important. Since we’ve cleaned up some of the worst offenses of the industrial revolution, it’s not as big an issue in the U.S. as it once was, but in much of the world, malnutrition and contaminated water slaughter children by the millions every year. Here, motor vehicle crashes and other unintentional injuries still take a dreadful toll, and you’d be surprised how much death and disease results from exposure to motor vehicle exhaust. (Check out the CAFEH study for some interesting info.)

Obviously, the physical environment is shaped strongly by the social environment and it's often hard to tell them apart. Are people in hazardous occupations, or harmful food environments where junk food is cheap and fresh produce unavailable, facing risks from the social or physical environment?

Now let's turn to personal characteristics and behaviors. Of course, we have our genetic endowment, which predisposes us to particular health problems as it interacts with our environment. Worst of all, each and every one of us is born with a progressive, incurable, ultimately fatal disease which will eventually cause us to lose lean muscle mass, lose skin tone, suffer declining immunological function, declining cognitive function, slower healing and recovery from injuries, and yes, we’re all going to die.

So what about those areas of personal responsibility? Libertarians will tell you that a lot of what drives our health status is individual choice. We should be left alone to make those choices, and to suffer or enjoy the consequences. I’m not going to get into the question here of whether free will is an illusion, but we are obviously not entirely autonomous. To a considerable extent, we do what is considered normal or respectable in our social milieu. We also don’t necessarily know exactly what’s good for us. And corporations, in order to extract money from us, will often deceive us about that. Tobacco companies spent literally billions over decades to persuade us that smoking wasn’t really dangerous, and kids today are subjected to thousands of commercials every year for junk food.

And, people get addicted. It’s common to blame addicts for their situation but that is a false view of human behavior. Our behaviors are driven by specific pathways in the brain that get hijacked by addiction. It’s very difficult to overcome. And finally, do we really want to make people bear the burden all their lives of choices they made when they were young and foolish, as we all have been?

So is tobacco a feature of the social environment, the physical environment, or personal behavior? It's all three, of course.

Ultimately, our good or bad health is largely a matter of chance: where we happened to be born, into what circumstances, with what genes, into what society, every random thing that happens to us. It doesn't matter who you are or what kind of personal responsibility you believe in, something bad might just happen to you.

So that’s where insurance comes in. Libertarians will say, “Why should everybody have health insurance? We don’t have a third party to buy our groceries.” Truly, I’ve heard that said. Well, it’s because of the immense disparities in people’s need for health care. It could be a little, it could be a lot, it could be catastrophic. Furthermore, there is a gradient over the life course. Without insurance, most people who really needed a lot of health care couldn’t possibly afford it. And, as I said at the beginning, if we depend on people to buy it out of their pocket it will be underproduced – there will be all those negative effects for the whole society of people not getting care they need. Note that underproduction in this case refers not to the sheer quantity, which in our country is too much, not too little; but rather to the right stuff at the right time. This is a very important distinction.

So next time: How insurance markets work. And no, it is absolutely nothing like Joe Lieberman wants you to believe.