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Posted by on Apr 16, 2013 in Featured, Health, Politics | 24 comments

Health Insurance and Personal Responsibility

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Little attention is being paid to personal responsibility in setting health insurance premiums. While health status and pre-existing conditions have been determinant factors in the past for obtaining individual health insurance and the premium rates for coverage, these differentials will be eliminated as part of the Affordable Care Act. And in obtaining group health insurance, an individual’s health status is usually not a consideration.

Personal responsibility in terms of health status has always been an important factor in deciding the premiums for life insurance. Thus, individuals with high blood pressure, elevated cholesterol, elevated blood sugar levels, smokers, drug and alcohol abusers, have to pay more in order for them to obtain life insurance, or may not be able to get insurance at all.

Some companies attempting to lower their costs for employee health insurance are offering incentives to workers for life style changes that lower blood pressure, body mass index, or other parameters, or who partake in wellness programs. (http://goo.gl/dVtMo) Both rewards for the employees such as lower premiums or deductibles may be offered, or penalties may be imposed such as higher premiums or an insurance surcharge.

It may seem odd that companies have to provide financial incentives to employees to prod them to lifestyle changes that will improve their health and longevity. But many individuals refuse to take personal responsibility for their health, with the rates of obesity skyrocketing in the United States over the last few decades, resulting in an increased incidence of diabetes, hypertension, coronary artery disease, strokes, and other disease entities, that will only increase in the future.

This leads us to a moral dilemma. Since health care costs are spread over the population that is insured, or partially paid for by taxpayers in Medicare and Medicaid, should those who are responsible and lead a healthy lifestyle pay more for those who disregard their health and eat and drink with abandon, or smoke, or use drugs, or drive recklessly, and so forth. Many of these people, who will be most in need of care, are poor, or with low educational levels, or with psychiatric problems. But some are quite intelligent, educated, and middle class. How do we get these individuals who are unwilling to assume responsibility for their own health to change their behavior and start acting in a way that will enhance their own health? It would seem to be unethical to refuse them care, even for those conditions that are self-induced. And if their health insurance deductibles for treatment are increased to penalize them, they will be less likely to seek care. In that case, their conditions will worsen and require more intensive treatment in the future.

Perhaps positive incentives can be tried such as lowering their health insurance premiums and/or deductibles for healthy conduct and any improvement that can be measured in the harmful conditions they exhibit. But what if they don’t respond to these inducements and persist in behavior that damages their minds or bodies and will ultimately cost responsible citizens money to care for them? This is unfair to those Americans who are attentive to their health and who will not become a burden to society because of self-destructive conduct.

I don’t know the answer to this quandary. My heart says society must pay for the care of those unfortunate individuals whose actions have resulted in serious illnesses. My brain says it is unfair to expect people who act responsibly in regard to their health to be saddled with the cost of care for individuals who give no thought to how their behavior will subsequently affect their minds and bodies. There appears to be no way to reconcile my heart and my brain over this issue. I am my brother’s keeper, or am I?

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  • Rambie

    “…Should those who are responsible and lead a healthy lifestyle pay more…”

    Your question is wrong. “Pay more”? No, pay the same? Yes. Live a healthy life style and you can still get cancer, hit by car/truck/etc, die of a heart attack, or in your exercising, even hurt yourself.

    Who would get to decide the “healthy lifestyle” parameters that everyone should live?

  • dduck

    Thanks for the thoughtful article, RAL. I’ll go with: “I don’t know the answer to this quandary. My heart says society must pay for the care of those unfortunate individuals whose actions have resulted in serious illnesses.”
    But, I also have no problem with anti-smoking, anti-big gulp, and other things libertarians and some liberals object to.

  • I kinda agree with Rambie here. Besides, corporations are fundamentally unethical and I see nothing to prevent them from making these rules so draconian no one could possibly meet them. It’ll end up like the fine print on an iTunes license, basically stripping away all rights yet everyone clicks “yes”.

  • zephyr

    Tough questions Robert, and good ones. What does it to take to get people to take responsibility for those things they do have control over?

  • There are some elements of our health that we have control over and these are the aspects I’m concerned about. Should we pay for the care of someone who develops severe coronary artery disease after smoking for thirty years. Or someone who is obese and develops diabetes, type 2. (Type 1 is auto-immune and beyond people’s control.) Or an alcoholic who develops cirrhosis. Tough question to answer.

