The Affordable Care Act (ACA) has polarized many people (if you are among the 3% that don’t believe me, check out the responses on my post Cancer v. The Constitution). While I am the first to admit the law isn’t perfect (for example, lack of accountability from insurers and providers regarding charges and cost of care), the legislation does contain many good things (e.g. health insurance for all, no pre-existing conditions, and no co-payment for vaccinations).

I believe than an imperfect law that sets us on the right course (affordable care for all) is better than our current health care system. Let’s not forget that even the constitution wasn’t perfect at birth, hence all those amendments I learned about studying for my citizenship test. The fact that a piece of legislature might need some fine tuning down the road is not a new concept and is surely something we can handle.

As I thought more about the ACA and about accountability from insurers, Big Pharma, and providers, I also thought about personal accountability. I know behavior can’t be legislated, but if you really believe in the concept of universal health care, then you must also believe that we are all stewards of the system and so it behooves each one of us to do our personal best with our health. First of all, we’ll be healthier (that’s the goal of not only the ACA, but really everyone’s goal, is it not?). And secondly, striving for better health as well as being responsible with health care lowers costs for everyone. Think of it as resource conserving, just like turning down the heat while you’re sleeping lowers your energy bill and reduces your carbon footprint.

If you believe in universal health care, I challenge you to make 4 changes this year in your health and/or how you access your health care (the latter obviously if you are lucky enough to have health insurance). The kicker is you have to build on each change, so once you have done one thing, you have to keep it up while working on the next.

If you’re stuck for ideas, here are some suggestions:

1. Walk 150 minutes a week (that’s 30 minutes 5 times a week). It has health benefits that equal a 20 lb weight loss. Start with 10 minutes a day at lunch – you’ll almost be 1/2 way there. If you are already exercising regularly, find a way to do just a little bit more.

2. Eat breakfast (a healthy one, if possible) every day. It doesn’t matter if don’t think you’re hungry (although, you probably are and just don’t know it). Many of my patients complain of fatigue and almost always when I ask what they had for breakfast, the answer is, “Nothing.” Your body has fasted all night and needs energy for that 30 minute walk you have planned! And if you are trying to lose weight, well, studies tell us you will be more successful if you eat breakfast.

3. Eat 25 g of fiber a day. You may think you eat a lot of fiber, but the average American diet has approximately 10 g. Check fiber content on food labels or online and keep a log for several days to keep yourself honest. A high fiber diet is associated with lower rates of obesity and makes you poop regularly. Hey, constipation accounts for 8 million doctor visits a year! In one study, Medi-Cal (California Medicaid) paid more than $18 million over a 15 month time frame for the diagnosis and management of constipation! Fastest way to 25 g a day is a high fiber cereal (remember breakfast!). My favorite breakfast is 1/3 c Bran Buds (13 g of fiber) with Greek yogurt and 2 tbsp. of walnuts.

4. Limit your sexual partners, don’t hook up, and make sure you have safe sex. STDs cost $17 billion a year, yet are essentially preventable. No night of passion is worth gonorrhea, chlamydia, or HIV.

5. Speaking of chlamydia, if you are a woman and 25 years or younger get tested every year for chlamydia. Chlamydia typically has no symptoms, but it can spread to the fallopian tubes causing a serious pelvic infection. Annual screening (and treatment if positive) in this age group dramatically reduces the risk of this pelvic infection. If you don’t have health insurance you should be able to get tested for free at your county health department, but college health departments and Planned Parenthood are also lower cost options.

6. If you smoke, quit now. Really, call 1-800-quit-now. Right now. Smoking causes asthma, emphysema, cancer, premature delivery, and if your baby is exposed to second hand smoke he is more likely to develop asthma or die from SIDS (sudden infant death syndrome).

6. If you are overweight or obese try journaling. Studies tell us people eat about 1,000 calories more a day than they think. Weighing and measuring portions and writing everything down is a cornerstone of weight loss. Try and lose 5-7% of your body weight, you will reduce your risk of getting diabetes and you will feel better.

7. If you don’t want to get pregnant (or get someone pregnant) use contraception. Yes, it should be covered by every health plan, but make every effort to get it and use it. Correctly. This requires heterosexual couples discussing if they do or do not want a baby. The IUD has lowest failure rate and if I wrote the ACA would be available with no co-payment for the IUD or for insertion. If you are using birth control pills, keep in mind that in one study of birth control pill takers with an average age of 22 many women missed pills. The average number of missed pills/month was four.

