Looking back over my medical records from last year, I noticed that most of the smaller charges were for seeing my regular doctor, prescriptions, and other things I would have wanted and paid for myself if I had no insurance. But I would never have had done several expensive things without insurance to cover at least eighty percent of the cost. I had no trouble getting these things done even though my insurance is under a managed care arrangement, so that I receive full coverage only if my regular doctor gives me a referral to some physician or facility listed as a participating provider.
Here are two examples. My prostate is gradually growing larger, as virtually every man’s does, and last year I began to notice symptoms. They were not very serious, and I imagine most men would have ignored them. But since I had met my deductible, additional care was not going to cost me much. I saw my regular doctor and got a referral to a urologist, who sent me for tests, then saw me again to go over the results. I had reasons for doing this: to talk with a specialist whose answers to my questions would be more dependable, to make absolutely sure the condition was not more serious than I thought, and to establish a basis for comparison in a future diagnosis when surgery might be in question. To me, it was worth the seventy dollars I ended up paying but not worth the three-hundred-plus dollars the insurance paid. Again, one Thursday night I slipped off a curb and twisted my ankle; Friday morning it was swollen and painful. Usually I would have put an ice pack on it, taken some pain killers, and waited until Monday to see whether it would quiet down. But I was planning to go away that weekend, and did not want to take the trip only to find myself in an out-of-town emergency room—which my insurance probably would not have covered, since it has very strict rules about using emergency rooms. I checked in with my doctor, who sent me for X rays, then on to a specialist, who told me to put an ice pack on the ankle and take some pain killers, supplied a lace-up brace, and said to stay off my feet as much as possible during my weekend excursion. All this cost me only around forty dollars, but the insurance paid over two hundred.
My parents, who have retired and are covered by Medicare and a medigap policy, also obtain a great deal of care they would never get—though they have a good income from their pensions and social security—if they had to pay all the bills themselves. For instance, for several months last winter my mother had a cough. It didn’t actually bother her much, and she would have put up with it, but my dad felt that would be foolish, since most of the cost would be covered, and, as he said: “We have nothing more important to do than look after our health and plenty of time to do that.” Having gone to the doctor, my mother was referred to several specialists, who sent her for X rays, an MRI, and a bronchoscopy, and did various other tests, including a long series for allergies and a psychological evaluation. They never did figure out what was causing the cough, and it finally got better.
I am of two minds about this sort of thing. I do not see how I or my parents did anything wrong. We followed the rules and got what our health coverage entitles us to. But I do not like the ever growing insurance premiums and budget deficits that result from other people with coverage doing the same, and I wish they took less advantage of coverage than my parents and I do. It seems we are being unfair at least to those who do take less advantage. But how can we be unfair if we are not doing anything wrong?
This question concerns the application of the Golden Rule. Taking advantage of health insurance coverage is wrong and unfair if in seeking care one is motivated by mere feelings rather than reasons; it also can be unfair if one deliberately exaggerates symptoms or is not wholly candid in providing information that might limit care. In the instances described, however, there seem to have been reasons for seeking care. If so, and if those seeking the care were not only truthful but appropriately candid, they did not act unfairly. The appearance of unfairness results from a defect in the social structure of the health care system, which lacks suitable controls to shape cooperation toward the common good.
Many people do unfairly abuse the health care coverage provided by private insurance or public programs.
Sometimes a mere emotion, rather than a reason, moves people to obtain covered services. They may disguise this by rationalization—usually referring to the basic good of health—but their real motive for seeing a doctor, seeking referral to a specialist, or wanting various examinations and tests is not rational. They are not hypochondriacs—people who suffer from neurotic anxieties—but they are excessively afraid of death and anxious about their health, so that they see the doctor about every small symptom. Some people with chronic, untreatable conditions regularly use professional services as a placebo or with unreasonable hope of obtaining relief. Again, some people feel they must make use of coverage lest they not get what they regard as their share of health care service, and so they keep an eye peeled for problems they would otherwise ignore: “I will see the doctor about this knee ache; after all, I hardly ever have a chance to use my high-priced health insurance.”
