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October 01, 2007

Mistaken Paradigms of Interests in the Health Insurance Coverage Debate

by Thomas May

Editor’s Note: A previous version of this article appeared as an op-ed piece in the September 29, 2007, issue of the Milwaukee Journal Sentinel.

Although one of the wealthiest societies in history, the United States is one of the few industrialized nations not to offer universal health insurance coverage for its citizens, with more than forty-five million Americans lacking it. This has resulted in a relatively poor level of health for the U.S. population when compared to other industrialized countries. For example, the World Health Organization ranks the United States thirty-seventh among global health systems, twenty-third in infant mortality rate, and eighteenth in life expectancy. Despite widespread consensus that the problem of the uninsured must be addressed, potential solutions disintegrate when political issues—especially funding—are raised. A significant reason for this is that while the moral ideal of universal access is widely lauded, it is difficult to see how devoting greater tax resources to this problem will directly benefit those who are already insured—and who are more likely to vote. After all, the problems leading to poor rankings by the World Health Organization are felt most significantly by the uninsured.

Perhaps for this reason, the problem of the uninsured is most commonly framed as a conflict of interests between individuals and between individuals and community. At an individual level, universal health insurance coverage would require government spending, in turn requiring either increased taxation or decreased spending in other areas that may be perceived as more beneficial to some who already are covered by health insurance plans. Either approach seems contrary to the interests of some of those already insured. At a community level, conflicts are perceived either in the priorities and role of government programs, with community interest in a healthy population contrasting with other priorities (e.g., education, infrastructure, or national defense), or the role of government in a capitalist society.

Considering Problematic Health Care Paradigms

This framework for understanding health care coverage has not always been presumed. Most importantly for the purpose of this article, when contagious infectious disease has posed a significant threat to the population, controversy surrounding, for example, the role of government in overriding individual interests to protect the public’s health is relatively absent. The U.S. Supreme Court ruling in Jacobson v. Massachusetts, 197 U.S. 11 (1905), is perhaps the best known legal illustration of this, but deeper examples of how circumstances of epidemic infectious disease influence the perception of interests and the role of government abound in political and legal philosophy. Even very conservative and libertarian political and legal scholars who are highly suspicious about government intervention, such as F. A. Hayek and Richard Epstein, recognize a legitimate role for government in addressing infectious disease spread, a paradigm that Epstein has characterized as the “old public health,” which he describes as establishing “the principle that epidemics offer strong reason for decisive public intervention.” Richard Epstein, Let the Shoemaker Stick to His Last: A Defense of the “Old” Public Health, 46 Perspectives in Biol. & Med. S138–39 (2003).

Infectious disease, however, has not been perceived as a significant threat for several decades. The U.S. surgeon general is purported to have famously declared the “war on infectious disease” dead in the 1960s. This timeline is important since the relevance of infectious disease in the social consciousness virtually disappeared at the same time that broad social programs and, most importantly, tremendous technical and pharmaceutical advances occurred in medicine. Today, while infectious diseases like malaria are recognized as problems in the developing world, paradigm examples of health care coverage issues in the developed world include access to limited resources like ventilators, critical care hospital beds, transplantable organs, or in the early 1970s, kidney dialysis machines, and to health care services like preventive care and drugs to improve quality of life for people suffering from chronic health problems.

These paradigms differ significantly from infectious disease in the perceived effect on interests that result from access, or the lack of it, to health care services. Whereas infectious disease paradigms include recognition of the effects of lack of coverage on the entire population (thus, the Jacobson ruling that recognized the threat to others posed by Henning Jacobson’s refusal of public health intervention), contemporary paradigms perceive the effect of lack of coverage to be limited to those not covered (and their immediate friends and family): your lack of access to health care services, it is perceived, may negatively affect your health but will not affect my own health so long as I am covered in a way that ensures my access to the same health care services to which you lack access. Defenders of the current insurance system are quick to point out that the health of insured citizens is reasonably good and warn of rationing and long waiting lists if universal insurance systems are adopted. It is this perceived paradigm that frames the problem of the uninsured as a conflict of interests between individuals and individuals and community: why should I pay higher taxes or accept reduced other benefits when your lack of access to health care services does not affect my own interests?

