Does health reform treat the obese unfairly?
Making entitlement policy when choice/responsibility is indeterminable
Insurance is generally designed to protect against accidental loss; that is, the event that triggers a claim must be outside the control of the beneficiary of the insurance. Hence insurance fraud occurs when someone, for example, sets fire to their own house and then files for insurance payments (claiming the fire was accidental or caused by someone else). Health insurance has not traditionally hinged on this “normal” definition of accidental loss for a simple reason: (mentally healthy) people do not normally hurt themselves on purpose because 1) it is painful/damaging; and 2) there is no monetary benefit in doing so – insurance doesn’t pay you directly, it pays after the fact for cost of the care you get. So unlike burning down your house, where the insurance company will just send you a check for its value (and not cover the cost of rebuilding your house), there is no monetary incentive to purposely hurt yourself.
But while there may be no incentive to hurt yourself, it is still possible to identify a meaningful “accidental loss” criteria. For while you may not purposely break your arm, you may purposely choose to back flip off the balcony knowing full well the high likelihood of breaking your arm in the process. This is relevant because it is in both the insurance company’s interest to find ways out of covering you (they make more money) and in other people’s interest that the insurance company not cover you (they pay lower premiums) when not morally or contractually necessary.
So although you would obviously have chosen not to break your arm in back flipping off your balcony, there is both an economic (more profit, lower premiums) and a moral reason (you’re responsible, so no “accidental loss”) to not compensate you. Hence the debate that is the subject of this New York Times article on whether obese people or the health problems associated with obesity should be covered under health care reform.
At issue are two questions: is obesity unhealthy and if so, is obesity a choice. There is at least some debate on both questions. The article cites medical experts who say that obesity leads to an increased risk of chronic disease. But others argue that people can be healthy in fat bodies. On the second question, there is clear evidence that eating choices can lead to obesity, but so can genetics.
The problem for policy makers is that for neither question is the answer uniformly “yes” or “no”. It depends on the person. And more importantly, it is impossible to tell in every case if obesity is a choice or a result of luck. Thus, policy makers must either treat everyone as if it is a choice or everyone as if it is luck. If they treat everyone as if it is a choice, then health insurance companies may choose not to cover obese people for conditions that are the result of their weight (even for those people for whom it is not a choice). If they treat everyone as if it is not a choice, then health insurance companies must cover the consequences of obesity (even for people who are that way because of a few too many “greasy burger binges”).
Either way, some set of people gets a raw deal economically (and — if you believe health care should only cover (bad) “luck” and not those things you are responsible for — a raw deal morally too). If we cover obese people who are responsible for their condition, then everyone else has to pay higher premiums. If we don’t cover obese people who are not responsible, then they are unfairly forced to pay for things that should be covered.
I only have space today to raise the question. And I don’t think I have any good answer to it, anyway. So I pose it to you: how do we deal with public policy issues where there are differences that are vitally important morally (and economically), but because of the limits of human knowledge, we have to treat everyone the same?
-Marc
Related posts:
- Should health care cover spiritual medicine?
- Obesity and personal responsibility
- Who should pay for health care reform?
- Was health care reform illegal?
- Lights, camera, health care reform?
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