Sometimes, too, not only people with merely emotional motives but some who have a reason for seeking health care deliberately exaggerate their symptoms in order to obtain service, or more or speedier service. People do this for diverse reasons. Some people, lacking confidence in their primary care physician, almost always wish to be referred to a specialist and/or have the reassurance of additional tests. Some, thinking the newer always is better, are dissatisfied unless the most up-to-date equipment is used to diagnose and treat their problems. Some, abusing prescription drugs for their psychological effects, seek unneeded medication. And, of course, some people feign illness to obtain a medical excuse for absence from work or school, or failure to fulfill some other duty. Whatever the motives, such deliberate exaggerations are lies and, as such, always are wrong.
Patients should develop a cooperative relationship with physicians who can be trusted to serve their true interests. They should be not just truthful but entirely candid—for example, by providing information about their past medical history or a symptom’s development that might lead the physician to delay expensive examinations or decide against a referral to a specialist. Unfortunately, managed care insurance plans and other health care systems in which primary care physicians act as gatekeepers for access to specialists and hospital services create a conflict of interests for those physicians. They must try to serve both the patients’ interest in obtaining appropriate services and the interest of the organizations paying for services in limiting costs.285 Patients dealing with such physicians can rightly keep information to themselves if they fear providing it might give the physicians an excuse for denying them access to services they think they need.
Your stated reasons for obtaining a referral to a urologist and the tests for which he sent you may well have been your actual motive. (I put it that way because people whose motives are mere feelings sometimes rationalize them in similar terms.) Only you can identify your own motives, and I shall assume they were sound. The persistence of your mother’s cough certainly gave her a reason to see her primary care physician, though the reasonableness of your father’s view of the matter is questionable. Perhaps you or your mother exaggerated symptoms or were not appropriately candid. But assuming you and she did nothing wrong in these respects, both of you obtained service to which your health coverage entitles you, and both acted fairly. In obtaining care for your twisted ankle, you were partly motivated by a rational concern to decide about your weekend plans and partly by a rational interest in avoiding the uncovered cost of emergency room treatment. As often happens, in this instance a rule meant to limit unnecessary use of a costly facility was self-defeating for the insurer. But, again, assuming you were not only truthful but appropriately candid, you acted fairly.
bout your other concern—the ever rising insurance premiums and budget deficits resulting partly from the heavy use of health coverage? The answer is twofold. First, many people do abuse their coverage, as already explained, and it is entirely fair for anyone who does not, to wish the abusers would desist. Second, here as in many other matters, tension between the common good and individuals’ rational self-interest generates a paradox. Everyone can reasonably wish that everyone would make more conservative use of covered health care services, even while no one has a good reason to do so.
Before the introduction of health insurance and public health care programs, most people purchased health care, as they do food and other necessities, with their own funds. People who lacked funds and urgently needed care often obtained it free from providers, including hospitals sponsored by churches, and sometimes care for the poor and indigents was paid for by local charitable and relief agencies, which were close to their clients. Nonrational use of health care was rare, and people who paid for their own care, as well as providers or agencies supplying care to those who could not pay, set limits even to the rational use of available services. Generally with the counsel of the physician involved, they considered the relationship between benefits and costs, and made hard choices between the benefits to be expected and other needs. But health insurance and public programs not only removed the financial incentive to use health care services rationally, and to limit even that use, but lowered the threshold at which taking advantage of health care resources is rational, eliminated the main disincentive to rational use, enabled providers to increase their charges, and ensured that they usually would be paid in full.286 No longer was there the same convergence between the proper interests of health care consumers and providers, on the one hand, and, on the other, their common interest in preventing waste and limiting costs.
An imaginary case analogous to the present problem will help clarify it. Imagine a tropical isle whose native population regards its grove of palm trees, like the plentiful fish in the sea, as a common resource freely available to all. The palms provide all the coconuts anyone wants, and a mature tree occasionally is cut and used as material for a new fishing boat. Building boats is hard work, however, so that families delay until their old boat no longer can be repaired and absolutely has to be replaced; as a result, the palm grove is not endangered by the occasional cutting. But suppose some ingenious fellow invents a new technique for building boats much more easily. Fascinated by the new technique, some families build extra boats they seldom use; their tree cutting is wasteful and unfair. Most build only boats they will use regularly, but they now build a new one as soon as their present boat becomes less serviceable and begins needing repairs; and although their tree cutting is neither wasteful nor unfair, the average family now builds a new fishing boat twice as often as previously. Three times as many mature palm trees are cut, the supply of coconuts is no longer adequate, and thoughtful people begin to worry about the grove. Every family wishes boats were built less often, as in the old days, but no one family’s decision to delay building will save the palm grove.