Universal Benefits of Universal Coverage

I emphasize perceived paradigm above because I strongly believe this paradigm is mistaken in how it frames the conflict of interests. A strong case can be made that even under this paradigm the effect of the problem of the uninsured on the interests of all is significant. As described above, the primary obstacle to addressing the health insurance crisis lies in how the benefits of universal coverage are viewed. Both the concern with higher taxes (or reduced benefits in other areas of society) and the concern about fewer choices under universal plans center around a perspective that pits individual interests (of the currently insured) against broader com­munity interests in health insurance coverage. This dichotomy is mistaken.

The benefits of addressing the health insurance crisis are significant even for those who already are insured because the impact of the insurance crisis is felt in many areas that affect the health of the entire community, insured and uninsured alike. First, it is unclear whether the “advantages” of the current health care system can be maintained unless the health insurance crisis, among other problems, is addressed. Already, skyrocketing costs are forcing employers to adjust health insurance benefits, with many resorting to plans that offer fewer benefits, less choice, and higher deductibles and co-pays. While the problem of the uninsured cannot be held entirely responsible for these skyrocketing costs, it surely must be recognized as a major contributing factor. Furthermore, the fact that skyrocketing costs are forcing employers (the most common source of health insurance coverage for most Americans) to reconsider health benefits means that those who are currently insured are at increasing risk of becoming uninsured. In fact, the “working poor” are the fastest growing subset of the uninsured.

Second, because the costs of treating the uninsured are largely absorbed by hospitals, these costs have contributed to fewer facilities and personnel for those who are insured. The increasingly competitive health care marketplace has resulted in less ability to “cost shift” expenses associated with care for the uninsured and has increased financial burdens on hospitals where there are high numbers of uninsured patients. The past twenty-five to thirty years have seen a notable decrease both in the number of hospitals and hospital beds in the United States. One analysis of American Hospital Association data showed “a consistent downward trend” in the number of hospitals and hospital beds between 1975 and 2001 as a result of hospital closures and mergers. Another study found a 16 percent decrease in the number of acute care hospitals between 1985 and 2000, along with a 26.4 percent decrease in the number of hospital beds in that period. According to a March 2003 report released by the Institute of Medicine entitled The Future of the Public’s Health in the 21st Century, the problem of the uninsured is a major factor in this decline, with urban areas in particular having less total inpatient capacity and being less likely to offer trauma and burn care where uninsurance rates are higher.

In some areas, decreasing availability of health services can be more clearly and directly related to the problem of the uninsured. Consider, for example, the relationship between the uninsured and the decreasing number of emergency rooms in the United States, resulting in overcrowding of emergency rooms and long waits both for the insured and uninsured alike. The Emergency Medical Treatment and Active Labor Act, 42. U.S.C. § 1395dd, requires that any patient presenting to an emergency room receive medical screening and (necessary) treatment regardless of ability to pay. For this reason, many uninsured people, unable to obtain appointments with primary care physicians (who can refuse to see patients for any reason—including lack of insurance—in the absence of a prior relationship), are forced to use emergency departments as their venue for primary medical care. Regarding these services, a 2003 Institute of Medicine publication entitled A Shared Destiny: Effects of Uninsurance of Individuals, Families, and Communities details the myriad of financial problems created for health care institutions by uncompensated care provided to the uninsured. Because of the financial crisis faced by many hospitals, these institutions simply cannot afford to absorb the financial drain that emergency departments thus represent. It should come as no surprise that the reason most commonly cited for many emergency department closures is misuse of emergency rooms, primarily by the uninsured.