  • dduck

    Not so tough if you don’t pick and choose, but administer to the sick and those that have accidents due to their own carelessness.

  • sheknows

    With the exception of obesity, it is pretty difficult to tell which among us is abusing their health as with tobacco and alcohol.
    Insurance companies go with the odds but they have gone a step further now to insure they always make the most money possible. The newest tactic is to make certain hospitilized patients get discharged ASAP, usuallly before it is recommended from a medical standpoint. In fact, patients can sign a paper stating they beleive they were discharged too early as in the case of Medicare patients shipped out prematurely. Hospitals do this now because the insurance companies call the shots by stating how long they will pay for a certain condition and what criteria THEY consider relevant for payment. It aint much anymore ! They are trying to shove you out the door after 3 or 4 days after being in ICU or CCU.
    The ugly truth is…we are just slaves to the corporate giants that are “too big to fail”. Our insurance premiums aren’t high or higher because we carry the extra weight of those who let their health go. They are higher because the insurance companies can do whatever they WANT to do and employ their endless greed ad infinitum.

  • In (slight) fairness, there have been studies that shorter hospital stays — with proper outpatient care — are actually better. Fewer chances of secondary infections and a quickened recuperation.

  • dduck

    Thanks Barky, I didn’t want to get bogged down with facts.

  • KP

    People in the know (hopefully that includes most medical professionals) can tell a chronic abuser of alcohol or tobacco after a quick glance. Fail that, add listening to the tone of their voice; or them huff and puff and cough. If that fails, add it all up and take their blood pressure.

  • KP

    Having said that, absent objective testing or testimony, it’s not enough evidence to charge them more money for health insurance. BUT — physicians might need to get more aggressive and call out their patients. We know it when we see it. These patients are often begging for intellectual intervention and/or some tough love.

    All too often, docs take the easy way out. They bend and write a script, or look the other way. My experience, and conversations with physicians who are debt free, is that once they are out from under enormous debt and have a more fixed income it is easier to practice medicine the way it should be done.

    Fee for service might be a problem.

  • SteveK

    All (read each and every) ‘First World’ nation, except for the United States of course, have put their people before Big Business when it comes to “entitlements.”

    “My country ’tis of thee blah, blah, blah…” has become a joke and to see some who ‘have their lives covered, all’s under control’ even wonder why those who don’t deserve care and consideration of their nation blows me away…

    coda: My life is ‘covered, all’s under control’ but I’m ashamed (disgusted actually) that some have a problem with what is so obviously the right thing to do.

  • KP

    SteveK; about two years ago I had a conversation with a client who lives in Slovakia. We discussed health care and he remarked that Europeans are perplexed at the idea that in America “not everyone has medical coverage”. I think he said something similar to you; every other first world country takes care of medical needs.

    I agree; but how we get there (and I think we will), over time, is the rub. Does the ACA move us there? I have concerns about that and am thinking it may implode under it’s own weight and poor craft. But I could be wrong. Perhaps it is the foot in the door to a correction over the next 10-15 years.

  • adelinesdad

    This thread is making me nostalgic for the long debates we had when the ACA was still a bill. Good times. One of my proposals, at the time, was that insurance companies should not be able to discriminate based on health status, but should be allowed to discriminate based on behavior, in a highly regulated manner in which price differentials are limited: maybe the highest premium cannot be more than twice as much as the lowest available premium, for example. The main challenge is the verification, but I think with some ingenuity it’s not impossible. I can imagine a plan where, if you are not willing to undergo any additional testing, you get a “standard” rate which is the same for everyone who chooses that plan, regardless of health. However, if you are willing to undergo testing to make sure you aren’t smoking, for example, then you could get a discount. Maybe if you install a device in your car that forces that you wear a seat belt, you’d get a discount. Can a reliable test be developed to make sure you are eating your broccoli and exercising (not based on weight, which is not a close enough indicator of behavior)? I wouldn’t say that’s out of the question. Who decides what to measure? The insurance company, which have a financial incentive to make sure they are measuring the correct behavioral indicators, and if consumers don’t like a particular company’s measurements, they can go elsewhere or opt for the standard plan.

    I’ts not perfect, but just something I was thinking but obviously we’ve gone a different direction now, and are now making futile attempts to backtrack a bit by instituting “soda-taxes” and the like.