Such a problem can be solved only by the cooperation of everyone involved, and authority is necessary to organize and direct cooperation. Authority need not mean a single decision maker or bureau, but it does mean some way of guiding decisions in accord with the common good. The islanders need a way of guiding decisions that not only will prevent waste but limit even rational boat building, so that there will continue to be enough palm trees to meet everyone’s needs.
Similarly, people in affluent societies who use health care services paid for by insurance and public programs have a problem requiring cooperation and the authority necessary to organize and direct it. Everyone involved would benefit if the nonrational use of health care services were eliminated, and most would benefit from the savings realized if even their rational use were somewhat limited. But as long as services are not effectively restricted, individuals with reasons for using them will take advantage of their availability. They cannot be faulted for doing so, since no individual’s restraint would serve the common good by reducing the costs of insurance and public programs.
Moreover, unlike the need for food, which is finite, the need for means of preventing, curing, and struggling with disease and accidental damage to the human organism is as limitless as human ability to invent such means. From that point of view, there is no way of setting a term to the expansion of health care resources. In reality, though, health care technology and services cannot go on expanding indefinitely; otherwise, there soon will be no resources to meet other needs. Consequently, health care services somehow must be limited and rationed.
Health plans requiring coinsurance payments and the payment of a deductible before coverage begins attempt to preserve or restore something of the discipline that existed before the development of health insurance and public programs.287 As your examples make clear, the attempted discipline is inadequate. Many insurance companies, health maintenance organizations, and some public programs have tried to solve the problem, as your managed care plan has, by using primary care physicians as gatekeepers who limit access to specialists, hospitalization, and so on. As has been explained, however, that generates a conflict of interest, and sometimes the conflict is aggravated by financially rewarding those gatekeepers who limit services more drastically while penalizing those who limit them less. Usually, too, the gatekeepers must obtain approval from another, more remote authority for at least some of their decisions. Thus, the system generates a costly bureaucracy and gives considerable power to people whose only role is limiting care and whose knowledge of patients and their needs is at second hand. Even so, to the extent gatekeepers and managers conscientiously try not to deny essential services, many people, like you and your mother, will receive a great deal of health care whose utility is marginal in view of its great cost and rather small benefits.
What should we do about this problem? First, not unfairly use the health care coverage that insurance and public programs provide. Second, resist all so-called reforms that continue or increase the use of primary care physicians as gatekeepers, since that cannot solve the problem and may even aggravate it. Third, not oppose the rationing of health care services, which is inevitable, but oppose unfair methods of rationing—for example, denying care to the working poor who lack insurance, as the U.S. system effectively does, or on the basis of age, as the British system does with respect to certain procedures. Fourth, take advantage of opportunities to clarify the problem for others. Fifth, encourage and support systemic changes that you think would contribute to the common good.288
285. See Marc A. Rodwin, “Physicians’ Conflicts of Interest in HMOs and Hospitals,” in Conflicts of Interest in Clinical Practice and Research, ed. Roy G. Spece, Jr., et al. (New York: Oxford University Press, 1996), 197–227.
286. See George J. Annas et al., American Health Law (Boston: Little, Brown, 1990), 121–26.
287. If a person or family with health insurance receives a service the insurance covers but is required to pay part of the bill, that payment is a coinsurance payment. If the insured person or family must pay the entire bill for covered services until a certain level of total payments has been made in a given period—e.g., $500.00 in the current year—that total payment is the deductible. This method of limiting the use of health care is common in the U.S. Nations with a more socialized system of health care try to achieve the goal in other ways—e.g., by making patients wait, setting budgets for providers, and limiting the availability of expensive services.
288. Having tried to clarify the ethical elements of this problem, I deliberately abstain from discussing various proposals for trying to mitigate or solve it.