Welcome to Ethics Consult – an opportunity to discuss, (respectfully) debate and learn together. We select an ethical dilemma from a real, but anonymized, patient care case, then provide expert commentary.
Last week you voted on whether it is ethical for the government to cut health insurance for risky activities.
Cut health insurance for risky activities?
And now, bioethicist Jacob M. Appel, MD, JD, steps in.
Life insurers generally charge a premium for high-risk behavior. According to a 2013 article in US News and World Report, hunters pay an additional $500 annual premium and climbers pay an additional $1,500; scuba diving and skydiving can add $2,500 to its rates. Health insurers don’t always dig so deeply into the personal behavior of policyholders, but some refuse to cover people engaged in hazardous activities. In 2006, a large Illinois company reportedly sent letters to its employees informing them that any motorcycle-related injury would result in the immediate termination of their health insurance. In contrast, Medicare and Medicaid generally cover all injuries to their clients, regardless of the origin of those injuries.
The main reason public health insurers don’t exclude these risk takers is that health insurance no longer functions like insurance, at least not in the traditional sense. As political historian Edward N. Beiser observed in “The Emperor’s New Scrubs” (1994), “health insurance” is a misnomer. The underlying principle of traditional insurance is the spreading or “pooling” of risk. Although the odds of my house burning down are pretty low, the odds of someone’s house catching fire are reasonably high, and fire insurance spreads the cost of that burden fairly. Everyone pays; a few unlucky victims are compensated. In contrast, the vast majority of Americans will eventually suffer injury or illness beyond the age of 65, so almost all of us will draw resources from Medicare. Rather than an insurance program, Medicare is a means-testing program whereby, in theory, workers pay their money to the government, which stores it for them and returns it later to pay their medical expenses (although the reality is that payroll taxes pay for today’s older people, while future workers will supposedly pay for today’s workers to have coverage).
Since Medicare and Medicaid are default systems for health care coverage – replacing the poor and elderly where private insurance historically did not pay – denying insurance for high-risk behaviors will leave a group of injured patients with no way to pay for emergency treatment. Due to a federal law, the Emergency Medical Treatment and Labor Act of 1986 (EMTALA), hospitals cannot legally turn away these patients. Moreover, even if hospitals could legally opt out of such care, denying services in an emergency situation is morally indefensible. So rather than deterring behavior or conserving resources, Senator Cheapside’s approach would likely only shift the price of that care to hospitals, which would then pass that cost on to consumers through higher medical bills. .
Another possible problem with Senator Cheapside’s proposal is that it could save Medicare and Medicaid less money than he expects. Few people who have incomes low enough to qualify for Medicaid are likely engaged in beekeeping, bungee jumping, or many other expensive pursuits that concern them. Similarly, many older Americans, who have Medicare, do not practice hang gliding for sport. By far the most important avoidable expenditures for the health system are those related to more mundane risks, namely obesity and smoking. No doubt smoking and excessive eating could be deterred by refusing to pay for medical conditions resulting from such conduct. Yet this approach would punish binge eaters and drug addicts for health problems that may prove beyond their control and could even condemn them to further illness or death.
Jacob M. Appel, MD, JD, is director of psychiatric ethics education and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and an MS in Bioethics from Albany Medical College.
Check out some of our previous ethical consultation cases:
Stop Life Support for tax relief?
Prescribing off-label pills for optimal pilot performance?
Exhibition of forced weighings for hospital workers?