8. If you are pregnant, make every effort to breastfeed. Breastfed babies have a much lower risk of many health problems (and breast milk is free!). By one estimate, if 90% of babies were exclusively breastfed for 6 months $13 billion in health care costs could be saved.

9. If your doctor gives you a prescription, be honest with yourself and your doctor about whether you will really take it. A lot of money is wasted on prescriptions that are filled but only a few pills out of a 30-day supply are used (never mind increasing medical waste). If you have second thoughts about the medication you are prescribed, talk with your doctor.

10. If you think you need medical care on the weekend or at night and it’s not an emergency, call/check to see if there is an urgent care clinic. Emergency rooms are filled with patients who have diaper rashes, minor injuries, or colds. The problem? It is far more expensive to treat these things in an emergency room than in a clinic. If you have chest pain or are short of breath you need an ER, but if you’re not sure if you really need emergent care, think about calling and asking.

11. Give up trans fats. These are modified fats found in many prepackaged foods and used in many restaurants (except in New York and California, where they are banned from restaurants). Trans fats (the label will say “partially hydrogenated oil”) cause heart disease. Big offenders are frosting in a can, cake mixes, and coffee creamer. People talk about banning sugar, but you can consume sweets responsibly. There is really no safe lower limit for trans fats.

12. If your doctor recommends a test, ask how it will change your care. Many tests are just not needed, and some carry significant risks (for example, the radiation from a single CT scan of the abdomen and pelvis has a 1/1,000 risk of causing cancer). If your doctor gives a lame-ass answer like, “I’m just looking,” get another doctor. Medicine isn’t a fishing expedition. Every test should specifically rule in or out a specific condition.

13. Don’t ever use a tanning bed. Ever. Using a tanning bed before the age of 30 increases your risk of melanoma (the most deadly skin cancer) by 75%. Melanoma kills more than 8,000 Americans a year. Tanning beds also increase your risk of other skin cancers (squamous call and basal cell cancers). The World Health Organization (WHO) has tanning beds on the same list as plutonium with regards to cancer risk!

14. To further reduce your risk of skin cancer use a sunscreen with an SPF of 30 or more for extended outdoor physical activity (use at least an SPF 15 for every day). Wear UV-blocking sun glasses to protect your eyes and a hat to provide extra protection for your face and eyes.

Need more suggestions or have your own? Ask/leave them in the comments.

Accountable care should be an idea that we can all embrace.


Join the Conversation


  1. My note to myself: if you have a chronic condition (asthma, high blood pressure, diabetes, etc), stick to your management program. It’s cheaper than ending up in the ER with an acute crisis…

  2. Bullshit.

    It’s so nice to hear people acquiesce to the concept of continually lowering standards such that we’ll just accept a bad law because we’ve accepted them in the past. That’s interesting logic. So why not go back to slavery since we’ve had it in the past. Women had no rights and were treated as property in past, we should go back to it. How does that make any sense? Why can’t we expect our politicians to write better laws? Are we lemmings?

    You really think our health care system is not as good as it can be? Tell me why then so many innovations have come out of our system? Tell me why so many foreigners, including Canada’s prime minister come to the US to get treatment? How many people are going to China to get their healthcare? Or Japan or Sweden or any other nation?

    It’s always nice to think that something NEEDS to be fixed just because of some data showing an uptick on x issue. However, completely changing our system is an over-reaction.

    Overall the trend in underage pregnancy has been going down over the last 3 decades; yet there are small upticks here and there. The move to universal healthcare would be akin to making children sterile until they are adults because of those small upticks.

    You think that by all of us “buying” into a universal healthcare system we’ll be better off? Then explain to me why in Europe they have as much obesity as we do?

    A lot of people don’t understand why the A.I.D.S. epidemic in Africa can’t be controlled. Part of the reason experts have found is that A.I.D.s drugs are available for free so the citizenry isn’t that concerned about getting the disease. Since they can easily get drugs they can get A.I.D.S. and go on with their lives. You think by providing universal care people will just start being healthy? Since they aren’t paying (at least in their minds because we will pay for it in higher taxes) their behaviors will get worse. They’ll smoke more, drink more and do more unhealthy things.

    Back to my point about innovations; A.I.D.s drugs didn’t come from Africa.

    You can’t talk about trans-fats without talking about saturated fats. Sat fats are far worse for you than trans fats and when you remove 2g of trans-fat from a product the sat fats go up by 2g. How is that better?

    That’s no different than the hysteria surrounding high fructose corn syrup. First of all there is no proof that the body can tell the difference. Second of all, high fructose corn syrup has less fructose than table sugar. So how is going to real sugar better?

