Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether it's ethical for the government to cut health insurance for risky activities.
Cut health insurance for risky activities?
Yes: 63%
No: 37%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Life insurers generally charge a premium for high-risk behaviors. According to a 2013 article in U.S. News & World Report, hunters pay an additional $500 annual premium, and rock climbers pay $1,500 extra; scuba diving and skydiving can add $2,500 to one's rates. Health insurers do not always dig as deeply into the personal 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 result in immediate termination of their health insurance. In contrast, Medicare and Medicaid usually cover all injuries of their clients, regardless of the origins of those injuries.
The primary reason that public health-insurance entities do not exclude these risk-takers is that health insurance no longer functions as insurance -- at least, not in the traditional sense. As political historian Edward N. Beiser observed in the article "The Emperor's New Scrubs" (1994), "health insurance" is a misnomer. The underlying principle behind traditional insurance is the distribution or "pooling" of risk. Although the odds of my house burning down are quite low, the odds of somebody's home catching fire are reasonably high, and fire insurance evenly distributes the cost of this burden. Everyone pays in; a few unlucky victims receive compensation. In contrast, the vast majority of Americans will eventually experience injuries or illnesses beyond the age of 65, so nearly all of us will withdraw resources from Medicare. Rather than an insurance program, Medicare is a resource management program, through which, in theory, workers fork over their money to the government, which stores it for them and returns it later to pay for their medical expenses (although the reality is that current payroll taxes pay for today's elderly, while future workers will supposedly pay for today's workers to receive coverage).
Since Medicare and Medicaid are default systems for healthcare coverage -- filling in for the poor and elderly where private insurance historically did not pay -- refusing insurance for high-risk behaviors will leave a pool of injured patients without any way to pay for emergency treatment. As a result of a federal statute, the Emergency Medical Treatment and Labor Act of 1986 (EMTALA), hospitals cannot legally turn such patients away. Moreover, even if hospitals could legally opt out of this care, refusing services in an urgent setting is morally indefensible. So rather than deterring conduct or conserving resources, Senator Cheapside's approach would likely just shift the price tag for such care to hospitals, which would then pass this cost along to consumers through higher medical bills.
Another possible problem with Senator Cheapside's proposal is that it may save Medicare and Medicaid less money than he anticipates. Few people who have incomes low enough to qualify to receive Medicaid are likely engaged in beekeeping, bungee jumping, or many of the other expensive activities that concern him. Nor are many elderly Americans, who benefit from Medicare, hang gliding for sport. By far the greatest 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 may 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 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 a bioethics MA from Albany Medical College.
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