Welcome to Ethics Seek the advice of — a chance to debate, debate (respectfully), and learn together. We select an ethical dilemma from a real, but anonymized, patient care case, after which we offer an authority’s commentary.
Last week, you voted on whether it’s ethical for the federal government to chop medical health insurance for dangerous activities.
Cut medical health insurance for dangerous activities?
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Life insurers generally charge a premium for high-risk behaviors. In accordance with a 2013 article in U.S. News & World Report, hunters pay an extra $500 annual premium, and rock climbers pay $1,500 extra; scuba diving and skydiving can add $2,500 to at least one’s rates. Health insurers don’t at all times dig as deeply into the private behavior of policyholders, but some refuse to cover individuals engaged in dangerous activities. In 2006, one major Illinois corporation reportedly sent letters to its employees informing them that any motorcycle-related injuries would lead to immediate termination of their medical health insurance. In contrast, Medicare and Medicaid often cover all injuries of their clients, whatever the origins of those injuries.
The first reason that public health-insurance entities don’t exclude these risk-takers is that medical health insurance now not functions as insurance — a minimum of, not in the standard sense. As political historian Edward N. Beiser observed within the article “The Emperor’s Latest Scrubs” (1994), “medical health insurance” is a misnomer. The underlying principle behind traditional insurance is the distribution or “pooling” of risk. Although the chances of my house burning down are quite low, the chances of any individual’s home catching fire are reasonably high, and fire insurance evenly distributes the price of this burden. Everyone pays in; a couple of unlucky victims receive compensation. In contrast, the overwhelming majority of Americans will eventually experience injuries or illnesses beyond the age of 65, so nearly all of us will withdraw resources from Medicare. Fairly than an insurance program, Medicare is a resource management program, through which, in theory, staff fork over their money to the federal government, which stores it for them and returns it later to pay for his or her medical expenses (although the truth is that current payroll taxes pay for today’s elderly, while future staff will supposedly pay for today’s staff to receive coverage).
Since Medicare and Medicaid are default systems for healthcare coverage — filling in for the poor and elderly where private insurance historically didn’t pay — refusing insurance for high-risk behaviors will leave a pool of injured patients with none approach to pay for emergency treatment. In consequence of a federal statute, the Emergency Medical Treatment and Labor Act of 1986 (EMTALA), hospitals cannot legally turn such patients away. Furthermore, even when hospitals could legally opt out of this care, refusing services in an urgent setting is morally indefensible. So somewhat than deterring conduct or conserving resources, Senator Cheapside’s approach would likely just shift the worth tag for such care to hospitals, which might then pass this cost along to consumers through higher medical bills.
One other possible problem with Senator Cheapside’s proposal is that it could save Medicare and Medicaid less money than he anticipates. Few individuals who have incomes low enough to qualify to receive Medicaid are likely engaged in beekeeping, bungee jumping, or lots of the other expensive activities that concern him. Nor are many elderly Americans, who profit from Medicare, hang gliding for sport. By far the best preventable expenditures for the healthcare system are those related to more mundane risks — namely obesity and cigarette smoking. Arguably, one might deter smoking and excessive eating by refusing to pay for medical conditions resulting from this conduct. Yet that approach would punish overeaters and addicts for health woes that will prove beyond their control and might even sentence them to worsening illness or death.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board on the Icahn School of Medicine at Mount Sinai in Latest York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
Take a look at a few of our past Ethics Seek the advice of cases:
Stop Life Support for a Tax Break?
Prescribe Pills Off-Label for Pilot’s Peak Performance?
Forced Weigh-Ins for Hospital Staff Fair?