    And don’t even try to use the whole “artificial” is bad argument because there are plenty of natural things that aren’t healthy as well. Hemlock is natural, wanna eat it? Radon is natural, wanna sit in a house full of it? Sulfur is natural; wanna swim in a lake full of sulfuric acid? I know of 2 you can visit; one in Costa Rica; one in Portugal. Let me know how you like it.

    Although your list is common sense; it’s too idealized. 50% of healthcare problems are self-induced. Why should I be responsible for that? I train in a very dangerous martial art that puts my body at great risk. Why should someone else pay for that? Shouldn’t I get their permission first? And that’s just me. I’m not including the people who smoke, drink, do drugs that harm their bodies. Why should I pay for their lack of self control? Are we slaves to each other now?

    A better solution to our “healthcare problem” is to make people responsible for their own actions. Rather than saying an insurance company can’t deny pre-existing conditions; they should deny self-induced post-existing conditions.

    If a healthcare problem is identified as self induced, say cancer from smoking, than the insurance companies don’t have to cover it. You get diabetes from being obese because you overeat, you won’t get coverage. Etc, etc.

    The company that makes Miracle Grow did just that on all its employees and it worked. If you are overweight you pay a higher premium for your healthcare. They don’t hire people who smoke because they liken it to drug addiction (they test for it during the pre-employment drug screening). This reduced their overall healthcare costs and created a healthier labor force. That to me sounds more effective than universal healthcare.

    1. Jaime, farmers are complaining that cattle feed prices are going up because you’ve cornered the market to make all those straw men. Perhaps that’s why you see so much bullshit around- you’ve attracted hungry cows.

      Are you seriously proposing that no law should be passed unless we can be guaranteed that it will work perfectly in perpetuity? Which congressman would you trust with that crystal ball?

      No one has ever said that the highest end of US healthcare isn’t great, and yes, wealthy people from all over the world come here for care. But that wasn’t the point. The point was that healthcare should be available for everyone, and in a way that doesn’t drive up everyone’s costs. People who can’t afford routine or maintenance healthcare often wait until the condition can’t be ignored and then go to the ER. The condition is then more expensive to treat, and having the care in the ER only exacerbates the costs. Pay attention now, because this part is important: these increased costs are *already* shared by everyone. Universal healthcare does keep the cost-sharing, but reduces the cost.

      Most medical innovations come from North America, Europe, and East Asia because that’s where the money and scientific infrastructure are. Not because we don’t insure everybody. I suspect you made up your “experts” claiming that Africans don’t mind getting HIV. I’ve lived there, and your claim strikes me as diametrically opposed to reality.

      And I’ll ask a similar question of you that I’ve asked of someone else. Where do you draw the “self-induced” line?

      Nonsmokers can and do get lung cancer; I know one right now. Will you cover her? How are you so sure that the ex-smoker down the hall didn’t get cancer for exactly the same reason? What about secondhand exposure? Does occupational exposure count as “self-induced?” What if we identify something as an occupational risk factor after someone has retired from that job? Are they or their still-employed coworkers out of luck? What if the employer didn’t tell them about the exposure? What about kids who are injured playing sports?

      That’s the problem with legislation based on slogans– it ignores reality. People get sick and injured for lots of reasons, and causation isn’t as black-and-white as you’d like to think.

      1. Oh, boy.

        I didn’t say that the only metric to allow a law to be passed is to see if it can work in perpetuity. However, if we know a law is flawed than they should re-write it to minimize the flaws.

        We have a law against murder and yet people still do murder. However, does that mean that we should pass one that may allow for ritual religious killings just because we need a better murder law?

        Or more recently the anti-bullying law in Michigan (I think?) that allowed for bullying on religious basis. By your argument that law should have passed, flaws and all.

        if we are going to give politicians the power to make rules that directly affect people’s lives than we should expect them to be as close to perfect as possible. Passing a law just because we should is no reason to pass a law.

        Think of it this way. Universal healthcare will mean that we all pay for everyone else’s medical expenses. Including abortion, sex changes and other sort of “controversial” issues. I don’t think they are controversial as I think that a woman’s right to an abortion is untouchable by any law and no one has any claim to prevent it. If someone wants a sex change they can get it any time they want and no one has a claim to prevent it.

        We can have abortions under our current President; however, do you really believe that a President who bends the knee to a Jewish Zombie God will allow the government to pay for them when they are in power? You think someone like Romney, Santorum, Perry, Bachman, Gingrich and even some Democrats would allow women to get abortions if they had a say? Or what about homosexuals? You think those lunatics will allow them coverage?