    I’ve since developed a theory that interdependence in a society must be proportional to trust and trustworthiness. A cohesive society is one that is very intertwined and where all the individuals can trust each other to act in the interest of the whole. HCR increased our national interdependence, which on the surface, according to my model, is a good thing. However, that depends on
    whether we have the level of justifiable trust necessary to sustain that level of interdependence. Interdependence without trust leads to free-riding and conflict, which is worse than if we hadn’t become so interdependent and simply coexisted. We’ll see which way it goes.

  • zephyr

    Europeans are perplexed at the idea that in America “not everyone has medical coverage

    Understandable since basic decency is being trumped by something peculiarly impersonal and profit driven in our culture. I guess that’s obvious enough.

  • ShannonLeee

    Being in Europe… my impress is that people believe everyone should be covered…regardless of lifestyle choices. It is considerably easier to live a healthy lifestyle in Europe. Considerably more people walk and ride their bikes to work and the store. The food, the normal food, is typically Whole Foods quality.

    Reducing health care costs will require systematic changes to our culture. Excluding people via a check list is not going to solve our problems.

  • dduck

    Weee, here come the health police.

  • Dduck, IIRC you were OK with NYC’s big soda ban. Is one method (gov’t rules) better than another (insurance co rules)?

    A) correct me if I am wrong in my assumption of your permission
    B) at least gov’t laws have some element of democratozation. Corporate rules are anything but …

  • Er, sorry, damn autocorrect. Should have read “correct me if I’m wrong about your position”.

    I should stop using my iPhone to comment here …

  • dduck

    B, of course I agree with the soda limitation and other rules, especially ant-smoking. Insurance companies are in business to provide coverage (compensation) for insured risks, that is their business, and we all can be thankful that insurance was invented. Yes, they, and Medicare and Medicaid do have rules and regulations, some good and some bad depending on your particular viewpoint and personal medical situation.
    So, where’s the disagreement, other than outright fraud or squeezing the truth. Name me one organization that does NOT do that.
    BTW: I don’t know what corporate rules are.
    The whee was a comment on a trend and not specific.

  • ferretgal

    I think there is a basic misunderstanding here of how health insurance works. By pooling participants, we “even out” the risk–that is, those who are healthier/at lower risk in some sense “subsidize” those at higher risk (i.e., older etc). Really, one of the only truly “risky” health behaviors that can be identified is smoking tobacco. Other than that, the scientific evidence–not media or popular opinion–proving what’s healthy and what’s unhealthy is difficult to come by. For example, although most would agree that “exercise is good,” there’s a lot else to discuss: How much is enough? Too much (joint damage, etc)? What kind? And what about those with illness or injury that limits them? For another example, if you truly review medical EVIDENCE, you will find little proof that the latest demonized condition, obesity, “causes” disease/higher costs. Plus, there is no real “cure” for that “disease.” Recommended reading: “Overdiagnosed” by H. Gilbert Welch. In short, how do we decide who gets charged more? Based on what evidence? Who decides? Do you want profit-driven companies making those decisions? If not, who do you trust to do so? And as pointed out by others, anyone can be in a car accident; being vegetarian (as I am) doesn’t protect you from that. I find it interesting that those who champion personal freedoms are so quick to condemn others; how is it that our society has become so intolerant of diversity?

  • dduck

    Thanks, ferretgal, it’s nice to hear some reasonable discourse on insurance and insurance companies. A few around here don’t know how insurance works and therefore just vilify it.

  • sheknows

    A Few around here have actually worked as underwriters for health insurance companies and know EXACTLY how they work.

  • dduck

    SK, said: “Insurance companies go with the odds but they have gone a step further now to insure they always make the most money possible. The newest tactic is to make certain hospitilized patients get discharged ASAP, usuallly before it is recommended from a medical standpoint.”

    Well, pooling of risks and actuarial, morbidity and mortality studies and tables are also known to a few also. As a producer and CLU/ChFC I’ve seen some people take advantage of the insurance company and some insurance companies take advantage of the insureds.
    All organizations have bad players including insurance companies and governments.
    You might be surprised to learn that some hospitals can actually benefit monetarily from screwing up with patients:
    http://www.nytimes.com/2013/04/17/health/hospitals-profit-from-surgical-errors-study-finds.html?_r=0
    Although my work was mainly in the life and investment end of the insurance business and not in health insurance where more abuse may take place, I am defending the insurance industry in the broader sense since I have seen the good it can do, and not some individual companies that indeed I avoided placing business with.
    BTW: the quality of the state’s insurance departments directly correlates to the “quality” of the insurance companies admitted and regulated in that state.

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