Why Should We Cover People Who Don’t Take Care of Themselves?

One of the most common ideas in the whole healthcare financing discussion is a moral one. Why, people say, should my taxes and my healthcare premiums go to take care of the huge medical problems of people who don’t take care of themselves? As one commenter on THCB put it: “…self inflicted injuries to not be covered at all, ideally. If someone drinks their liver away I don’t think we should all have to buy them a new one. Same for smoking.”

This is a common idea, one that seems logical and right on the surface. But there are four assumptions built into it, all four of which have problems:

1) That the “self-inflicted injuries” that people commonly identify (smoking, drinking, other addictions, obesity) actually are major predictors of cost.
2) That we can clearly differentiate “self-inflicted injuries” from other medical problems
3) That to the extent that they are actually “self-inflicted,” the patient could just stop doing them if they just had enough gumption, or enough something.
4) That if our goal is to cut unnecessary medical costs, refusing medical coverage would cut costs.

But each of these four is problematic.
1) The best predictors of medical costs are not smoking, drinking, or obesity, but depression and stress. (“Association Between Health Risks and Medical Expenditures“) So trying to dis-insure “self-inflicted injuries” might miss the target of lowering healthcare costs.

2) Trying to decide what is “self-inflicted” and what is not presents a major problem. A friend has a lifelong condition that gives him excruciating pain. He has struggled manfully (and successfully) against addiction to booze and painkillers to ameliorate his pain. He has always felt bitter toward his father because his father was addicted to booze and painkillers. He recently realized that his condition is genetic, and guessing from some symptoms he observed, realized that his father was fighting the same excruciating pain. His attitude toward his late father changed instantly.

You can easily see other people with addictions and troubles that you don’t have. What you can’t see is what led them to that situation. You may be the very model of the perfect human, with no addictions of any kind, nothing in your life that you don’t want there, and you have never made any mistakes in your life that could have led you down the wrong path. Maybe. But even if you are, who exactly would you want sitting in judgment about which of your medical difficulties are “self-inflicted,” and which are not? Your individual doctor? Or a committee, say? A “death panel?”

3) The idea that people with “self-inflicted” problems such as smoking, drinking too much, other addictions, or obesity could just stop doing them is blatantly, obviously, provably false. And if it is false, then we have no logical or moral basis for refusing to help people who have those problems. Even if they could have avoided those problems by making better choices in the past, it is very difficult to unmake those choices now. They need a lot of help.

4) If your goal is to spend less on these people, making sure they don’t get coverage won’t do it. People with coverage cost the system less than people without coverage. In fact, they cost the system half as much. No matter the source of their problems, self-inflicted or not, it costs less to give people with lots of problems more, smarter, earlier care rather than less — unless your plan is to just take them out and shoot them when they show up in the ER.

So no part of the idea that we can and should reduce healthcare costs by refusing coverage of people with “self-inflicted injuries” is supportable. In the end, it makes no sense.

As a healthcare speaker, writer, and consultant, Joe Flower has explored the future of healthcare with clients ranging from the World Health Organization, the Global Business Network, and the U.K. National Health Service, to the majority of state hospital associations in the U.S. Joe writes at imaginewhatif.

16 replies »

  1. That is a horrible way to think. People lives are more important than cost. People still deserve healthcare despite what your perfect ass may see as their moral failings. I mean really dude. I couldn’t even read the whole thing. It is pathetic to be so cold.

  2. People who drink and smoke only do so because the government allows them to be provided with alcohol and cigarettes, so the government should pay for their healthcare.

  3. I see your point. Self-destructive behavior is obviously the same as self-victimization. It is easy to imagine I was calling “stupid” those who are guilty of such behaviors but nothing is further from the truth. In addition to frustration, anger, amazement and impatience I have empathy, sympathy, pity and sometimes heartfelt pain for that group. But I stopped short of calling them stupid.

    “Stupid” was characterizing a misguided thought process, not individuals.

    I carefully used “mean-spirited, selfish, short-sighted and atavistic” to describe individuals who want to justify additional punishments for those already self-punishing (i.e. blaming the victims) reserving the word stupid to describe the argument they were trying to advance.

    Sorry for miscommunicating. Really stupid on my part.
    Hope that helps.

  4. “John Ballard says:

    March 21, 2012 at 8:56 am

    Thank you for this. We have too much blaming of victims. It’s the medical analogue to saying a rape victim provoked rape. Really stupid when you think about it.”

    When one drinks, smokes, eats, or abuses drugs to the detriment of one’s health, is not this person both the victim and the “rapist”? I apologize for using your offensive term and hope this does not deminish the persuasiveness of pointing out your hypocritical and inconsistent statements or offend your mother-in-law. At least I didn’t call you stupid!

  5. @Barry Carol
    I claim no expertise about statistics and can easily see how poverty can very well correlate with high infant mortality (and perhaps birth mother mortality as well). But that “anchor baby” claim I find very questionable. You and the Pew people need to get together and decide who is correct.