        By that statement, don’t you think that we should think long-term if we’re going to pass a law allowing the government to control healthcare?

        Lots of people say our healthcare isn’t good, which is part of the reason why they want the government to control it. Where is it written that health care SHOULD be available to all?

        That means that we all have claims to a doctor’s ability and they are slaves to us. So are they our slaves? Is that in the hypocratic oath? And this speaks exactly to a MAJOR flaw in Obamacare. It doesn’t call for ANY increase in the number of doctors.

        That alone is why costs will not be under control. The number of doctors will either remain the same or go down. That will limit supply and you can ignore certain facts, but you can’t ignore the fact that no one can escape the law of supply and demand.

        So what will happen? They won’t be able to control costs such that they will have to raise taxes. Will that put costs under control? No. So what will they do? Tax us all at 100%? No, they’ll start cutting things and believe me abortion will be the first thing on the chopping block. Healthcare for homosexual partners will be 2nd. Not only that they will limit MRIs and other innovations that while helping us to save lives will be too expensive so they won’t happen. They won’t even come into existence.

        Just because everyone is covered does NOT mean costs will be under control. All the bill does is create more demand; it does not address the issue of supply.

        Read the history on the Canadian health system. The same thing happened. Demand went up; supply stayed the same; costs got out of control and now the Prime Minister of Canada comes to the U.S. for treatment.

        If that’s not a slap in the face of the Canadian system I don’t know what is.

        My statement about innovations was attacking the idea that our health care system is bad. Not saying that only innovations come out of countries that don’t cover everyone.

        There’s a reason why an iPhone is $600; it’s uses innovative technology. MRIs are expensive in the same sense. That’s part of the reason why our healthcare is so expensive. We have all these great innovations. Someone has to pay for it.

        Nonsmokers who get cancer would be covered. I’m talking about the provable stuff. I am not some lunatic who doesn’t believe in the scientific method. If the doctor says to me “Jaime, you got cancer. Do you smoke? And I say “yes” and it’s provable through testing than I wouldn’t get coverage.

        I think we have enough scientific knowledge that we can prove whether someone is a smoker or isn’t. I’m sure with the same science we can prove whether someone is a drug addict. Unless you believe that someone could accidentally fall on a full needle of heroin.

        In cases of fraud the party committing the fraud would be liable. That’s already been handled by the court lots of times. In cases of occupational injuries you’ll have to be specific. A dock worker gets injured on the job gets covered.

        Someone like me who will probably need a new set of knees when I’m 80 because of my martial arts training won’t get covered because I did that of my own volition. And that’s fine. I make no claim upon someone else to take care of me let alone have to pay for me without their express permission.

        And I didn’t make up those experts. It’s in an episode of Frontline called “The Age of A.I.D.S.” And I clearly stated that it was part of the reason. I didn’t say it was the only reason and I didn’t say they Africans are happy to get A.I.D.S. I said that the readily available drugs mitigated the fear of contracting the disease. In line with what’s said in the Frontline episode.

    2. Tell me, why are Americans flocking to India, Mexico, Colombia, Thailand etc in their thousands every year for surgeries? if US healthcare is so amazing why do people go to developing countries for their hip replacements and heart bypasses?

      your entire country is founded on greed, arrogance and self interest, there’s no care for fellow humans, no belief in the common good. you’ll spend trillions on pointless wars and then scream “Not my problem!” as American children die because of tooth decay, because their parents are poor. Disgusting.

      1. Spoken like someone who is a complete expert on the U.S. and U.S. culture.

        Please provide me the data that shows that more people are going to those countries than coming to the U.S.

        You couldn’t be more wrong about our . On a per capita basis U.S. citizens give more to charity than any other country in the world. There’s tons of evidence on that.

        You have no data to prove any of your bullshit. No children are dying from tooth decay and no parent or person would simply allow it because we’re “arrogant and self interested.”

        You sound like someone who is completely jealous of the U.S. way of life such that you have to bash it to make yourself feel better.

        I’m sure you would tell Bill Gates and his wife that all the money they have given to charity was wrong.

    3. “How many people are going to China to get their healthcare? Or Japan or Sweden or any other nation?”

      Hundreds of thousands of Americans are going abroad every year to get affordable health care. Look for a recent item on the New Yorker website.

      “Then explain to me why in Europe they have as much obesity as we do?”

