An Uninsured Discussion

Recently, during one of the Republican primary debates, a healthcare question was posed to a candidate on-stage. To paraphrase:

“A 30-year old man with a good job decides not to get health insurance. He gets into an accident and goes into a coma, requiring intensive care. What is society’s responsibility to him?”

The press ran with the story, with headlines such as, “Tea Party audiences cheers letting uninsured die,” and “Tea Party debate crowd on Uninsured Americans: Let Them Die!” Video of the exchange, initially directed by Wolf Blitzer to Ron Paul, a physician, can be found here. Take a moment and visit.

This is a critically important question, not only for the clear ethical challenges it presents but also because it demonstrates the parsing effects that politics can have, as people try to encapsulate broad, nuanced questions into easy to digest, headline-ready comments.

As a physician, what are your thoughts?

Let’s look at some of the constituent parts of this complex question.

First, a man with the means has decided not to get insurance because - as the Blitzer vignette states - he has chosen to spend $250 a month elsewhere. This speaks both to the cost of insurance and to an individual’s prioritizing expenses.

Regarding costs of insurance, it is pertinent to remember that we, as Americans, have pursued a for-profit approach to health insurance. Insurance companies are entitled, by the simple definition that they are businesses, to strive for profitability. They want to take in more than they spend.

This may or may not be the best business model for health insurance, but it’s what we have right now.

An individual making a choice not to be insured? As evidenced by that passionate debates going on nationwide regarding the government “mandate” of health coverage under the Affordable Care Act / Obamacare, many people feel this is an inalienable right, akin to life, liberty, and happy pursuits. It may not be a prudent choice, but perhaps it is our right to insist that it is our choice to make.

What happens when this man gets unexpectedly ill and expects care to be provided - Society shouldn’t let him die, right? This scenario opens up the subsequent challenges that our country faces, and that we as providers face.

Physicians generally need the care we provide to generate dollars and cents, so our salary gets paid or we generate sufficient incomes to pay ourselves, our employees, and our loans. There is no escaping this truth.

There also has been a viscous cycle of reactive pricing, where providers raise rates to battle insurance company and Medicare reimbursement algorithms, leaving the uninsured with a pricing model that is unpredictable at best, and not uncommonly catastrophic.

So - to state as impartially as I can - a voluntarily uninsured man, unexpectedly injured and requiring intensive care, will incur extraordinary charges that are based on unclear criteria, for which he has no expertise to challenge and no standing to approve or disapprove, and he is expected to pay in full.

The vignette is convenient for the sake of making a point, but probably does not represent the situation facing many of the millions of uninsured Americans. While a handful probably do have the means and make a choice, the majority would not place themselves in that description.

If you make $2,000 a month (pre-tax), do you or do you not have the “means” to pay $250 a month for insurance? Small businesses face this same dilemma, with a multiplier.

And, though we often lump people into “insured” and “uninsured,” the truth is that $250 a month buys you different things, in different geographies, with different limitations and exclusions. Should government tell business, or states, what $250 a month must provide?

And, what if this man had insurance, and when he got injured he was emergently transported to a hospital that was not a preferred provider for that insurance company, leaving him on the hook for thousands?

This vignette outlines some of the topics that I will be addressing in upcoming blog posts. To dumb down the questions of health insurance for the sake of national television audience is, I suppose, a necessary evil of politics these days - Wolf Blitzer, you did your job - but it is our responsibility to understand the minutia and consider things case-by-case as we make decisions at the bedside and, also, in our hospital boardrooms and private practice meetings.

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