Let’s start at what could be regarded as “the beginning," at least in economics.
In 1972, Michael Grossman published “On the Concept of Health Capital and the Demand for Health” in the Journal of Political Economy. If there were a Nobel Memorial Prize in Health Economics, he would have won it. Using Gary Becker's household production framework, Grossman revolutionized and formalized how economists think about health.
A key feature of the new framework was the conceptualization of health as something that is produced by individuals and households by combining market inputs, such as nutrition, tobacco, alcohol, and medical care, and non-market inputs, such as own time spent in exercise, information gathering/education, child care, and leisure/relaxation. Another feature of the model is a stock of health capital that depreciates over the life cycle, but that individuals and households can invest in through preventive inputs (again market goods, such as healthy foods, preventive medical care, and non-market own-time spent in, say, exercise). Such investment can add to the stock of health in future states of the world thereby slowing the rate of depreciation, at least over some range of the life cycle. (After all, in the long run, we are all dead.) Inputs such as tobacco (and alcohol at higher consumption levels) have negative marginal product thereby increasing the rate of depreciation and lowering the stock of health capital in future states of the world.
Grossman's model sees humans as demanding health, not medical care per se. Medical care is demanded as input to health production. Health is demanded and produced for the utility it provides as a consumption good in the current time period (because it translates into more healthy days, presumably higher wage income from the productivity gains, and feeling better). However (and this is what was innovative about the Grossman model), health is also demanded as an investment good, that is, a good that if invested in would yield more healthy days over the life cycle. More future healthy days yield utility through the extra earnings that are realized from them. As number of healthy days rises and as the wage rate rises, returns to investment also rise, leading to more investment in health (holding all else constant).
The Grossman model wasn't just theoretically elegant. It also explained a lot of observed human health-related behavior. It could account for why individuals with higher rates of time preference were less likely to demand preventive care as a hedge against future (unhealthy) states. It predicted that such individuals would be more responsive to changes in current prices, such as can be achieved by a "sin tax" on tobacco or alcohol, than to new information about future health consequences of consumption of such goods. It predicted that individuals with lower rates of time preference would be more responsive to information about the (future) bad effects of current consumption of goods such as tobacco and alcohol. These effects have been confirmed empirically (see for example here.) The model also predicted that more efficient producers of health (usually the more highly educated) face a lower "shadow price" for health, therefore demanding more of it. (The shadow price can be thought of as the money and time that individuals have to spend in producing an increment in health.) The model also predicted a wide range of wage rate effects on both investment decisions and on the substitution of market goods for own time in the production of own and child health.
What can we learn from this? Well, one thing is that medical care is one input among many to improving our own health now and in the future. Moreover, it may not be the most important input. However, when needed, if delivered too late or not in the right amount, it is likely to have severe negative consequences for the individual. It is necessary, if not sufficient.
It also means that rational economic actors may differ in the amount of health they choose to produce or to invest in. But the reasons for this do not translate readily into "personal accountability." The Grossman model suggests that economic actors who are less efficient at producing health face a higher shadow price. All else equal, they will rationally demand less health. The model suggests that individuals with lower wage rates and life expectancies will face a lower return on investment in own health and will rationally reduce investment in that health. The model suggests that individuals with higher rates of time preference, i.e., they discount future health states at a higher rate, will invest less in achieving those states.
Is it a "free choice" when the (shadow) price of health, the subjective discount rate, and the ROI that condition the choice are determined in large part by a circumstance of birth, early home environment, and even the culture and context into which they live? What does it mean to hold individuals personally accountable for making the rational choice not to invest as much in current or future health as someone judges they should, given the price they face, the discount rate they have inherited, and the ROI they're likely to realize? If they are rationally not purchasing health insurance should we force them to? Are we, in effect, requiring them to be irrationally exuberant? To produce more health and to invest more in future health than their price, time preference, or the ROI would warrant?
Or do we have an obligation as a society and a community, to counter these "market forces" that are so obviously harmful to less educated, less advantaged individuals and to society? Do we "nudge" them to be irrationally exuberant about their own life and health prospects? Do we demand that they over consume and over invest in their own health and penalize them when they rationally opt not to? Or do we offer them more education, greater future opportunity, the potential for a higher wage and a longer life to increase the ROI and reduce their discount rate? Do we subsidize health insurance and provide lower co-pays and deductibles to reduce their shadow price of health? These are the ways to create the proper incentives for disadvantaged and less educated individuals to invest in their own and their children's health.
If health reform is repealed, if the electorate continues to hear simplistic, but emotionally engaging rhetoric, about personal accountability, free choice, and so-called "rational behavior," one day we will have created an even more unequal society.
The obvious "market solution" is to improve the long run return on investments in health among the disadvantaged through meaningful and effective publicly funded education. The obvious short run "market solution" is to reduce the costs of investment and the shadow price of health for the disadvantaged by providing health insurance cover and reduced out-of-pocket costs.
That these policies are likely to produce a less unequal society and a more educated electorate is pure benefit to a democracy that favors, benefits from, and rewards commercial and individual endeavor.