Personal Responsibility in Health Care

PERSONAL RESPONSIBILITY IN HEALTH CARE

Christopher Ebbe, Ph.D.    2-11

ABSTRACT:  How the issue of mandating health insurance purchase interacts with our human tendency to forgive the unfortunate outcomes of a person’s risk-taking is examined. 

KEY WORDS:  health insurance, risk-taking, risk assessment

One of the chief points of conflict regarding last year’s Federal health care law was (and is) the mandate that all citizens purchase health coverage, or pay an annual fine to contribute to health care expenses.  Opponents believe that this requirement is a violation of the Constitution, and this contention will be determined in the courts.  Proponents believe that the mandate is the only way to finance the health care to be provided under the new law, since, as with all insurance, participation by a large number of people who receive little in the way of benefits (who are “healthy,” in this case) is necessary in order for expensive benefits to be available to those with more health problems.  (If only those who are unhealthy pay, then their premiums for coverage will be much closer to what the health care would cost them out-of-pocket, and this would not really be insurance.)

Since another important element of the new health care system is that applicants for coverage cannot be denied coverage because of health problems that they already have, proponents fear that if people had the option of not purchasing coverage as long as they don’t need it, they would rush to purchase coverage when they do need it and would then be covered even though they had not “done their part” to fund the total system over time (and would presumably stop that coverage again as soon as they were well).  Depending on how many people did this, this ploy could make coverage significantly more costly for those who purchase and continuously maintain coverage.  (The new health care law deals with the issue of those who truly cannot afford coverage by providing them assistance to purchase coverage.)  All major treatments are now so expensive that very few people have the cash (or the financial future) to actually pay out of pocket.

It is ironic that the Republican Party, which ordinarily views itself as strongly valuing personal responsibility, is in this case supporting the individual’s right to “scam the system.”  They might argue that they want everyone to take responsibility for their own health care coverage (or lack of it) by doing away with the mandate, but the results of this position include the system providing a great deal of health care that is not paid for directly by the recipient or by any health care coverage.  Opponents of mandatory health insurance have no good advice for those of us who do not want to pay the extra cost-spreading charges used by hospitals and doctors to cover the care they provide to those who have no coverage and insufficient cash.

One solution to this problem of opting not to pay for coverage until needed might be to allow insurance companies to charge an extra amount to those who enroll only when they become ill, based on the amount of time that they previously did not have coverage.  (This is similar to Medicare Part D coverage, which costs more per month the later a person enrolls.)

Another solution would be not to provide health care, even emergency room care, to those who do not have coverage or the cash to pay.  This would be an appropriate response to the individual’s decision not to have coverage, but it would also be an unpalatable solution in the eyes of most people, since particularly when faced with an emergency need, it seems to be hard-wired into us through evolution (or other means) to provide that care.  It is hard to imagine a person dying in front of health care personnel and those personnel not providing care simply because the person can’t pay (which is why most states require emergency care to be provided regardless of coverage or ability to pay).  Beyond emergency care, the health care system often provides care to those who cannot pay or are unlikely to ever be able to pay and then charges their paying clients more in order to make up for this loss.  This “cost-spreading” could be legally prohibited as well.

This situation faces us with an interesting dilemma—whether to strictly enforce the consequences of being irresponsible by not purchasing health coverage (or risk-taking, depending on your view) by not providing care, or to be more forgiving and provide the care anyway, which rewards being irresponsible and also takes away the incentive for many more people to drop their coverage, too.  Because life is complicated and always to some extent unpredictable, it appears that we have evolved to be quite forgiving about responsibility failures.  We know that circumstances could defeat our own efforts to be responsible and avoid harm and that we would then want others to help us anyway.

We are well aware that we sometimes forget things or get things mixed up, even though most of the time we don’t, and we know, for example, that our attention sometimes wanders while driving, but we don’t want that to invalidate our driving or health care coverages.

The situation is different, however, when a person has the ability to be responsible and chooses not to be.  How would we feel if we forced those who choose not to purchase health coverage to sign a statement notifying them that they will not be treated for future injuries or ailments?  If they choose to forego coverage, knowing that they will not be treated, could we really turn them away later?  Would they believe that we would turn them away later?

We have other circumstances that relate to this as well, as when people are injured bungee-jumping or sky-diving or rock-climbing.  Many of us think that since those people know that they could be injured or killed doing these clearly risky activities, their health insurance companies could legitimately refuse to cover any unfortunate results of these activities.  On the other hand, it goes against our natures, apparently, to actually carry out this denial of care when the injuries occur.

Human beings have apparently evolved to readily tolerate risks, even though we often evaluate these risks poorly (minimizing the risk of sky-diving if we want to engage in sky-diving, for example, while as a parent greatly overestimating the risk of childrens’ vaccines).  Our attraction to gambling illustrates our ability to subjectively underestimate the chances of losing and overestimate the chances of winning!  We underestimate the risk of having a car accident, while probably overestimating the risks of eating trans-fats or fast food.  We don’t even know the relative risks of car accidents versus sky-diving, and even if we did know, most of us would continue to subjectively underestimate the risk of car accidents (because everyone drives, and because we “need” to drive for important purposes), and overestimate the risk of sky-diving (because it is completely optional and seems to much more frightening to most people).

The conclusion to this analysis is that since it is not psychologically acceptable to actually refuse care to those who choose not to purchase insurance, we will either give them a somewhat free ride or we must require that they purchase insurance.  (Note that this conclusion would apply even if last year’s health care law had not passed.)  If they are honest about the matter, opponents of mandatory insurance should acknowledge that it is OK with them for people to get a “free ride” and OK with them for the rest of us to pay for unfunded care by paying more ourselves.  Of course, it may be perfectly fine for the body politic to agree, democratically, to accept cost-spreading, but it should be publically acknowledged that the rest of us are paying the freight, and we should be informed of what that extra charge is.

blog\postings\healthcareirresponsibility