    And personally I find the term “anchor baby” as offensive as Gook, Darky, Wetback or Pickaninny. When I come across that term my reaction is the same as when I read or hear the ACA or PPACA called Obamacare. It’s a signal letting me know what is likely coming next and I am almost certainly not going to be in agreement. Persuasive arguments always go to unnecessary extremes to avoid such terms, if for no other reason than one refrains from profanity when speaking with bosses, clergy or in-laws.

  6. John –

    Of the roughly 4 million babies born in the U.S. each year, Medicaid pays for slightly over 40% of them. The infant mortality statistics have a lot more to do with the incidence of poverty than with the healthcare system or its quality. Moreover, between 300,000 and 400,000 of these births are estimated to be so-called anchor babies – born to illegal immigrants, who come here, sometimes by taxi, specifically to give birth so the baby can have birthright citizenship. In border cities like El Paso, Texas, approximately 80% of all births are anchor babies. It’s a significant issue.

    U.S. life expectancy statistics are also strongly influenced by the amount of poverty compared to other developed countries. No matter how many times these points are made, these stats continue to be put forward as evidence of the poor quality of the U.S. healthcare system. It’s comparing apples and oranges. You are correct though about the high cost of care much of which has more to do with higher prices per service, test, procedure or drug than with excess utilization though utilization is also an issue when it comes to end of life care.

  7. “Taxing something is a supportive action.”

    I say we support Capital Gains much more than we do now! Tax them at much more supportive level, just like regular income.

  8. Yeah tobacco, alcohol, obesity, etc. are all bad for our health. But I fail to see how all the self-destructive behavior in the world causes the US to have terrible comparative results for infant mortality, life expectancy and a string of other embarrassingly poor metrics with the rest of the developed world, not to mention we pay a helluva lot more per capita getting there.

    The problem is not bad health. Hell, that’s why we have the system. The problem is what it costs — way too much. These arguments about bad health reminds me of the Lilliputians going to war about which end of the egg to crack when the problem is cracking too many eggs, not how they get cracked.

    We need to take care of those who fail to take care of themselves for the same reason that we engineer cars and highways not to kill too many drivers and passengers. Drunk, blind, old, stupid, juveniles, people texting and eating while driving — lots of way people get hurt and killed. But that’s not a good reason to forget safety and risk management.

    “Why Should We Cover People Who Don’t Take Care of Themselves?”
    We “cover” their health because that’s what doctors do.
    We “cover” the costs because that’s what insurance does.
    And we “cover” stupid, careless, irresponsible people, even criminals and those too ignorant to know better, because we are the richest damn country in the world and those who argue otherwise are mean-spirited, selfish, short-sighted and atavistic.

    I’m really getting tired of cave man arguments.

  9. Oh, and if realizing that extending lives that wouldn’t survive without what amounts to be fairly heroic interventions to disrupt the course of natural selection defines me in a derogatory term like “social darwinist”, then so be it.

    Glad to learn you are so willing and eager to support those who need your infinite resources of time, money, and energy.

    Sorry, reality has returned to earth, more specifically the US. It’s a shame leadership is still living in denial, as do a size able portion of health care providers.

  10. Taxing something is a supportive action. Maybe “promoting” is not the perfect choice of wording, but tell us all how rational it is to want to advocate for universal health care when 20% of your population is slowly killing themselves while expecting the other 80% to support such self destructive CHOICES?

  11. Joe, great post. This is one of the strongest philosophical arguments I can recall on THCB, or any health care blog, in quite some time.

  12. DeterminedMD, taxing something is not promoting it. It is disincentivizing it, reducing consumption from what it would be without tax. By your logic, increasing the cigarette tax is promoting it even more, when of course a higher tax would instead make tobacco less appealing.

    Also, did you just out yourself as a social Darwinist?

  13. But yet, no one person at this site, writer or commenter, has addressed this single question: how does the US Government demand health care insurance coverage and still promote the use of tobacco by at least taxing the product?

    They are mutually exclusive to promote, if that is the correct statement. But, then again, I am expecting people in public office to be sensible and appropriate, and god knows few and far between as politicians really do what is right and correct. Hey, most of you commenting here vote, so you are the poster children for what roams the halls of state and DC government!

    always the agenda. Never really what is the public good.

    By the way, how about this question: if medicaid and medicare are just extending the lives of people who would normally not live as long in cultures that do not fight the normal evolutionary trends of a species, then why doesn’t the author of this post ask the better question of “why should we cover people who CAN’T take care of themselves?

    Reality is a bitch, isn’t it!?

  14. Yes, John.

    The “Ich, Du, Sie” fallacy.

    I have blamelessly suffered a medical misfortune;

    YOU should have taken better care of yourself

    THEY are parasitic moochers and looters.

  15. Thank you for this. We have too much blaming of victims. It’s the medical analogue to saying a rape victim provoked rape. Really stupid when you think about it.