The preceding arguments, however, are not necessary to establish the significant effect of the problem of the uninsured on the interests of all. This is because contemporary paradigms of health care are themselves too narrow. The so-called war on infectious disease is not over—and in fact is regaining prominence in a world that has seen HIV, SARs, and the threat of bioterrorism extend beyond remote borders to U.S. shores in recent decades. A National Intelligence Estimate in 2000 and the congressional Aspen-Brown Commission formed in 1993 have both recognized infectious disease as one of the greatest threats to national security, a threat now viewed as even more significant because biological terrorism is considered a real possibility. Most recently, fears about avian influenza have raised public awareness of the inevitability of an influenza pandemic (be it avian or other), of which public health professionals have long warned. Particularly for newly emerging infectious diseases (for which no treatments or vaccinations exist, and for which development and distribution of treatments and vaccines will only occur well after the disease has ravaged large numbers of people), the effect of having large portions of the population lacking health insurance coverage will have significant negative repercussions for the insured and uninsured alike. Here, I would like to point to a few of these areas, hoping to increase recognition of the self-interested reasons to pursue the moral ideal of universal health insurance coverage.

Infectious Disease Threats and Health Care Access

The high number of uninsured people means that for a very large segment of the population access to the health care system will come only as a last resort, and then much later than those who are insured would enter the health system for similar ills. Numerous studies have shown that the uninsured use significantly fewer early detection services. One review of the literature relating insurance coverage to utilization of health care services found studies to be “quite consistent” in finding that insurance coverage increases use of health services, including outpatient primary care as well as acute ambulatory care and inpatient services. Of greatest relevance for identifying impending infectious disease epidemics, one study found a significant positive link between insurance and (nonpreventive) “reactive” visits to emergency rooms and outpatient clinics, the type of health services utilization most likely to be used in the event of an infectious disease outbreak. This fact is significant. During the SARS epidemic, for example, physicians cited the inability to identify the disease in a timely manner—not the lack of a treatment or cure—as the greatest challenge impeding its containment.

To the extent that lack of insurance slows access to the health care system and use of early detection resources, the problem of the uninsured will slow the identification of an infectious disease outbreak. This is especially true in urban areas. Urban areas contain a disproportionate percentage of ethnic minorities and the economically disadvantaged, both populations that are significantly less likely to have health insurance. In addition, because urban areas represent a concentration of people, they contain higher absolute numbers of people lacking health insurance coverage. At the same time, urban areas more readily facilitate disease spread. Because people in urban areas tend to live in multiunit housing (sharing air circulation, waste disposal, etc.) and come into contact with greater numbers of people in their daily lives, infectious disease spreads more rapidly. Since the key to slowing disease spread lies in early detection, when large segments of the population lack access to early detection and preventive services (like primary care providers), disease spread within the community at large increases.

Perhaps the best example to illustrate the benefits of public funding for access to preventive health services lies in the mandatory childhood vaccination program for entering the U.S. school system—widely recognized as one of most successful public health programs in history. The program has resulted in the eradication of smallpox, the elimination of polio, and a radical reduction in the number of cases of diphtheria, measles, pertussis (whooping cough), rubella, mumps, and a number of other serious diseases. The success of this program depends on enough children receiving vaccination so as to achieve a phenomenon known as “herd immunity.” Herd immunity is a concept at the foundation of the U.S. vaccination program. No vaccine is 100 percent effective, so the eradication, elimination, or radical reduction of epidemics relies on the protection provided when a large enough percentage of a given population is immune that those who are not immune are unlikely to ever be exposed to the disease. In this way, even those for whom vaccination is not effective, or who must forego vaccination for medical (or other) reasons, are protected through the reduced likelihood that they will be exposed to the disease. The greater the number of people not immune, however, the greater the chances become that the protection provided through herd immunity will be lost. Lack of access to vaccination, then, would threaten both those who do have access to this health service and those who do not. Most importantly, and for this reason, the success of this program is the direct result of public funding for vaccination of those children who would otherwise not have access.

The lesson of these examples is simple; health is largely a community good, and the effects of an individual’s lack of access to health services extends well beyond that person’s immediate circle of family and friends to the community as a whole. If we are not motivated to address the health insurance crisis for moral reasons, perhaps we can be motivated by self-interest to protect our own health by recognizing the broader community effects of the growing health insurance crisis.

Thomas May

Thomas May is an associate professor at the Medical College of Wisconsin, in Milwaukee, where he teaches courses in bioethics and public health ethics.