      They don’t.
      Actually it’s kind of refreshing to see someone claim Europeans are as obese as Americans. Conservatives usually use Americans greater rate of obesity as an excuse for why our health care system is so much more expensive than theirs. (It isn’t because of higher obesity!)

      “If a healthcare problem is identified as self induced, say cancer from smoking, than the insurance companies don’t have to cover it.

      What if someone quit smoking 20 years ago and developed lung cancer? Are they 20% responsible for it? What if you never smoked but worked in a bar twenty years ago where other people smoked? Are you 8% responsible for it? Who will decide how much responsibility is assigned? The government?

      Come on, isn’t that crazy? Trying to take an illness and blame someone for having it is just a bad idea.

      1. Hundreds of thousands? You call that a lot when we have 300MM people here? That’s not even statistically significant.

        Your list is interesting, but I see 6 European countries in the top 10 that aren’t that far off from our level of obesity.

        If you smoked 20 years ago and develop cancer then you are 100% responsible for the cancer you develop later in life.

        If it is proven that you did not smoke, but developed cancer than you are not responsible. We have the science to prove who smoked and who didn’t. Not to mention that the affect of 2nd-hand-smoke has been quite exaggerated. Even the guy who started that craze admits that it’s gotten out of control.

        You can’t blame someone for causing their own illness? Really? You think the rest of us are responsible for someone’s activities that caused their illness? That’s lunacy. Where is that written? Who agreed to any of that?

        In your mind we are all slaves to each other. That’s very interesting.

      2. “Hundreds of thousands? You call that a lot when we have 300MM people here? That’s not even statistically significant.”

        I would wager more Americans leave the USA to seek health care than foreigners come here to get it. But if you have some statistics on how many foreigners actually come to the USA to get health care, you could share them.

        “Your list is interesting, but I see 6 European countries in the top 10 that aren’t that far off from our level of obesity.”

        The UK is the highest in Europe and our obesity level is 33% higher. I’ve lived in Germany and think of the Germans as being pretty hefty, especially compared to the French, and yet their obesity rate is less than half ours. It’s really not comparable.

        The rest is pretty silly, really. If someone smoked one cigarette when they were 16, they’re responsible for getting lung cancer? You think you can tell whether someone smoked 40 years ago? It’s a waste of time.

    4. Jealous? Don’t make me laugh. The US is my idea of hell. A deluded theocracy, utterly convinced of it’s own exceptionalism, built on the backs of the poor, with basic rights (healthcare, marriage, gender recognition, social safety nets, reproductive choice etc) denied to the vast majority of citizens.

      Oh, and ,Deamonte ,Driver’s family would disagree that kids in your awesome country don’t die due to simple dental issues.

      1. Really? We are a theocracy? We’re Saudia Arabia? Are you sure?

        When did this happen? President is a secularist (thankfully) and we have a separation of church and state (thankfully).

        Show me one country that was built on the backs of the rich? Europe? You think Portugal was built by rich people?

        We don’t have healthcare at all here in the U.S? Didn’t the Canadian Prime Minister come here for treatment? Did that happen in another dimension? Is that a fact that is so inconvenient that you’ll ignore it like a theist ignores the evidence of evolution?

        We don’t have marriage in the U.S? We don’t have gender recognition? The last time I checked it’s illegal to burn a woman in the U.S. but perfectly legal to do so in some Arab countries.

        Social safety nets? We don’t have medicare, medicaid, social security, bankruptcy protection? None of those exist in the U.S.?

        Reproductive choice? Abortion is legal in the U.S. I think you mean these countries:
        Brazil, Colombia, Chile, Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Venezuela, Angola, Benin, Central African Rep.Chad, Congo, C’te d’Ivoire, Dem. Rep. of Congo, Gabon, Guinea- Bissau, Kenya, Lesotho, Madagascar, Mali, Mauretania, Mauritius, Niger, Nigeria, Senegal, Somalia, Tanzania, Togo, Uganda, Egypt, Iran, Lebanon, Libya, Oman, Sudan (r), Syria, United Arab Emirates, Yemen.
        Bangladesh, Indonesia, Laos, Myanmar, Papua New Guinea, Philippines, Sri Lanka. Malta, Vatican City.

        Denied to the vast majority of its citizens? What the hell are you talking about.

        Are you that desperate to make an argument that you’re being obtuse on purpose?

      1. Yes you do. I’m European. I see it all the time.

        So my family in Portugal and France who tell me about the obesity issues in their countries are wrong?


  3. Thank you for your compassion and insight Dr Gunter. I was once a patient of yours at Kaiser Pain Clinic and I have much respect for you as a doctor, writer and human. Be well.

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